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Readers Write 12/1/09

November 30, 2009 Readers Write 18 Comments

Submit your article of up to 500 words in length, subject to editing for clarity and brevity (please note: I run only original articles that have not appeared on any Web site or in any publication and I can’t use anything that looks like a commercial pitch). I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!

Healthcare Solutions
By Dan Field, MD


  1. Tort reform. Cap every state as has been done in California and Texas.
  2. Medical justice panels. A jury by our peers. Medically trained arbitration panels to hear cases.
  3. Eliminate doctors’ malpractice costs for patients who demand free care. If the government insists that ED docs see every patient (through EMTALA), they are de facto government employees for those patients and should receive government indemnification.
  4. Limit advertising again. It was a bad move when they opened it up.
  5. Research, publicize and reward best practices. The worst hospital at Kaiser today has a better record of sepsis prevention than the best Kaiser hospital two years ago. Some have had ZERO sepsis in two years. Sepsis costs $40,000 to $100,000 per patient and frequently adds to the nation’s iatrogenic death load. Replicate this through the major diseases and some of the $500 billion of savings we need to achieve becomes realizable.
  6. Divest physicians of the benefit of profiting from ordering tests. A study shows a doctor who owns a scanner is seven times more likely to refer a patient for a scan.
  7. Generics drugs for everybody, name brands for those who want to pay out of pocket (or from the HSAs).
  8. Revamp medical reimbursement
  9. Create a two-tiered medical system where everyone has catastrophic coverage and HSAs. Allow the rich and others to opt out for value-added service. This might be just enough incentive to keep some innovation moving forward. I seriously doubt most medication advances are necessary — seems to me they just add a molecule so they can extend the patent without any new, real benefit. First tier accepts all, including, pre-existing illness, with no rescission. Everyone pays same rate for basic tier, everyone gets a tax credit. Not sure how to deal with those that don’t work. Incentivize healthy behaviors — non-smokers with low cholesterol and great genetics are an attractive subgroup. Second tier insurance companies will compete for these stars with lower premiums. Veal calves with remotes and cancer sticks will be avoided like the plague and end up in the first tier or paying more.
  10. Accept that disparities will continue but that they will be better and more morally acceptable disparities than before.
  11. Allow true portability.
  12. Give needles to addicts, along with access to treatment.
  13. Strongly consider legalizing and decriminalizing drugs.
  14. Realize that screening doesn’t save money for society.
  15. People should have a right to unlimited end of life care … as long as they can pay for it.
  16. All government officials must utilize the system they insist we follow, especially “the public option”.

Dan Field is a physician with The Permanente Medical Group.

CPOE – One Size Fits All?
By Mark Moffitt

The goal behind Computerized Physician Order Entry (CPOE) is worthy — replace handwritten physician orders using information technology to minimize translation errors and provide conflict checking at the point of entry. There’s only one problem: many physicians are not satisfied with CPOE. The reason I hear often by non-physicians is this: “Older physicians reject technology. The newer generation of physicians is more accepting.”

I admit I have voiced this sentiment in the past. But after working with physicians and having seen them embrace technology that makes them more productive, I’ve changed my view. My view now is that physicians accept technology if it helps them be more productive and they reject technology that makes them less productive — regardless of age. However, I have observed that physicians over 50 are less tolerant and more vocal than physicians under 40 when their workflow is slowed. Maybe because they have more work to do in less amount of time?

Most all in the industry know the issue. CPOE shifts work done by low-cost clerical staff on a hospital payroll to the highest-paid people working in a hospital. Compounding the problem, physicians are not always employed by a hospital. So the work is shifted from a hospital payroll to an individual physician. And time spent in front of a computer is time not spent with patients. And seeing patients equals making money.

Let me qualify my statements above with this: This discussion is restricted to CPOE in an acute care setting and does not apply to all physicians. Some physicians love the current model for CPOE. It works for them. It makes them more productive.

National adoption of CPOE is low. The 2008 KLAS CPOE Digest reports that less than 10 percent of hospitals are “doing some level of CPOE.” In only six percent of hospitals nationwide, physicians enter more than 50 percent of orders directly using the system.

CPOE adoption is affected by many factors. One factor is availability of CPOE. Another factor is ease of entering orders. Another is physician workflow.

Physician workflow is influenced by factors including specialty, size of hospital, employment model, practice size, etc. There is no one model for how physicians do their work. There are many models.

It’s possible that CPOE, once widely available, will be embraced by physicians and the nationwide adoption rate will rise quickly to near 100%. The other possibility is that the current CPOE model does not work for all physicians and CPOE adoption rate climbs slow and stalls at some level, say 50%. What outcome do you think most likely?

Given the money involved, I wonder why more research isn’t being done to find other models that provide the benefits of CPOE that doesn’t require a physician to sit at a computer and enter orders? Why, when many physicians have expressed dissatisfaction with the current model? Why, when the industry is spending BILLIONS, partially underwritten by the federal government, to implement CPOE and other technology in healthcare?

For what it’s worth I’m doing my part by researching a new model for CPOE. I call it CPOE without the “POE.” Not a replacement for CPOE, but an alternative to physicians entering orders on a keyboard. Same benefits, only a different model. I’ll write about this topic in a future article.

Mark Moffitt is CIO at Good Shepherd Medical Center in Longview, TX.

Those Who Believe in The Network Will Go Far
By Carl Byers

 As one of Mr. H’s and Inga’s biggest fans, I am lucky to have had the chance to meet them in my travels as CFO of athenahealth. It is therefore an honor to submit this post.

I soon will be far from the world of HCIT. As announced in June, in early 2010 I will step down from the job I have treasured for more than twelve years to live abroad with my family. My wife and I have dreamed of immersing ourselves in another culture before our kids (ages 11, 7 and 3) are too cool to hang out with Mom and Dad. We will be in Chile for 18 months, and we look forward to returning with new energy and a fresh perspective on the world and on our role in it.

As a finance guy, I am not a technology innovator or a clinical subject matter expert, so I can’t address the future of technology or patient care. What I can address is a question that I am often asked gingerly and respectfully: “How is athena able to achieve such a high value?” Last week, on a panel discussion in Boston, an audience member’s way of asking was far less discreet: “Everyone thinks you are overvalued. Why is that?”

carlbyersThere are all sorts of fancy answers from capital markets people to explain prices based on total addressable market, long term margin profiles, and Price-to-Growth ratios (in fact, a fellow panelist from Goldman Sachs gave this type of answer to the questioner). I won’t attempt to do that sort of analysis justice here. And, I certainly can’t tell you why stock prices jump around as much as they do, but I do have a clear point of view on athena.

Simply put, I think our company trades where it does because of the scope of our vision and the confidence people have in us actually accomplishing it. It was Warren Buffett who said that, in the short run, the market is a “voting machine” and in the long run it is a “weighing machine.” I have no idea what the votes will say from day to day or even year to year, but I know that the weight of our business will be extremely hefty over time.

How can I be so sure? The reason athena has done well as a public company is the same reason athena has done well in the marketplace — because we offer a better way to solve our industry’s most complex problems and the market is responding. athena is one of very few companies in our sector that is not hopelessly stuck in a software mentality, and the market understands that the days of software as we know it are limited.

From complex reimbursement processes, to clinical coordination, to patient communications, to research, the future of health care (just like the future of the rest of the world!), is not software; it is “The Network.” In 1992, I worked on the Clinton campaign staff in Little Rock. If James Carville were in HCIT, he’d put an even sharper point on it — “It’s the Network, stupid!”

The market understands this because outside of HCIT, The Network has already taken over. This shouldn’t be news. How long has it been since salesforce.com put that big “no smoking” sign on the word “SOFTWARE”?  For how many years has Sun Microsystems declared, “The Network is the Computer”? My boss and friend Jonathan Bush said it even more clearly a couple of years ago: “Software is dead… Dead. Dead. Dead.”

And yet everyone — from pundits in Washington to some of our industry’s best technologists — remains fixated on terms like “versioning,” “implementation,” and “interoperability.” Not only is client-server software fundamentally unable to succeed in this new reality (whether installed locally or hosted from a giant data center), it drives business models with much lower visibility, much weaker alignment of incentives with practitioners, much lower sustainable margins, and much lower lifetime value of a customer than does a software-enabled-service like athenahealth.

What the software mentality misses is that at its core, the problem with health care is one of supply chain coordination. Isolated practitioners typically know next to nothing about what care has occurred in a patient’s life outside of his or her own four walls. Creating software that asks practitioners to type into templates in isolated local databases will not accomplish much of anything given the broader coordination challenge. This is why EMR adoption is so incredibly low today. Only through the emergence of copious networks of information and related process-oriented services will the silos break down and will the coordination (and quality) actually improve.

In every industry (including health care), the only way such networks come about is when there are financial incentives to exchange information. PBMs, pharmacies, and manufacturers of pharmaceuticals seem to have figured out how to build networks, and they didn’t need federal interoperability standards to do it! All they needed was a strong financial incentive to get aligned and remove wasted effort from the supply chain so patients could get their meds without huge inventory write-downs or large commissions for middlemen.

Similarly, athena is focused on building real networks so that the supply chains that extend into and out of the physician office can improve — not just for the coordination of payment information with payers, but also for the coordination of physician order information with labs and pharmacies. athena is also building a network for coordinating schedule, payment, and results communications with patients and referring providers. And to do this, we don’t need to wait for federal transaction and software standards — we just need an opportunity to earn financial rent for having made it happen (and in the process having made physicians, their trading partners, and the industry better). Networks cannot be only about information, they have to relate to real work — and it is through accomplishing the work that revenue, profits, and value flow.

So, as I start a new personal chapter in the New Year, my answer to that persistent question and my message to our industry is this: those who believe in software alone will fall away; those who believe in The Network will go far. Companies that embrace this distinction and produce tangible improvements in the delivery of care as a result will help to bring about the health care vision we all seek.

Thank you for the opportunity to comment here on this very unique network of your own.

Carl Byers is senior vice president and chief financial officer of athenahealth of Watertown, MA.

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Currently there are "18 comments" on this Article:

  1. Mark,

    Your article qualifies you as a Master of the Obvious on CPOE.

    I am beginning to believe IT leaders are still in the dark ages. Articles like Mark’s keep appearing in print, of the “you should allow physicians to participate in HIT projects” genre. This is akin to the New England Journal of Medicine printing articles that surgeons need to use sterile tools during surgery.

    In 2009, I can only assume these folks are ignorant of the teachings of the Jedi Masters:

    Dr. Donald A. B. Lindberg (now Director of the U.S. National Library of Medicine at NIH), 1969:
    “Computer engineering experts per se have virtually no idea of the real problems of medical or even hospital practice, and furthermore have consistently underestimated the complexity of the problems…in no cases can [building appropriate clinical information systems] be done, simply because they have not been defined with the physician as the continuing major contributor and user of the information.”

    Dr. Octo Barnett’s [Harvard] health IT Ten Commandments, 1970:
    1. Thou shall know what you want to do
    2. Thou shall construct modular systems – given chaotic nature of hospitals
    3. Thou shall build a computer system that can evolve in a graceful fashion
    4. Thou shall build a system that allows easy and rapid programming development and modification
    5. Thou shall build a system that has consistently rapid response time and is easy for the non-computernik to use
    6. Thou shall have duplicate hardware systems
    7. Thou shall build and implement your system in a joint effort with real users in a real situation with real problems
    8. Thou shall be concerned with realities of the cost and projected benefit of the computer system
    9. Innovation in computer technology is not enough; there must be a commitment to the potentials of radical change in other aspects of healthcare delivery, particularly those having to do with organization and manpower utilization
    10. Be optimistic about the future, supportive of good work that is being done, passionate in your commitment, but always guided by a fundamental skepticism.

    [Dr. Barnett played a key role in the 2009 National Research Council report about current approaches to health IT being inadequate, Press Release at http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=12572, and full report “COMPUTATIONAL TECHNOLOGY FOR EFFECTIVE HEALTH CARE: IMMEDIATE STEPS AND STRATEGIC DIRECTIONS. – ed.]

    Dr. Morris Collen’s Five Rules, 1972
    Most common causes of health IT failure:

    * Suboptimal mix of medical and computer specialists … resulting in communications difficulties and in the computer staff underestimating the vast medical needs
    * Gross underestimation of the large amounts of money needed
    * Suboptimal systems approach with serious incompatibilities between modules
    * Unacceptable terminals
    * Inadequate management organization and poor judgment

    Dr. R. Friedman, Reasons for slow spread of EMR, 1977:

    * Poor engineering and unreliability
    * Physicians not provided with computer-based applications that exceeded their own capability!
    * Inability to prove a positive effect on patient care
    * Difficulty transferring one application from one institution to another

  2. Carl,

    Enjoy your next life in Chile. Consider a purchase of Casillero del Diablo 2008 Pinot Noir Reserva. The best Pinot Noir I ever purchased under $20. Magnifico!

  3. Mark – you raise some interesting questions here. Having read your previous articles and seeing what you did with the iPhone at your hospital, you’re more like a master of innovation. Looking forward to reading about your new CPOE model ideas.

  4. Dan the 16 ideas sound good.

    Now please uncover your political leaning so the other side can find fault in the logistics or cost (jk).

    Honestly we need more creative, direct ideas like Dan’s to rebuild this healthcare system.

  5. Dan – WOW! What a clear and solid post. Nice to see it all put together so succinctly.

    Mark – keep wishing. Maybe the problem will go away. Or, maybe doctors will be asked to be clear, careful and actively engaged in what turns out to be a pretty important part of the health care process. Let’s earn that high salary, especially when shortchanging it or delegating it to a unit secretary to interpret your scribbles has been shown to kill people.

    Carl – So, if software is dead. dead. dead. What’s exactly behind the curtain at Athena? Just raw TCP/IP? Just some Cisco gear switching packets? Let’s drop the marketing jibberish. Athena, just like SMS of old writes or pays someone in India to write software that you operate on behalf of your customers for a fee. A fee that is probably includes a reasonable profit margin – or at least that’s what your investors are sure hoping. If you’re truly just philanthropic and don’t intend to profit, probably should fess up sooner than later.

  6. “S Silverstein Says:

    …I am beginning to believe IT leaders are still in the dark ages… ”

    Perhaps you need to re-read your past comments on HIStalk to understand what you believe. I believe what you believe is:

    (1) MDs, and medical informaticists in particular, are blessed, and would solve the health IT problem (and maybe the whole healthcare problem while they’re at it) in a jiffy if everyone else would just get out of the way, and
    (2) IT folks are blackhearted scheming idiots who delight in the pain and suffering of clinicians and could give a rat’s ass about patient care and safety

    Do I believe right?

  7. S Silverstein response reflects disheartening and maddening trend. HCIT industry acts like (believes?) we’re “EMR pioneers in discovery mode”.

    People seeking insight on problems well-addressed, long ago.
    Vendors and hospitals say “we’re finding our way”, while blatantly ignoring or dismissing solid industry knowledge (UCSF $50M and 7 years later) because “they’re different/ special”. (Ugh). Is there a precedent in ANY other IT niche or industry for this Groundhog Day approach?

    U.S. Government commissioned Battelle Study (late 1970s?) to evaluate performance of MIS (FIRST commercial EMR) and define Critical Success Factors. PROVEN benefits so compelling, report initially held up to be sure results weren’t “vendor slanted”.

    Lesson #1 – YOU DON”T GET BENEFITS WITH FOCUS ON “CODING” AND “INSTALLING” SOFTWARE! Yet this is what we’ve done in spades for decades since (with rare exception).

    “Junior Mint” noted MIS design for mid-size community hospital (El Camino) but it also well supported NIH, NYU and Beaumont (Army Hospital) – highly diverse complex organizations – in very early days. ALL had strong EXEC sponsorship, clinician leadership, CPOE use “mandates” with flexible, integrated, easy to use system. We knew then clinicians w/don’t type so rapid data entry achieved via first pointer device (pre Parc or Apple), sub-second response time and easy to use system interface. I am not convinced data entry/review can’t be streamlined with existing IT, human factors and better design.

    The industry quickly shifted focus from successful approach based on clinician adoption/ benefits and enabling workflows to IT centric model – automating paper processes and chart piling on technology. Results predictable – adoption and satisfaction woeful; clinical and financial improvements modest, at best. 10 years post IOM “push” JC issuing IT risk “critical alerts” with more studies and clinicians questioning entire premise and value prop of automating record.

    We knew vast majority of cost savings and quality improvements come from modifying MD ordering behaviors – Mel Hodge articulated this in 1970s/80s using “jet plane” dropping from sky daily metaphor someone recently resurrected. We recognized/respected role of nursing in EMR success and clinical and financial benefits realization- and complexity in automating RN workflows. Decades later, many MDs and RNs report being burdened by IT.

    Yes – good systems, even MIS, can be poorly implemented and world (IT and HC) more complex. But we guaranteed failure cobbling on (bug ridden) features” to disjointed systems, masking “speed to vendor revenue recognition” goal in cloak of hospital “speed to value”. Vendors and hospitals rarely define and target goals up front, much less build into design then are dismayed when benefits don’t magically appear. A decade into 21st century, we’re LESS IT savvy (you scoff) than 1970s/80s pioneers.

    CPOE not a clerical replacement function – we need “paradigm shift” (sorry) to think “clinical interactions / transactions” among multi-location care team (and patients) across community – using system to help deliver, manage, improve and coordinate care. To do so, clinicians need ready access to episodic and longitudinal data and useful tools (not fragmented records, tortuous interfaces and endless annoying pop ups labeled “decision support”!).

    “Requisition generation” is a BY-PRODUCT not focus of CPOE which is clinical process. MDs / providers must interact directly with system to evaluate data now increasingly entered in near real time at point of care, to make complex clinical and business decisions. And yes, you CAN do high tech and high touch care with useful and useable systems and motivated users.

    We’ve spent $BBs and are about to spend more taxpayer dollars on defining “meaningful use” many leading definition process have yet to experience. Before it’s too late, we’d best heed Lesson # 1 and ask why we continue doing same thing over and over, expecting a different result. The definition of insanity is playing out everyday in the industry – with stakeks higher if we don’t step back and internalize lessons learned.

  8. Really Mark, your articles are very interesting, you have a high professional profile, and is appropriate at this time on the health care.

  9. To Carl,

    Finaly, a man with vision! Your article says more about you than you may realize. I respect and identify with your family value and envy your ability to disconnect and recharge in Chile.

    Perhaps when you return, Washington may call.

    All the best to you and your family in Chile!

    P.S. The kids eventually grow out of their coolness and come back.

  10. To Mark: Thank you, Mark, I like what you’ve said (and I like the tone with which you’ve said it). I’m anxious to hear more about your non-POE ‘C’ model. Thanks.

  11. FabFil writes:

    Do I believe right?

    Well, no, you do not believe right; you apparently haven’t read the megabytes of material I’ve had online or referenced for the past ten years, or linked to on this blog, which outline my beliefs.

    Also, you have not responded to the points in my posting above. Let me restate:

    That articles extolling the virtues of “one shoe not fitting all” in HIT, and providing therather obvious insight that “physicians accept technology if it helps them be more productive and they reject technology that makes them less productive”, still need to appear in print in 2009, suggests Htrae is alive and well ( http://hcrenewal.blogspot.com/2008/05/htrea-parallel-world-of-hit.html ).

  12. you apparently haven’t read the megabytes of material I’ve had online

    Actually, it appears that FabFil has read all of it.

  13. “13. Strongly consider legalizing and decriminalizing drugs. ”

    Really? How will legalizing Meth, Heroin, or Cocaine reduce health care costs and improve quality? Or is this regarding Marijuana only?

  14. Programmer wrote “Actually, it appears that FabFil has read all of it.”

    Fabfil emailed me and indicated he had not, so you are wrong.

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