News 5/29/15

The idea that there’s anything but negligible or minimal cost associated with information sharing in this day and age is untenable. It costs virtually nothing to send an email or download an web page, why should life-saving patient information be any different? We can do better.

Re: Haley comments. These comments are laughable, lawyer/lobbyist spin. How is it morally superior for athena to charge customers 8-10% of revenues versus other vendors who choose different unbundled pricing strategies? athena has used a classic Washington insider strategy of convincing Congress that their business lapses are industry problems — reminds me of the old saying that business leaders are capitalists during good times and socialists during bad times. The only information blocking going on here is Mr. Haley’s withholding the truth from his hapless Congressional buddies. By the way, I’m not an EHR vendor or a customer of one — just calling it like it is.

Is this article, from a CIO in Oregon, “laughable”?

“Business practices not technical limitations, holding health care progress back”: http://www.bizjournals.com/portland/blog/health-care-inc/2015/04/business-practices-not-technical-limitations.html

Some key excerpts:

Five years into the federal EHR Incentive Program, with billions of dollars invested, patient data is still not moving as it must to support high quality, coordinated care.

Frustratingly, many of these barriers come from business practices, not technical limitations. In key markets, the presence of a dominant EHR vendor allows large health systems to “box out” clinicians using different EHR systems. The victim in this market strategy is always going to be the patient.

More specifically, a majority of hospitals in Oregon use the Epic EHR. The techniques used by Epic to “box-out” competitors and gain market share include charging their own customers transaction fees for exchanging data with non-Epic systems and requiring expensive proprietary interfaces designed for long-term profit.

These strategies generate substantial rewards for some EHR vendors, and make it easier for large health systems to convince some smaller organizations to use a shared EHR platform. While this may seem like positive outcome, it actually perpetuates the problem of critical information locked out of — or locked within — the largest vendor’s system.

Many practices are feeling forced to scuttle EHR systems they like — more affordable, interoperable systems, better suited to their practices — in order to exchange basic information with users of the dominant regional vendor. This is playing out around the country, just as it is in the Portland metropolitan region.

We need to stop enabling market dominance, and work for a system structured to support better, safer patient care through real EHR interoperability.

An opinion column by a customer of another vendor reiterating the same points that Mr Haley made? Sure, equally laughable if we’re saying that that is somehow worse than burying interface fees in an 8-10 cent charge on every dollar that I earn, which is what athena does. I’m not saying that Epic or athena is right, I’m just saying that each has there own strategies for market domination, and just because one charges a different way doesn’t mean that their total cost of ownership is higher, which is what is being asserted. And by the way, if most of Oregon is on Epic, and Epic doesn’t charge for Epic-to-Epic interoperability, shouldn’t we count on the “plus” side of the ledger the quality and safety and efficiency improvements that have come to Oregonians whose information is being routinely shared among different providers who happen to be using the same EHR?

Since Epic’s software holds health data from more than half the country’s residents, wondering if Epic would respond to a truth challenge on the cost of an average Epic implementation and upkeep?

In response to c harris re market domination and total cost of ownership:

Is the American Academy of Family Physicians’ (AAFP) testimony during the Senate HELP Committee Hearing, “America’s Health IT Transformation: Translating the Promise of Electronic Health Records Into Better Care” also “laughable”?

Excerpt from Testimony of Robert Wergin, MD, FAAFP, President, AAFP:

Vendors Engage In Data Hoarding. The AAFP also has written to the Federal Trade Commission about anticompetitive practices that hinder interoperability. The AAFP is concerned with the utilization of health
information technology to create competitive barriers against physicians and patients. The lack of
interoperability makes it practically infeasible for a physician practice to switch electronic health records should
the vendor or health care community use anticompetitive methods to limit the practice’s access to needed
health information on their patients.

This hoarding of data – this vendor lock – negatively impacts care and distorts market forces trying to decrease health care costs and improve quality. It is critical that health data flow to where patients wish to be treated – in fact, these records are the patient’s records and should be electronically available to any physician or other provider of care at any time. These records and data do not belong to the EHR vendor. The current market forces for EHR vendors and large (quasi-monopoly) health systems limit interoperability to retain customers and patients and to elevate prices artificially. We need to make sure the business incentives are aligned to ensure continuity of care for patients and appropriate access to data by providers.

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How about credit downgrades and layoffs related to EHR implementations?

Here’s a recent example from last week:

Lahey Health exec sheds light on reasons for layoffs (Boston Business Journal)

Lahey Health has had to lay off 130 people, the health system announced Thursday, letting go of 1 percent of its 14,000-person workforce. The layoff follows a trying winter and expensive rollout of its electronic medical record system Epic, which resulted in a $21 million operating loss in the first six months of 2015. Weeks prior to the announcement, Dr. Joanne Conroy, chief executive officer of Lahey Hospital & Medical Center, detailed the expenses and how the flagship institution has grappled with the problems. Lahey Hospital & Medical Center felt the brunt of the layoffs.

http://www.bizjournals.com/boston/blog/health-care/2015/05/lahey-health-exec-sheds-light-on-reasons-for.html?s=print

AMEN.

A”true multi-tenant cloud EHR system” would have the same interop and vendor lock in issues as any other system. The hypothetical cloud vendor could easily develop superior mechanisms for sharing between its own users (just like Epic CareEverywhere) but when it comes to cross vendor sharing, they would run into the same issues every other vendor runs into (limitations of CCD or HL7 standards, lack of common vocabulary).

Regarding costs…perhaps the costs of interfaces should be integrated into the cost of the application, although I suspect organizations would prefer to only pay for interfaces they use. Either way, interfaces are not as trivial as sending an email. Interfaces are often more complicating than the end user application so it is understandable that they would cost money. In addition, interfaces often need additional changes and/or regression testing with every code change.

Re c harris comment on information blocking and pricing approaches

I’m sorry -if your business model is set up so you only continue to make money from existing customers by building interfaces and installing new software, you have more of an incentive to create data silos. Also, Epic sharing information to Epic and using this as a way to continue to consolidate the market does nothing good for consumers. I think we all know the economics of monopolies.

I’ve included a recent post from Julia Adler-Milstien, PhD, Assistant Professor of Information, School of Information and Assistant Professor of Health Management and Policy, School of Public Health

Information Blocking: A New Term and The Promise of A New Era in Electronic Health Information Sharing
on the Health Affairs Blog, May 20, 2015.

Some key take aways:
-The key actors needed for health information exchange to occur (EHR vendors and provider organizations, like hospitals and physician practices) have incentives not to share information
-For vendors and providers to be considered as engaging in information blocking, have to meet the following criteria, which will be extremely hard to prove in practice:
Interference:
There must be “an act or course of conduct that interferes with the ability of authorized persons or entities to access, exchange, or use electronic health information.”
Knowledge:
“The decision to engage in information blocking [must be] made knowingly.”
No reasonable justification:
Conduct must be “objectively unreasonable in light of public policy

While not sufficient to ensure that we achieve broad-based interoperability of health IT systems (and realize the substantial potential value from the $28 billion public investment in these systems), reducing information blocking is not only a necessary step, it is perhaps the most critical step. Now that we have a clear statement that public benefit and public policy goals take precedent, and there is serious talk about enforcement mechanisms, providers and vendors may finally be convinced to shift their business practices and business models to deliver on these.

When the C-suite truly believes that they can be most successful by competing on the basis of sharing and using data, rather than hoarding and controlling data, we will know that we have succeeded.

http://healthaffairs.org/blog/2015/05/20/information-blocking-a-new-term-and-the-promise-of-a-new-era-in-electronic-health-information-sharing/

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Epic has a responsibility to lead on the sharing of information, not use this as a way to make even more money.

I reiterate my request for a truth challenge.

Re talking about BS –

If you think the only people interested in this discussion are interns that work for athena, perhaps start reading the news and also take a look at what Congress is doing.

There are always lots of talk of “interoperability”, but the reality is no one asks a bank to take your account record and transfer each transaction into a different bank. You only transfer the money. With C-CDA document types, this problem is largely solved for health care. A patient can transfer their C-CDA using the transmit function of VDT. Granted some vendors charge for the creation of a C-CDA, but it’s up to the hospital how they negotiate their contracts with said vendors.

So why is “interoperability” still a discussion point? It’s a simple Fear, Uncertainty, and Doubt situation.

Epic is in a unique situation where it’s way a head in the race. Competitors have very few items they can point to in an attempt to disillusion decision makers. Interoperability is one of them. So competitors yell, “BUT WE”RE OPEN!!! THEIR SYSTEM IS CLOSED” in much the same way Linux users used to do the same to Windows. What these competitors are missing is that an EHR is about far more than interoperability. I’ve seen few vendors live up to their commitments like Judy and Epic. Other vendors simply make promises that they don’t deliver. Interoperability isn’t that big of a factor in this scenario.

For example, I’ve seen vendors promise dates then simply have no part of a feature ready at that date. I’ve seen vendors make up stories about other competitors being purchased or up-for-sale to sway decision makers. I’ve even seen a CEO of an EHR vendor promise a job to an employee of the health system while an evaluation of his company’s EHR was occurring against Epic and others. Better yet I’ve even seen vendor employees involved in “performance improvement plans” for project managers of their deployment to try to shift the lack of delivery to someone else. Given the magnitude of shenanigans that non-Epic vendors partake in, it’s easy to see how Epic is winning (because INTEROPERABILITY isn’t as important as RELIABILITY!).

The message needs to be load and clear to other EHRs. Deliver on your promises and commitments and you might stand a chance. The problem is SO few have in the past customers have come to expect them to fail. In most cases, the other vendors EHR roll-out turns into an EPIC fail with a swift replacement by Judy and friends.

Dan Haley – what is your response? Where is your example? Where is your “truth” if it exists at all?

It’s rather disingenuous to talk about vendors “creating” cost barriers before there are any interoperability standards in place. Without the standards, the costs are real, so it’s not exactly rocket science to expect that someone has to pay for them. The bulk of the testimony you cite doesn’t support your assertions in any way.

Re: PM_FROM_HAITIES comment about other vendors promising dates:

I do, for the most part, think your statement is possibly true. But it is not completely true. My own experience is Epic has not always lived up to their own development promises. So while I’m guessing from your bias you are fan of Epic (and I realize you didn’t say Epic is perfect), I wanted to make it clear for everyone that they are indeed not. I cannot speak about other vendors.