Where's the Beef?

There is some good news about EHRs: a new study, by Adler-Milstein and Jha and reported in Health Affairs, found that there is no evidence that hospitals are using their EHRs to increase their Medicare reimbursements.  Such up-coding had been feared as a potential pitfall of the introduction of EHRs.  True, the study showed Medicare billings did increase in the hospitals with EHRs, but at comparable levels to hospitals who did not adopt EHRs.

This is what passes for good news in the EHR world.

That doesn't seem like quite enough, does it?  After all, EHR adoption has skyrocketed since HITECH spurred the launch of the CMS incentive program -- and over 408,000 health care professionals have received some $26b in such incentives over the past three years.  "Not making things worse!" is a pretty low bar for success.

There's more not-so-good news.  A recent JAMA study, by Samal et. alia, looked at the impact of EHR meaningful use on quality of care, and found very mixed results -- marginally better quality results on 2 measures, worse on another 2 measures, and no impact on the remaining 3 measures.  The study raised questions about how "meaningful" meaningful use is, and how we best evaluate its impact and the impact of EHRs generally.

Another new report, by D'Amore and colleagues, in The Journal of Medical Informatics, found major problems with even MU Stage-2 certified EHRs being able to exchange and read so-called C-CDA (consolidated clinical document architecture), as required in Stage 2.   The study participants were pleased to find that they were able to identify common problems and offer specific solutions, but noted that "without timely policy to move these elements forward, semantically robust document exchange will not happen anytime soon."

That doesn't sound good.

On the other hand, in a piece in Healthcare IT News, Jack Beaudoin says that the debate about EHR effectiveness should be over.  He dismisses the Samal study for several technical reasons, and cites preliminary results from a study conducted by HIMSS Analytics and Healthgrades, covering all U.S. hospitals and with a more sophisticated measure of the level of EHR adoption in each hospital.

I've not been able to find any published version of the study, just a tweet from HIMSS, but Beaudoin reports that the study found that EHRs do have measurable, positive impact on the outcomes of care, as measured by mortality.  Both he and the tweet cite a heart attack mortality rate half as high for hospitals with high adoption rates compared to those with low EHR adoption rates.

Although not every patient cohort, service line, or diagnoses/procedures had positive results, "overall, all five service lines studied show statistically significant positive relationships to EMRAM scores for at least one group of diagnoses and procedures."  (EMRAM is their adoption model.)

I would like to believe Mr. Beaudoin is right, but I think the jury remains out.  For example, in a recent report, Rand was rather reserved about the impact of EHRs, citing mixed or modest results on clinical quality.  They specifically pointed out the issues of usability and lack of interoperability as major problems, noting that "HITECH promotes adoption of existing systems, not better ones," which I think hits the nail on the head.

Rand specifically called out market leader Epic for how its closed architecture makes interoperability a challenge.  They're far from alone in this criticism.  KLAS recently focused on Epic's ability (or reluctance) to share data.  I would summarize both reports as finding that Epic is fine with connecting with other Epic installations -- of which there are no shortage -- but, otherwise, good luck connecting with them.

A good illustration of this may be that, as I reported previously, Epic recently announced an interoperability consortium (Carequality), which pointedly does not include major competitors like Cerner, McKesson, or athenahealth, who have their own consortium, CommonWell Health Alliance.    It'd be funny if it wasn't so important.

As FierceEMR asked in their editorial on the D'Amore study, when it comes to interoperability, do we "fix the potholes, or find a new path?"

Congress may be reaching even its limits for incompetence with the Hatfield-McCoy feuds going on between EHR vendors.  Members of both parties are calling for an investigation into what they deem the "information blocking problem."  The Senate Appropriations Committee has asked ONC to report how many organizations are involved in the practice, and warned that "ONC should use its authority to certify only those products that…do not block health information exchange."

Rep. Phil Gingrey (R-GA) went a big step further at a House Energy & Commerce Committee subcommittee hearing, charging that:

We’ve spent tens of billions on non-interoperable products. It may be time for us to look closer at the activities of vendors in the space, given the possibility that fraud is being perpetrated on the American people.”

He also specifically singled out Epic, which, in response, claimed they actually have a "great reputation" for interoperability.  They must talk to different people.

Look, we know that in the future that health records will be digital, just like most other kinds of records already are.  We know that siloed records, even if digital, are not of much value; it is the sharing, the analytics, and the real time response capabilities that will drive the real value.  There's so much potential:

• A study of Medicare ACOs, with particular focus on those offered by academic medical centers, cited health IT as crucial for their success.  The authors note: "There has to be an electronic medical record system robust enough to analyze and assess quality and safety issues.  It’s important to quickly identify areas where changes are needed."  
• Another study predicts that analysis of EHR records is faster and more cost-effective than the current system of clinical trials.  The lead author concluded: "The use of electronic health records in simplifying clinical trials means that we no longer need to remain uncertain about which medicine offers the best health benefits for patients."
• Finally, Health Affairs focused a recent issue on how "big data" can be used to improve our health care system. For example, one study outlined six use cases for how big data can use EHR and other data to identify and manage high risk/high cost patients.

But, like FierceEMR, it is not clear to me if going a new path might not be better than trying to fix all the potholes in the existing path.

As the importance of "patient-generated data" gains in importance, with lots more options for such data, I think we're going to find that the traditional provider-oriented EHR is going to become even more problematic.  As John Halama, CIO of Beth Israel Deaconness Medical Center told MobiHealthNews, "what I, as a CIO, need to do is gather the data on your medical record, inpatient, outpatient, devices in your home, and understand what I can do to keep you well.”  Not everything important about a patient's health happens in a provider's office or facility.

As I've discussed before, I think the problem is that we approach electronic health records with the perspective that they are a provider's record about patients -- rather than patient records that various providers have specified levels of access to and input into.  That is a huge difference.

Yes, I know -- Goggle Health failed and Microsoft Health Vault is, well, doing whatever it is doing, but that doesn't mean the approach is inherently flawed (as Robert Szczerba recently wrote about in Forbes).

New studies indicate that, although they expect EHRs to be used, as many as 53% of consumers worry about the safety of their data in EHRs (Morning Consult), and as many as 13% have withheld personal data from providers due to concerns about privacy/security (Campos-Costillo/Anthony).  I wonder if people would trust them more if the records weren't "owned" and controlled by their providers instead of themselves.

I've taken my shots at EHRs before (They Shoot EHRs, Don't They?), but it's not because I don't support the concept -- it's because I am so disappointed we're not achieving more with them.  

Getting Our Piece of the Pie

In a Linkedin discussion about one of my prior posts, one reader asked what my thoughts were about mHealth bringing about much needed change to the industry.  My brief answer was, essentially -- gosh, I sure hope so, but I'm worried maybe not.  I'm going to use this post to expand on that answer, as well as broadening it to include other new entrants in health care.

It's no surprise that everyone wants to get into health care -- with the nation's tab at $3 trillion and counting, there's a lot of money up for grabs.  People from other industries see an opportunity to bring their expertise and new ideas to our admittedly creaky health care system, and get their piece of that $3 trillion.  My concern is that they'll end up with their own version of the Stockholm Syndrome, with health care's familiar players co-opting their efforts at innovation.

Whenever I talk to a company trying to get a foothold in health care, it seems they always want to target one or both of the payor/provider markets.  This shouldn't be much of a surprise -- as Willie Sutton once said about why he robbed banks, that's where the money is (include pharma as well).  Plus, it's a lot cheaper to do B2B sales than to establish a retail presence, especially in an industry whose consumers who aren't very used to B2C.  Payors and providers are natural targets for new entrants into health care. 

Certainly there is a lot of money flowing into health IT, which is expected to be a major source of innovation.  Mercer Capital Group reported that 2Q 2014 was healthcare IT's first $1b quarter for VC funding, almost hitting $2b for the quarter.  More has already been raised this year ($2.6b) than all of last year ($2.2b).  Mobile health -- mHealth -- is a particular favorite, attracting $400m in 2Q alone, with wearables and apps being the big favorites.

It's no wonder money is being invested: the wearable technology market is predicted to be a $50b industry within 5 years, according to ON World.  That compares to perhaps $5b in 2014 (both estimates seem generous to me).  This kind of technology not only has the potential to greatly enhance the ability to track consumer health, and to create actionable data in real-time, but also has consumers keen to use.  Slightly more than half of consumers in the Accenture Digital Consumer Tech Survey 2014  said they were interested in buying wearable technology (although, as fair warning, a new survey from IDC Health Insights found that one in three owners of a fitness or activity tracker stopped using them in the past 12 months). 

Still, as great a B2C market as wearables appears to potentially be, the companies in it are already working on B2B approaches with providers (such as health systems) and payors.  As Lynn Dubrack, a vice president at IDC Health noted: "To control escalating healthcare costs, especially for chronic conditions, healthcare organizations are evaluating a variety of options to engage consumers and encourage them to take a more active role in managing their health,"  High on the list of those options are mHealth solutions.

Take corporate wellness programs.  Although data on the their effect on health care costs remains mixed, they are a popular strategy for battling health care costs; some 60% of American workers have a corporate wellness program available to them.  Fitness trackers are a natural for such programs.  One company in San Francisco gave all its employees Fitbits, and saved almost $300,000 on its health insurance costs.

Indeed, Fitbit has an entire section of its website devoted to Corporate Wellness programs.  Some experts believe one key reason Jawbone acquired BodyMedia last year was to help it sell to health plans and self-funded employers.

Similarly, disease management and other firms that deal with chronically ill patients are very interested in mHealth.  They love being able to know what is happening at every moment with patients, and provide feedback to them.  Remote patient monitoring is predicted to be a $24b global market by 2019, and the data is starting to demonstrate that it can, indeed, save money.

Look at a company like Glooko, which is an mHealth leader in diabetes management.  Their website prominently targets payors and providers.  Pick your preferred remote monitoring or disease management company, and odds are they're tailoring much, if not all, of their services to payors and providers, not to consumers.

Or take an example outside mHealth -- retail clinics.  Ten years ago they were a virtually unknown quantity.  Walk in without an appointment and be seen quickly?  A price list for their services?  And very affordable prices at that, so consumers wouldn't mind paying directly?  Their business model was revolutionary.  Providers were scared to death of losing business to them, and payors didn't know what to do with them, especially without upsetting their existing provider networks.  It sure looked like a new kind of DTC approach for many kinds of patient care.

Fast forward to now.  Patients are indeed "flocking" to retail clinics, but now they're mainstream.  They're owned by pharmacy chains, grocery stores, even health plans.  Consumers can still pay directly, but, for the most part, the retail clinics are just another network option for consumers.

Top-down innovation isn't working, and won't.  HITECH was supposed to reap all sorts of benefits by getting EHRs in providers' offices.  It has accomplished many of its adoption goals, but it's hard to call it a success.  A recent blog in Health Affairs described how health IT is failing because all of the existing structures in which it is being used do not allow the kind of local innovation and creativity necessary to solve the underlying problems.

E.g., the "problem" is not lack of an EHR, so simply putting one in a provider's practice isn't going to automatically make things better.  Otherwise, more physicians wouldn't say EHRs make patient service worse than better, or worsen clinical operations more than help.  And physicians so dislike the Meaningful Use program -- despite its good intentions and financial incentives -- that 22% are opting out or disregarding, according to a new Medscape survey.

Selling innovative services to payors and providers is fine.  They can use all the help they can get.  These mHealth and other new entrants can help payors and providers control the rise of costs, while improving patient care and/or convenience.  That's all good.  But that may not be the way to radically reshape our health care system. 

I just don't see truly game changing innovations coming from "the usual suspects" of our health care system -- even when done in partnership with non-traditional organizations.  We need innovators who don't want a slice of the existing pie, but are willing to throw it away and make a new kind of pie.

When Napster started, it didn't go to the music labels and make deals.  It went to consumers, and it wrecked the traditional music market.  That was great if you liked to buy music, less great if you were the one owning or selling it.  I didn't like Napster's loose approach to intellectual property, and it took iTunes to salvage the music market, but you have to admit that market will never be the same.  I doubt many consumers would want to return to the old one.

Where are the Napsters (or, preferably, the iTunes) for our health care system?

All Things to All People Isn't Working

When it comes to hospitals, we may need to paraphrase Lincoln: they can treat all of the people some of the time, and some of the people all the time, but they can't -- or, rather, they shouldn't -- try to treat all of the people all of the time.

US News & World Report just released their annual "Best Hospitals" rankings.  They evaluated nearly 5,000 hospitals against a detailed methodology.  It's a fascinating report, although not without critics, and the results are widely used in marketing campaigns by hospitals that do well in it.

What struck me was that, out of those nearly 5,000 hospitals, only 144 scored a national ranking in even one specialty.  None -- I repeat that, none -- ranked in all 16 specialties.  Only Boston, Los Angeles, and New York had more than one Honor Roll hospital.  Several states have no hospital with a national ranking in any specialty.

There's a lesson there.

A few days ago Clayton Christensen, the Harvard-based guru of "disruptive innovation," told Forbes that the U.S. health industry is "sick and getting sicker."  He offered several suggestions for what he thinks need to change, but I want to pick one in particular, his emphasis on cutting administrative waste. 

It is not unusual to cite administrative waste as a problem in our health care system, but Christensen comes at it from a different angle.  As he said:

An increasing proportion of [health care] cost is spent on administrative and overhead activities that are not productive in any way.  They exist because we assume every hospital should be able to do everything for everybody. But that’s not possible if we want quality and efficiency. Overhead creep is the result.

His key diagnosis is the assumption about doing everything for everyone.  With more specialization, he sees significant reductions in overhead costs.  That's probably true, but I suspect costs generally could be lower, due to both improved efficiency and -- most important -- to better patient outcomes (e.g., shorter ALOS or reduced readmissions) that should come with such specialization.

It has become the conventional wisdom that increased volume results in better patient outcomes, particularly for surgeries, and there are data to support this belief.  For example, Birkmeyer (2002), Boudourakis (2009), Lau (2012), Sammon (2013), or The Advisory Board (2014).  Other studies support similar conclusions for medical courses of treatment as well, such as Coté (2013), Joynt (2013) or Hellinger (2008). 

Hmm, more specialization of services should lead to lower costs and better patient outcomes.  What's not to like?

Toby Cosgrove, the CEO of The Cleveland Clinic, gets it as well (or at least, says the right things).  As he recently said at the Aspen Ideas Festival: "What we need to understand is that not all hospitals can be all things to all people."

Versions of that quote are starting to be a cultural meme, although seemingly spoken more than actually acted upon.  Cosgrove noted The Cleveland Clinic's expertise in cardiothoracic surgery, done on a scale that he believes results in care that is cost-effective and of high quality.  They draw patients for these services not just from their metro area, their region, or even just the U.S., but also internationally.  He wants to see a future where we get patients to the right physicians, rather than trying to have expertise available everywhere.

Frankly, though, I'd have been more impressed if Cosgrove had cited the services that they stopped providing because other facilities were better at them.

Given the solid data on the importance of volume/experience, then, why are each of my local hospitals trying to make themselves the leader in, say, open heart surgery?  Or in cancer, neurology, or sports medicine for that matter?  They each still want to be all things to all people -- and there just aren't enough of us patients to ensure that they each get the volume that would result in the best patient outcomes.  And I don't think my market is unique in that standpoint..

Somehow it is hard for me to believe they've got my interests -- the patient's interests -- as their top priority. 

There has been a tidal wave of hospital mergers and acquisitions in recent years.  Oft-cited reasons include to gain more negotiating leverage against ever-bigger payors, and ability to improve clinical integration, hopefully resulting in higher quality/lower costs.  Affiliations are seen as another way forward, and could, in theory, help address the specialization issue, with affiliated hospitals agreeing which types of care each would focus on. 

Unfortunately, that may not be their goal.  Becker's Hospital Review recently hosted an Executive Roundtable on affiliation, and I was struck by a comment one of the hospital CEOs made:

There are too many tertiary facilities' values are not aligned with rural hospitals' values: Their goal is to pull patients out of smaller communities, which is not what smaller communities are looking for in an affiliation. Keeping patients close to home is what's important.

Wouldn't you like to think that doing what is best for the patient is what's important?

There's a calculation some health economist is going to do someday.  Illustratively, it might be something like this: in communities under 50,000 people, we can take care of 20% of the community's medical needs.  Between 50,000 and 250,000, 40%.  Between 250,000 - 1 million, maybe 60%.  Between 1 - 3 million, 75%.  And so on.

The point is, most of us don't live in places where we should be expecting that we're going to get the best care for every condition locally.  Nor should we expect that even the "best" hospital/health system for some conditions are best for other conditions as well.  Who is treating you where for what matters.

That's a very hard conceptual change -- for us as patients, and for health care professionals as well. 

I'd like to think that for serious conditions -- and I would hope that would be most things that would cause one to be hospitalized, other than emergencies -- people would be willing to travel further if they knew the outcomes were likely to be better and the costs comparable or lower. 

That is, after all, the rationale for medical tourism, whose annual market revenues have been estimated to be as high as $55b, with perhaps 1.2 million Americans going outside the U.S. each year.  We tend to use the term in the context of patients going overseas, but maybe we should rethink that.  With that many potential customers spending that much money, one would like to think we'd be able to get more inter-city, intra-state and inter-state medical tourism going, especially for high-cost, high value conditions/procedures where a small difference in outcomes can literally be life-changing.

What we need, of course, are institutions able to offer a compelling story -- not just fluffy marketing slogans and nicer rooms, but documented outcomes and clearly lower costs, neither of which many health care organizations have historically been able to produce, much less compete on.  But one can always hope.

In the meantime, it is up to us as consumers to seek out the best care, not just settle for the most convenient.

(For more thoughts on how we could change hospitals, check out A New Way of Looking at Hospitals) 

Too Little, Hopefully Not Too Late

I was going to write about the deeply dismaying Supreme Court ruling on Hobby Lobby -- I don't think employers should be able to use their personal preferences to tell me how to spend my money, whether that money is post-tax or pre-tax -- but I thought Uwe Reinhardt addressed the topic so well in his The Illogic of Employer-Sponsored Health Insurance that I didn't see the point of rehashing it.  Instead, I'll start with some (apparent) progress on telehealth.

The Federation of State Medical Boards has recognized that telehealth requires some changes in the current state-based licensing approach.  The FSMB drafted model legislation that wouldn't require physicians to apply for licenses separately in every state in which they plan to "see" patients, as now.  The model legislation would create an interstate compact, binding on any state that adopts it.  The compact calls for an expedited licensing process, with one set of paperwork that could be used to apply for licenses in any state that was party to the compact.

The proposal would also raise the bar for physician qualifications, requiring that applicants be board certified (as I've written before, why aren't all physicians required to be board certified already?) and not be subject to disciplinary action or an active investigation by a licensing agency or law enforcement agency, neither of which is evidently true now when applying for a medical license in a new state.

The proposal would allow each state to decide what kind of fees they would charge for the expedited license, so while applicants should be saving time and effort they may still find the new process expensive.

The commission that would oversee the compact would serve as a clearinghouse for information on doctors, and any license revocation or suspension in a physician's home state would automatically have the same result on any license for other states obtained through the compact.

I have to admit that when I read that last provision I was reminded (as I wrote about in Quis custodiet ipsos custodes?) that the state medical boards too often seem to act first in the interest of their state's physicians, secondly (if we're lucky) in the interest of the state's residents, and virtually not at all for anything outside the state.  I know they are state medical boards, but -- honestly?  They're not sharing that kind of information now?  And how will complaints from patients in other states get back to the physicians' home states even under the compact?  Will they?

I'd call the proposal better than the current situation, but not nearly enough.


Telehealth advocates hailed the FSMB proposal, but, I suspect, partly out of relief simply to see any sign of progress.  It could go further.  As Jonathon Linkous, the CEO of the American Telemedine Association, told MobiHealthNews:

Their model is not a reciprocity model.  The physician would still have to pay a fee to every state, probably [also] a processing fee, and have a third party handle the paperwork, which may or may not be a good thing. And we don’t know if all the states will adopt it.

As telehealth advocates point out, so-called reciprocity for licenses is not an unheard of concept.  A valid drivers license from any state allows driving in any other state, and military physicians can practice in any state with a valid medical license from their home state.  So, yes, while FSMB is recommending some progress, one gets the sense they're being dragged kicking and screaming into the 21st century.  


It's not really clear to me exactly what we're getting for all this caution on licensing anyway.  Just within the past couple weeks we've seen the American College of Physicians say that annual routine pelvic exams aren't necessary for healthy women after all, one study find that one-third of knee replacements may be unnecessary, and another study find that the widely used steroid injections for spinal stenosis isn't really effective.  And some estimates believe as many as 100,000 health care professionals have drug addictions every year, with a lifetime risk of such abuse as high as one in ten.  No wonder experts continue to see huge waste and errors in our health care system.

It's not all due to shortfalls in the licensing process(es), but the state boards and FSMB don't get a pass on blame either.
 
Meanwhile, CMS is also making some progress on the telehealth front, proposing that four new telehealth services be added to the Medicare Physician Fee Schedule for 2015.  You probably also want to be living in a rural area if you expect to take advantage of these services.  As MobiHealthNews commented, the proposed rule:

...still shows a glacial pace for telehealth reimbursement, with many more requests denied than accepted, and a very dim view of reimbursement requests that involve new technology. Large scale Medicare reimbursement for telehealth still seems to be a long way off.

Say what you will about the VA (and people having been saying terrible things lately due to the recent scandal about waiting lists), in the area of telehealth they've been ahead of the private sector for some time.  They've got a broad program including real-time care, home monitoring, and store-and-forward options.

It makes one wonder why there were so many veterans waiting for appointments.  Did they not know about their telehealth options, were they not comfortable with/able to use the technologies, or were the waits for telehealth as bad as for in-person appointments?  It just goes to show that technology doesn't automatically solve problems, but requires changes in processes and attitudes to really be effective.


I was struck by a comment Jonathon Bush, the CEO of athenahealth, made at a recent Aspen Ideas Fest, as reported in The Atlantic.  Bush wants more capitalism in health care and more focus on what patients need, but that is confounded by outdated attitudes. In his words,

We act, as a society, on the unconscious level, like we're not in charge. This is a massive problem. Not just because we utilize expensive things, but because we give up the opportunity for those things to get better.

In fact, of course, it is us as individuals behaving that way.  For example, in Altarum Institute's latest consumer study, over 90% of consumers say they want to be in charge of their medical decisions or share them equally with their physicians, yet when they actually see their doctor only 41% come prepared with their questions and make sure they get them answered.  Forty-eight percent report simply being passive at their visit, only responding to what the physician asks or suggests.  And 70% would go along with their physician's recommendations despite doubts. 

It is perhaps no wonder that many of us, not just those getting care in the VA, have become too blasé about waits.  The New York Times reports that long wait times have become the norm, especially for primary care.  The VA took heat for its wait times but at least they have a mechanism for tracking and reporting them -- obviously flawed and inaccurate, but a mechanism nonetheless.  Can your doctor's practice or your health system say the same?

If only there were on-demand, real-time options to see physicians when needed.  Oh, wait -- there are.  We're just not able to take full advantage of them due to historical licensing and reimbursement barriers.

FSMB's proposal is a start, but let's not forget that it is only a start.