An Open Letter to the Obama Health Team

It seems likely that the Obama administration and Congress will spend a significant amount on health IT by attaching it as a first-order priority to the fiscal stimulus package. We take the President-elect at his word when he recently said:

“…we must also ensure that our hospitals are connected to each other through the Internet. That is why the economic recovery plan I’m proposing will help modernize our health care system – and that won’t just save jobs, it will save lives. We will make sure that every doctor’s office and hospital in this country is using cutting edge technology and electronic medical records so that we can cut red tape, prevent medical mistakes, and help save billions of dollars each year.” (December, 6, 2008)

Whether the health IT money is well spent will depend on how it is distributed and what it buys. Most observers suppose that federal health IT investment dollars will be used to help doctors’ offices and hospitals acquire and implement electronic health record systems (EHRs or EMRs). These are commercial software suites for entering, storing and managing patient health data within a practice or health organization.

We agree that some of the federal health IT money should go to purchase EHRs, especially to doctors and hospitals in rural and under-served areas, which otherwise could not afford them.

The Easy, Wrong Solution
The easy solution would be to spend most of the health IT funds on EHRs. The EHR industry has made it easy by establishing a mechanism to “certify” EHR products if they incorporate certain features and functions.

But the easy solution would not be the right one. EHRs still are notoriously expensive. Often, practicing physicians do not consider many of the features and functions to be useful or important. It can cost as much as $40,000 per physician in a medium size medical practice at the beginning of an EHR implementation. Even that regal sum may not completely cover the hardware and technical support necessary.

EHRs can be difficult to implement, upsetting practice workflows. In general, physicians’ practices have not adjusted quickly or smoothly to the disruptive nature of the switch from paper to electronic systems for patient care. Implementations can take months or even years to stabilize.

And the turmoil associated with the implementation can often have negative revenue repercussions for the medical practices they are intended to help. Physicians routinely report that, during the adjustment period, the number of patients they can see and treat in a day drops by twenty to thirty percent, with a commensurate decline in revenues.

Nor is there conclusive evidence that the use of EHRs improves patient care quality.

Finally, EHRs from different vendors are not yet interoperable, meaning that patient information cannot yet be easily exchanged between systems. If America’s physician practices suddenly rushed to install the systems of their choice, it would only dramatically intensify the Babel that already exists.

These barriers to adoption are well documented; they form the wall that has kept physician EHR adoption overall to less than 25 percent in this country. Even if a hefty federal subsidy reduced the exorbitant cost of the EHRs, many practices would suffer severe negative business impacts, and primary care access could temporarily be reduced on a national scale.

So important as EHRs are, at this point there are far better ways to invest in health IT for the doctor’s office and hospital. These approaches are low cost and would have immediate high impact on the quality and safety of care. They could build on and utilize existing health IT infrastructure, and be relatively non-disruptive to practice workflows. These factors would encourage adoption by minimizing risk for the doctors, their staffs, and their patients.

E-prescribing As A Model
The success of e-prescribing – as health technology and as public policy – makes it a model for future efforts. E-prescribing uses computing devices to enter, modify, review, and communicate prescription information. The entire process can be automated, from a prescribing doctor’s fingertips on the keyboard to the receiving pharmacist’s view of the medication order on his/her monitor. All this is possible through the use of standards- and web-based software that is free or inexpensive to the medical practice.

The only technology required of the doctor is Internet connectivity and access to one of the popular browser software programs, like Internet Explorer or Mozilla Firefox, which are already present in most offices and clinics around the country. E-prescribing takes advantage of this existing infrastructure, which is why its adoption is growing rapidly, particularly after CMS authorized an incentive payment to e-prescribing physicians of 2 percent of their total Medicare allowed charges during 2009.

E-prescribing has succeeded because it is an incremental and low-risk health IT that made it easy for physicians and pharmacists to electronically share prescription data, and because it was encouraged by financial incentives. E-prescribing produced significant benefits to physicians over the short term, but simultaneously provided a pathway to more comprehensive IT use over time. It also avoided a sharp decline in access to primary care.

More Bang, With Less Turmoil, for the Buck
We believe that the Obama administration could leverage IT spending in similarly inexpensive ways. Smaller, incremental steps would likely impact a larger number of medical practices in the short-term, benefiting patients while limiting the disruption to doctors.

Here are three suggestions:

1) Referral Management. No patient ought to be referred from a primary care provider to a specialist unless the relevant personal health data are available. Yet, as often as half the time the paperwork arrives, if it arrives at all, after the patient’s specialist appointment. This wastes time, results in duplication of tests, medications and procedures, and may imperil personal health.

Care can only be coordinated and continuity assured if information follows the patient wherever the next care event will occur. The solution is relatively easy and no more difficult than e-prescribing.

Create financial incentives for the implementation of simple tools that allow doctors and practices to share health data and communicate with other doctors. It should start with the specialists to whom they refer patients, and include the specialist when (s)he returns the patient to the primary care physician. A 1-2 percent bonus to doctors who e-refer would significantly increase continuity of information among doctors, which would translate to better continuity of care for patients, and lower costs to the system.

2) Patient Communications. Patients want and deserve to communicate through secure email with their medical home practices. They also increasingly want to use the Web to schedule appointments, pay bills and view portions of their medical records, such as lab results. These online services are not expensive for medical practices to provide through companies that offer them as “web portals” and they offer more than convenience to patients.

These communication tools are a means of closing the “collaboration gap” that exists between busy physicians and their busy patients, allowing routine tasks to be moved outside the rushed seven-and-a-half-minute office visit. This gives consumers time to digest and reflect upon how best to meet their health and wellness goals and offers doctors the luxury of better-informed patients. While some consumers are willing to pay their doctors an additional monthly fee to obtain these online services, a small payment from Medicare similar to that offered for e-prescribing would make the business case for doctors’ adoption of these patient-friendly online services. Adoption would surge.

3) Infrastructure Build-Up and Maintenance. Nowhere is access to the Internet more essential than in health care. We must assure that broadband Internet connectivity reaches every medical practice and every home in America, no matter how rural a region or how low income a neighborhood. Currently there are too many areas in the country where cable and DSL do not reach, often due to the small numbers of subscribers and the consequent barrier to investment by network carriers this imposes. The federal health IT initiative should subsidize both the establishment of broadband service in those areas, and the subscription fees for low income and health disparity populations that could benefit the most from Internet connectivity with health care providers and online care services.

The new Administration and Congress are about to throw a lot of money at the health IT problem, and the conventional thinking is to buy everyone an EHR of his/her choosing. While we enthusiastically applaud the vision that this represents, a more measured approach would create a smoother and more productive transition. At the same time, it would signal the EHR industry that, for national deployment, they need to come to terms with issues they have avoided so far, like interoperability and cost.

Will We Need a Bailout of the Health Care System, Too?

September 29, 2008

By David Kibbe

A huge bailout is being planned in Washington to avert a calamity that was brought about, in large measure, by the financial system operating the way financial operators told us it was supposed to function. The money is needed, we are told, to bail out the financiers who assured us -- up until just a couple of weeks ago -- that the system they operated was sound and would need no rescue.

What is the likely spill over to health care from the misbehavior of the financial system's owners, operators, and managers? I'm going to suggest there are likely to be both direct and indirect effects. One of the indirect effects is that we may lose faith in doctors, nurses, and hospitals, or at least come to suspect that the practice of their craft and trade is not aligned with their espoused principles of "doing no harm" and acting in our best interests.

Financially what we have discovered is that the assets of the system are so rotten in so many places, and in so many institutions, that none of the leaders in these institutions trust one another any more. So now they refuse the risk of doing business with each other without the federal government -- you and me, taxpayers -- serving as a backstop and guarantee.

The entire country, excepting perhaps the perpetrators of this massive but preventable mess, is rightly suspicious about the most basic issue: the motives of those in whom we have put our trust to manage finance, the banking system, and the credit markets -- in short, our money. They have steadfastly told us that they were working in our best interests by rationally investing our savings, our 401Ks, and our mortgages, in a financial system that efficiently allocates risk with reward, balancing both in a manner that maximizes the growth and stability of our nation's economy, and therefore our money invested in that economy.

Well, they lied. They weren't protecting us. They weren't helping us invest wisely. They were taking advantage of us, enriching themselves through a myriad of complex premiums, mortgage rate schemes, and derivatives. They told us that markets work best when government interference is the least. But this was self-serving manipulation of our trust. What they were really doing was diverting money ginned up by their schemes into their own pockets.

Any sentient observer of this trickery on such a massive and systematic scale will start to ask questions about who else among our highest paid and most trusted professionals might be lying to us about the well being we place in their hands. Who else, they will ask, is making money off our trust in them? Who else, they will ask, is skimming money off the top of an inflated and ultimately doomed -- because unsustainable -- market for complex services? Where is the next bubble that privatizes profits but socializes risk?

And I think the answer is pretty easy to imagine, and the sector easy to identify. It's the health care system, composed of health plan administrators, doctors, nurses, hospitals, pharmacies, device manufacturers, and so on, pledged to protect us and act in a non-profit (or at least financially fair) manner, to do us no harm, help us prevent illness, and treat us with skill and compassion when we are sick. But it's not happening exactly that way, is it? We trust them to protect and help us, but are they instead using our trust to enrich themselves?

My son, Ian, recently underwent an appendectomy. All went well, and I am grateful to the hospital staff, doctors and nurses who helped him get better quickly. But the bill was over $20,000 even though he spent less than a day in the hospital! He received an expensive MRI although the symptoms and basic tests were absolutely classic, as confirmatory of an appendicitis as I've ever witnessed, and his doctors admitted that the MRI was "probably not necessary." After the fact, he received a bewildering set of bills and explanations that took the good will of several experts in the Health 2.0 community to sort out (I want to thank, especially, Christopher Parks of Change:Healthcare for assisting Ian to make sense of this confusion).

This is perhaps not a very dramatic example of what I am suggesting is a profession and industry losing its moorings and escalating prices to serve the pecuniary interests of its own ranks. However, in a very personal way it has caused me to lose trust in the owners and operators of our health care system that they are acting fairly and that they are matching resources with a realistic appraisal of risk. And I know that there are other Americans who feel the same way and share my worries, perhaps millions of them.

I know that some readers will think that I'm over reaching with my analogy, stretching the fabric of comparison beyond what it can carry. But I would argue that when confidence in a fundamental American institution becomes as shaky as it now is with banks and mortgage lenders, and with the government officials who set fiscal policy and regulations to prevent the kind of meltdown we are now experiencing, it seems reasonable that people will become suspicious and cautious about others.

I'm very worried that there is as much excess and greed in health care as there has been exposed in banking and on Wall Street, and that a collapse and bailout is eventually likely, but that we have not reached the crisis point quite yet. But aren't we getting there? Fifty million people are without health insurance, and at least that many are under insured, while revenues going into the industry continue to increase at double digit rates of increase year after year. Medicare Part A, the portion of the fund that pays for hospital expenses for Medicare beneficiaries, went broke this year.

The net yearly shrinkage in employees receiving health care benefits from their employers is between 2 and 3 per cent, and disposable personal income spent for health care has now, for the first time, exceeded the costs of housing, groceries, and clothing for the average American. How can this go on much longer?

There is enormous anger at Wall Street among our countrymen and countrywomen, in all walks of life. If a bailout of health care is required, I think we'll see the same anger towards doctors, hospitals, and health plans. It may well be deserved if we don't get a grip on things medical.