A Dream of Reason

By BRIAN KLEPPER and DAVID KIBBE

The dream of reason did not take power into account...Modern medicine is one of those extraordinary works of reason...But medicine is also a world of power.

-Paul Starr, The Social Transformation of American Medicine, 1984

Today's unveiling of a Declaration of Health Data Rights is an important action, long overdue, that represents a collaborative effort by a group of health care professionals - activists, entrepreneurs, technologists and clinicians - all colleagues we hold in high esteem.

The Declaration's several points arise from a single, simple premise: that patients own their own data, and that that ownership cannot be pre-empted by a professional or an institution. And there lies its power, especially in the context of early 21st Century health care. It is a transformative ideal that currently is not the norm. But we join our colleagues in declaring that it should be.

It is fair to note that this effort - making sure that all of us have immediate access to personal health information in easy-to-use (i.e., electronic or "computable”) format - is NOT the most important thing we need to achieve in health care right now. We all know that the system is wildly out of balance, with costs so excessive that even the insured mainstream of Americans risk financial ruin with a major health event, and quality that varies from superb to atrocious. Restoring a semblance of stability and sustainability to America's health system will require many measures that may not include an individual's right to control his/her own health information.

But it is an appropriate, critically necessary seed, nonetheless. Information withheld from patients, purchasers and professionals, wittingly or unwittingly, is the deepest root of America's health care crisis. Too often it is an act of power, enabling - and we use this word in the clinical sense - actions without accountability, and trumping the checks and balances that laws and markets strive for in progressive societies. There are many other roots to our current dilemma, of course, but nothing is as pernicious or corrosive as the lack of information transparency. It has been the practice in American health care for decades, with ramifications so grave that, by itself, it has placed the nation’s future in peril.

And so the right place to begin is with a straightforward statement that health information belongs first and foremost to patients. We hope that this seed will take root, that doctors around the country will erect a small poster in their waiting rooms saying "We support the Declaration of Health Data Rights."

And we also hope this event will spur a new sensibility about who owns information, about accountability, so that pricing and quality information on doctors, hospitals, health plans, drugs, devices, diagnostic procedures and treatments become freely available to health care patients and purchasers, so that absolute power is trumped and so Americans can have health care that is trustworthy, excellent and affordable, no matter where it is received.

Brian Klepper PhD is a health care market analyst and advisor to the industry. David C. Kibbe MD MBA is a Family Physician and Senior Advisor to the American Academy of Family Physicians who consults on health care professional and consumer technologies.

Clinical Groupware: When Not-As-Good Is Actually Better

By DAVID C. KIBBE

In a February 13, 2009 blog post I introduced the idea of Clinical Groupware as a low cost, modular, and cloud computing alternative to traditional electronic health record technology for physicians and medical practices. Central to the concept of Clinical Groupware is IT support for care coordination and continuity, achieved through shared access to personal care plans and point-of-care decision supports. In this post I'd like to put a few more ideas on the table, specifically with respect to the market niche that Clinical Groupware may ultimately fill, including comments by several individuals whose opinions or work may be crucial to the success of Clinical Groupware over the next 1-3 years. (Anything farther out than that is simply dreaming.) Consider this an interim report on an emerging story with an indefinite timeline.

Interest in this topic has been, of course, heightened by the recently passed federal AARA/HITECH, provisions of which will provide incentive payments to physicians of as much as $44,000 over a five year period commencing in 2011, provided that the physicians can demonstrate the "meaningful use" of "certified EHR technology." It's always more exciting when there's real money in the mix. Will Clinical Groupware qualify as "certified EHR technology?" Many physicians and developers are hoping it will. Here's why.

I see Clinical Groupware as a disruptive, low cost but high capability technology, an alternative to the costly EHR technologies that are now implemented in about 15-20% of ambulatory care settings; the rest of the market has not become consumers of these products. When 80% of potential customers aren't buying, one thing you can say for certain is that non-consumption is an important characteristic of that particular market. And that's what we have here. Doctors have taken a long look in the vendors' shop window and overwhelmingly decided that the combination of cost and performance characteristics offered there don't warrant a "buy now" decision.

Notice, there is no Apple iPhone adoption problem among doctors. To the extent that there does exist an "EHR adoption problem" for physicians, we should look to the characteristics of the products on the market for the sources of the problem, and not simply blame the purchasers out-of-hand. In my own experience most physicians are not Luddites, nor are they frightened by or confused by information technology in general. They purchase and use technologies they see as valuable to them and their patients, and that offer the performance characteristics they want at the price point they deem reasonable. It's just plain silly to get angry at physicians for being prudent shoppers. No one blames auto consumers for not having liked the Edsall or the Pontiac Aztek.

But this is all in retrospect. What's likely to happen in the future?

Of course no one can predict the future; all we have to go on is the past, and things don't always repeat themselves. But there is sound business theory based upon study and research over many decades, that can help us make educated guesses about future health IT product offerings, as well as about purchaser buying behavior. Clay Christensen, the noted Harvard Business School professor and author of several books on innovation, has described situations that favor the development of disruptive innovation in any industry. His ideas about change and innovation are worth a careful read:

The initial products and services in the original "plane of competition" are typically complicated and expensive, so that the only customers who can buy and use the products...are those with a lot of money and a lot of skill. In the computer industry, for example, mainframe computers made by companies like IBM comprised that original plane of competition from the 1950s through the 1970s... The same was true for much of the history of automobiles, telecommunications, printing, commercial and investment banking, beef processing, photography, steel making, and many, many other industries. The initial products and services were complicated and expensive.

Occasionally, however, a different type of innovation emerges in an industry -- a disruptive innovation. A disruptive innovation is not a breakthrough improvement. Instead of sustaining the traditional trajectory of improvement in the original plane of competition, the disruptor brings to the market a product or service that is actually not as good as those that the leading companies have been selling in their market. However, though they don't perform as well as the original products and services, disruptive innovations are simpler and more affordable. This allows them to take root in a simple, undemanding application, targeting customers who were previously non-consumers because they lacked the money or skill to buy and use the products sold in the original plane of competition. By competing on the basis of simplicity, affordability, and accessibility, these disruptions are able to establish a base of customers in an entirely different plane of competition...In contrast to traditional customers, these new users tend to be quite happy to have a product with limited capability or performance because it is infinitely better than their only alternative, which is nothing at all.

...When a disruptive technological enabler emerges, the leaders in the industry disparage and discourage it because with its orientation toward simplicity and accessibility, the disruption just isn't capable of solving the complicated problems that define the world in which the leading experts work. (The Innovator's Prescription, 2009, pgs. 5-6)

Is it accurate to compare the emerging Clinical Groupware with disruptive innovations in other industries, with the early PCs, the transistor radio, and Southwest Airlines, for example? Are we about to enter another "plane of competition" beyond the one that was established by EHR vendors like NextGen, GE Centricity, Epic, and Allscripts? And, perhaps most importantly, will the new EHR technology compete "on the basis of simplicity, affordability, and accessibility" with the older products in way's that establish "a new base of customers and disrupt the market?"

Well, one consistent sign of disruption is visible opposition and protectionism from companies who sell top tier products at the highest profit margins. And we are certainly seeing that! As reported in the Washington Post and elsewhere, the industry is attempting to raise barriers to new products characterized by simpler, more accessible, and less expensive EHR technology, mainly through regulatory control that would constrain the features and functions used to "certify" these products; through complex standards that make it more difficult for small companies to bring their products to market; and, most recently through state legislation that would ban non-certified products from being bought, sold, or used. (I understand that New Jersey state legislators with close ties to top tier vendors have introduced a bill that would make it illegal for anyone "to sell, offer for sale, give, furnish, or otherwise distribute to any person or entity in this State a health information technology product that has not been certified by CCHIT," and which would levy heavy fines on anyone who did. This would make it illegal, in effect, for Google Health or Microsoft HealthVault to operate in the state of New Jersey.)

But it is less the disparagement and discouragement to innovation, and more the enthusiasm and hopefulness attached to new health IT models, that indicates to me there may be a surge in popularity for Clinical Groupware during 2009 and 2010. A growing number of experienced engineers, technologists, patient advocates, and health professionals have indicated common support of the basic innovative ingredients in Clinical Groupware. These include: low cost, simplicity of use, interoperable modularity, software as a service, a focus on coordination, and engaged communications with patients and among providers. Here, for example, is Adam Bosworth of Keas, formerly Google VP in charge of Google Health, writing in a recent post on his blog:

...[M]ost small practices can’t really afford to use big iron EHR’s. Even if it is free, they can’t really afford to do it because it will still require training, more time per patient potentially, and so on. Lastly, most EHR’s don’t work with other EHR’s so that coordinated care across practices isn’t supported and most people who are elderly or who have serious illnesses have more than one physician treating them.

The way around this is to build systems that don’t just duplicate what physicians do today during their face to face meetings with their patients, but rather provide new capabilities that will help with continuous and coordinated care and can generate additive revenues for physicians and then evolve by adding those features that automate the current physician activities as demanded by the physicians.

What would such systems support? They would support having a way to chat with or exchange messages with a patient for a fee so that unnecessary office visits can be removed and the patient is more likely to reach out for help. Think eVisit-lite. They would support a simple way to monitor the health of a patient who either has a chronic disease or is on path to developing one, again for a fee, so that physicians are actually getting paid instead of punished for keeping their patients healthier since, ideally, healthier patients will generate fewer visits/procedures over time. In short these systems will support physicians managing an ongoing paid relationship with the patient rather than an episodic one measured only by in-office visits. What should be done about helping physicians who are afraid of losing time to retraining? These systems should be as easy to use as a Southwest airlines reservation page. These systems should have a cost so low that physicians don’t care. Most of these points aren’t typical of most of the big EHR’s currently being sold. Again, hence our fear that a de-facto monopoly of the incumbents will lose this opportunity to let 100 disruptive innovations flower. (May 29, 2009 http://adambosworth.net/)

Adam isn't the only one interested in letting "100 disruptions flower." Steve Downs and John Lumpkin at the prestigious Robert Wood Johnson FoundationNEJM editorial in late March, 2009. Downs and Lumpkin write -- their enthusiasm nearly jumping off the page -- in part: have recently blogged about the need to develop an "interoperable and substitutable web-platform" for EHR technology that is akin to the Apple iPhone apps model, an idea that is foundational to Clinical Groupware, and which was first described in detail by Ken Mandl and Isaac Kohane in a

Perhaps the key is to put more money behind companies that offer EHRs that allow 3rd party app development. Will seeding a fund convince other investors to get in? Are there startup ventures out there that could take advantage of the fund? A venture fund for app developers. Apple and Kleiner Perkins did this – they set up a $100 million fund to invest in companies that would develop applications for the iPhone. (June 4, 2009 http://www.thehealthcareblog.com/the_health_care_blog/2009/06/catalyzing-the-app-store-for-ehrs.html)

Meanwhile, over at ZDNet, noted business journalist Dana Blankenhorn is hopeful that David Blumenthal of ONC will come through as a supporter of innovation.

CCHIT changes its certification criteria every year, and every year it becomes more detailed. While the 2009-2010 standards have now been unveiled only 40 ambulatory EHRs have been approved under the 2008 standards, and only six are approved for emergency departments. By making all vendors jump through these hoops CCHIT imposes an enormous tax on all vendors and limits competition to those large enough to deal with it. What reformers ...seem to want is a more basic process, one that assures interoperability and encourages innovation. Placing that authority in the government instead of CCHIT does not guarantee this result, but it is certain CCHIT is not going down that road. What I expect to happen now is for the newly-appointed ONCHIT advisory committee to seek a compromise, and David Blumenthal will try to craft a solution that keeps all options open. (May 21, 2009 http://healthcare.zdnet.com/?p=2318)

Representatives from the medical specialty societies are also beginning to understand the value to their members of component-based EHR technology and software-as-a-service. For example, a senior team of researchers from the American Academy of Family Physicians, led by Paul Nutting at the University of Colorado Health Sciences Center, recently reported on initial lessons from 36 patient-centered medical homes. In their report in the May/June issue of Annals of Family Medicine, the authors highlighted as a common problem in medical home transformation the lack of a "plug-and-play" platform for EHR technology, and the slowness of response and high costs associated with some single-vendor EHR/EMR technology vendors. Among its findings and recommendations, the panel of authors stated:

...[I]t is possible and sometimes preferable to implement e-prescribing, local hospital system connections, evidence at the point of care, disease registries, and interactive patient Web portals without an EMR.

The AMA has just announced, in an appearance at the Microsoft Connected Health Conference, June 11, 2009, "..a new physician Web-based portal the AMA is developing ... will provide physicians access to practice-related products, services and resources in a single location. The AMA plans to launch its new portal nationally in early 2010." The platform will help physicians exchange health information with their patients through Microsoft's HealthVault application, and will include an ePrescribing module as well.

And then there are the open source folks. Fred Trotter, an expert in online security and a leader in the free and open source, FOSS, movement in health IT has recently discussed in his blog how momentum is growing towards a disruptive set of innovations:

The ‘Clinical Groupware‘ people want to see the certification of a suite of technologies that may or may not add up to a traditional EHR. The EMR-lite people want to see faster and lighter tools. The PHR people and consumer advocates want EHR systems that empower the patient instead of the provider. The Health 2.0 people want to see completely different models of finance and care become possible. Of course, the FOSS people (like me) want FOSS EHRs to get equal footing. (June 2, 2009 http://www.fredtrotter.com/2009/06/02/can-cchit-move-beyond-problem-ehr-certification/ )

One of the nice things about blogging is that people respond with their thoughts and opinions, and sometimes with new information that adds value to an idea, making it a collective -- rather than a merely personal -- concept. This is what appears to be happening with Clinical Groupware. I've received hundreds of emails and telephone calls from people who have connected the dots around this concept in their own way; most simply want me to listen to and understand their approach or, in some cases, discuss their innovative products. But a few commenters have asked the necessary, hard questions about what will make Clinical Groupware a successful disruptive innovation in a marketplace -- medical practice health IT -- that has been notoriously difficult, even fickle, to sell into. These questions, in turn, have forced me to think more deeply and to reach out to experts and innovators whom I trust to test the ideas.

Next week, at the 6th Annual Healthcare Unbound Conference in Seattle, I'll be moderating a panel on Clinical Groupware with a number of representative companies, and discussing their business models with the audience. Should be very interesting, and I hope to report back to you as developments warrant.

David C. Kibbe MD MBA is a Family Physician and Senior Advisor to the American Academy of Family Physicians who consults on health care professional and consumer technologies.

The Health Industry's Achilles Heel

June 10, 2009

By BRIAN KLEPPER and DAVID C. KIBBE

"You never want a serious crisis to go to waste."

- Rahm Emanuel, White House Chief of Staff

Timing matters. The health industry has demonstrated steadfast resistance to reforms, but its recently diminished fortunes offer the Obama Administration an unprecedented opportunity to achieve meaningful change. The stakes are high, though. The Administration's health team must not miscalculate the industry's goals, or waver from goals that are in the nation's interest. The two are very different.

Aligning the forces of reform will be the first challenge. The White House and Congressional Democrats appear to be collaborating to develop a unified reform design. Even so, the effort is hardly pure. Lawmakers have been receptive to industry influence. The non-partisan Center for Responsive Politics reports that, in 2009, health care interests have already spent $128 million on Congressional lobbying contributions, more than any other sector. The tide now turned, most of that largess has gone to Democrats.

All reform discussions acknowledge the twin goals of universal (or expanded) coverage and controlling cost. But as the state initiatives in Massachusettsand California have shown, expanded coverage is easier. Coverage pays for care, so the industry is delighted to oblige. Cost reductions, though, are harder. The mechanisms that undergird health care's excesses are embedded in its operations, and waste is responsible for much of its profitability.

The Obama health team already has firsthand experience with the industry's maneuvering. First it saw the health IT vendors' association, HIMSS, hijack the well-intentioned $19 billion HITECH allocations for electronic health records by capturing control of the agency that specifies the certification criteria for product subsidies. Now those funds will probably favor outdated, non-interoperable, client-server technologies from a small number of legacy IT companies. Newer, more effective, less costly web-based tools from hundreds of innovative firms will likely have to base their success on market appeal, without the government's help.

And then there was the May 14 cost backpedaling by six major health industry associations. After apparently agreeing to voluntary cost reductions with President Obama, they reversed, insisting they had offered to only "ramp up savings" over an unspecified time frame. At least one health plan is already preparing an anti-reform campaign, similar to the Harry and Louise ads that helped turn public sentiment against the Clinton health reform effort.

These developments confirm the industry's focus on the status quo, backed by cash and lobbying strength. The question is whether it can again stave off reform, sealing another win at the American people's expense.

But the industry has an Achilles heel. Its fundamentals have eroded, potentially easing the way for operational restructuring. Consider the evidence that commercial health plan enrollment is in freefall, as mainstream purchasers - employers and individuals - are priced out of the coverage market.

• AIS and Kaiser Family Foundation data show that, after reaching 180 million enrollees in 2005, commercial health plan enrollment has plummeted by more than 20 million lives (11.3%).
• In recent discussions, health plan executives have acknowledged that the multiplier to estimate total covered lives from employee lives has fallen from 2.2 to 1.8. This 18 percent change mostly reflects kids whose parents' employers have stopped subsidizing dependent coverage. It could represent twelve million new uninsureds, previously unaccounted for, and another nine million new Medicaid lives.
• Last month the Wall Street Journal cited Wellpoint's loss of 500,000 lives since December 2008, and United's loss of 900,000 in the last year. Similar enrollment declines have been reported at health plans throughout the country, the result of a decade of premium growth at four times general inflation, exacerbated by a severely downturned economy.
• The Congressional Budget Office estimates that, in 2009, seven million Americans currently enrolled in commercial health plans will avail themselves of the COBRA subsidy that was part of the American Recovery and Reinvestment Act. Unless the economy rebounds or Congress extends the program, many of those enrollees will lose coverage as well.
  

Premium pays for nearly all health care products and services - from office visits to stents - so decreasing enrollments have stressed the industry more than at any time in memory. Ancillary issues, like drops in investment income and anticipated payment reductions to Medicare Advantage health plans, are also reverberating throughout the industry, compounding its financial troubles.

But even in the face of hemorrhaging enrollments, the health plan sector has not visibly changed its medical management approaches. Instead, most organizations seem to be waiting, presumably for the new revenues associated with universal coverage. It seems likely that the health industry will campaign for Massachusetts-type reform that forces concessions from purchasers rather than in the ways health care is financed, delivered and supplied.

To be meaningful, though, reform must fix the three deep structural flaws that enable the excesses that have benefited the health industry and created the cost crisis. A specialty- rather than primary care-dominated system promotes more expensive downstream care at the expense of less costly upstream care. The lack of an interoperable information technology infrastructure has created barriers to quality/cost transparency, transactional streamlining, and science-driven decision support. And a fee-for-service reimbursement system has encouraged more care, independent of appropriateness, rather than the right care. Industry groups fight hard to preserve these approaches and the excesses they produce, and to block the most obvious remedies to overspending.

Health care could be far more affordable. Experts agree that at least one-third of all health care cost is inappropriate care or administrative waste. As a recent White House meeting showcased, many health care managers have attained consistent, significant savings through innovations ranging from primary care clinics, data analytics, and Web-based management tools to health literacy and incentive programs.

As health care financing pressures intensify, the Administration must leverage the industry's discomfort by making the achievement of expanded coverage contingent on key operational reforms: re-empowered primary care, a national technology framework for outcomes management and payment tied to results. These are pragmatic goals that, when implemented elsewhere, have been shown to improve quality and drive down cost. Carefully explained, they will make sense to most Americans.

Finally, being effective with this immensely important issue will demand that the Obama team reach out and recruit the active leadership and support of the nation's non-health care business leaders, the one group csollectively more powerful than the health care lobby.

If the Administration can get the backing of influential leaders outside health care, and if it is willing to hold out on expanded coverage until the industry accepts changes that can rightsize cost, then we'll have a chance to establish affordability and sustainability in American health care.

Brian Klepper is a health care analyst, consulting with the industry. David C. Kibbe is a Family Physician, Senior Advisor to the American Academy of Family Physicians and a technology consultant.