Clinical Groupware - Platforms, Not Software

DAVID C. KIBBE and BRIAN KLEPPER

Clinical Groupware is rapidly gaining acceptance as a term describing a new class of affordable, ergonomic, and Web-based care management tools. Since David first articulated Clinical Groupware's conceptual framework on this blog early last year -- see here and here -- we've been discussing Clinical Groupware with a growing number of people and organizations who want to know what it is, where it's going, and what problems it may solve, particularly for small and medium size medical practices, their patients and their institutional/corporate sponsors and networks.

Clinical Groupware heralds a shift away from medical applications that are primarily based in local hardware and software. It creates a more fluid functionality in those applications, and empowers communications as well, by leveraging Internet connectivity, Web-based data resources, and new services (i.e., capabilities) performed upon these data by agents or applications.

In other words, Clinical Groupware is about platforms that can integrate modular applications, which in turn are supported by subsystems of data services. Although it is still in its infancy, Clinical Groupware is an end-to-end digital revolution in health IT.

It is still too early for a single best example of Clinical Groupware to have emerged. The creation of platforms, modules, and data services in health care has begun only recently, fueled by and borrowing from developments in popular computing that include search, social networking, geo-location, identity management, photo and music-sharing protocols, and remote storage.

Clinical Groupware is sometimes understood in terms of "remote hosting" or an "application service model" (ASP) of software. It is true that this might be a starting point for some users. But as a phenomenon, it is far more powerful than simply running a software program over the Internet instead of on your computer or local area network.

Tim O'Reilly uses "Internet as operating system" as a short-hand way of describing the robust complexity of features and functions available to users of today's browser-based and mobile computing platforms. This approach contrasts markedly with the older client-server computing model. In client-server arrangements, a computer-resident operating system coordinates access to applications and machine resources on a single or, at most, a few computers on a network. In the "Internet as OS" model, the Internet itself coordinates that access across large numbers of computers and users.

The browser or the smart phone may be the means of gaining access to this new and rich "compu-cology," to coin a term. But what really matters most of the time is what is happening between your interfacing device and the many applications on the net that it can reach.

Consider the difference between the mere delivery of an application, such as an ePrescribing software program, over the Internet, versus the richness and complexity of two very popular, although very different computing platforms, Google apps and the iPhone with its app store.

Google's core competency is, of course, its search technology, which almost instantaneously takes the search string from your browser or mobile phone and serves it up to Google's proprietary software at one or more of its massive server farms. But Google also offers free (or very inexpensive) applications such as calendaring, email, photo organizing and sharing, word processing and presentations, mapping, etc. most of which are capable of sharing, indexing, and processing several different types of information in the background in a connected manner. Thus, at the push of a button while in Picasa Web Album, Google's online photo storing/organizing application, one can publish individual photos, or whole albums, to groups of people in one's Gmail account, while also allowing those people to upload new photos to some albums, but not others. It is also easy to place photos on a map location, view both photos and maps in Google Earth, and then share these with others. In each case there are complex data look-ups and indexing occurring, mediated by Internet protocols for identity management and access permissions, in the background.

The iPhone is a more proprietary platform - a "walled garden" in the jargon of the day - that integrates multiple data processing activities, some of which are hardware resident and others that occur online. Its wireless capability supports access to the Web, which can integrate with the built-in GPS location services that are in communication with satellites circling the earth. This arrangement can tap into a world-wide technical infrastructure that can help you find the nearest Chinese food restaurant or get to a nearby hospital trauma center. It can allow you to search for a doctor, map the location of the doctor's office, and get performance ratings on that physician's or organization's quality and service. Many different applications "run on" the iPhone device, but they depend on what O'Reilly calls "network available services" for value creation that far exceeds the features of the phone itself.

In other words, these new Web-based platforms allow distinct functions to interact with and leverage one another, creating a robustness of capability and productivity that was unthinkable in earlier, more limited hosted arrangements. Thinking of these platforms as merely running remotely-hosted applications is to miss their possibilities. Clinical Groupware, a very powerful and practical medical application of this model, is the revolution ahead that will foster intense competition among vendors vying for platform real estate.

Still skeptical? In fact, the leadership at ONC/HHS have already realized that the future of Health IT lies in a whole that is greater than the sum of its parts.

In early April, ONC awarded $60 million to four institutions - Mayo Clinic, Harvard University, University of Texas Health Science Center at Houston and University of Illinois at Urbana-Champaign - through the Strategic Health IT Advanced Research Projects (SHARP) program. Each institution's research projects will identify short- and long-term solutions to address key challenges associated with health IT and meaningful use. John Halamka recently blogged about the Harvard research, which will "investigate, evaluate, and prototype approaches to achieving an “iPhone-like” health information technology platform model, as was first described by Mandl and Kohane in a March 2009 Perspectives article in The New England Journal of Medicine." Further, Halamka writes:

The platform architecture, described as a “SMArt” (Substitutable Medical Applications, reusable technologies) architecture, will provide core services and support extensively networked data from across the health system, as well as facilitate substitutable applications – enabling the equivalent of the iTunes App Store for health.

This new approach to a health information infrastructure was the focus of a June 2009 working group meeting at the Harvard Medical School Center for Biomedical Informatics and an October HIT meeting which brought together more than 100 key stakeholders across academia, government and industry in an exploration of innovative ways to transform the national health IT system.

One of the challenges facing the Clinical Groupware, modular application approach, is that of data exchange between apps and data integration among several different apps. It is clear that the Harvard SHARP research grant will have these problems as high priorities for solutions during 2010 and 2011.

Meaningful Use in the Real World -- Is the Additional Administrative Burden Worth the Bonus for Small Practices?

By DAVID C. KIBBE

An article in the April 10, 2010 New York Times entitled "Doctors and Patients, Lost in Paperwork," brought attention to what may be, in the near term, the Achilles heel of the plan to incentivize doctors for the "meaningful use of EHR technology." The article cited a study published in the Archives of Internal Medicine this past February, which asked a large cohort of physicians in internal medicine training programs about the time they were spending on clerical work, most of which is documentation in patient charts, both paper and electronic. A stunningly large 67.9% of the respondents reported that they were spending "in excess of 4 hours daily" on documentation, while only 38.9% reported spending an equal amount of time in direct patient care.

Now, I am fully aware that practice in the inpatient, hospital setting is not the same as practice in the office, clinic, or ambulatory care environment. Patients tend to be sicker and require more consistent attention while in the hospital, which often means more documentation is necessary. However, the study and the NYT article point to a real world problem that crosses all medical care settings and impacts physicians and other professional providers of all kinds: the enormous burden of documentation, clerical work, and administrative forms completion that impedes real care giving and makes health care less and less efficient even as we add more and more technology.

In both the inpatient and outpatient settings much of the time-consuming and bureaucratic red tape is the product of the fee-for-service health insurance system, in which there are multiple permutations of payment rules, including authorizations and other kinds of forms to be filled out, each health plans forms different from every other health plan. Particularly in the outpatient settings, and for small medical practices, the amount of paper and electronic data collection that must be done to be able to assure payment from a health plan can be staggering. One physician recently compiled this list of activities necessary for a "routine" office visit, CPT coded 99213: verify eligibility; check in; copay determination; get patient to nursing station; see physician; check out; claim to billing person; scrub claim; co-insurance; deductible; send bill to patient; collect remainder; scrutiny; privacy concerns; liability concerns; paperwork_paperwork_telephone calls_paperwork!

Here's the point. In the real world, most physicians in private practice, and particularly those in primary care, feel that they are deeply under water and drowning in administrative trivia that contributes nothing to, but may often detract from, the quality of care experience that they are able to provide their patients. The administrative documentation is interruptive, mindlessly repetitive, often needlessly duplicative, and costly to the practice in terms of time, money, and nerves. This burden is one, and perhaps the major reason, that so many physicians are selling their practices to hospitals and integrated delivery systems. As one family physician recently put it to me, "I just couldn't get to sleep at night worrying about all the insurance hassles. At least now that's someone else's worry."

This is the thorny context into which ONC/HHS are launching the ambitious EHR incentive program legislated into existence by ARRA/HITECH, and which will pay physicians up to $44,000 over the next five years for the "meaningful use of certified EHR technology." While I have expressed on several occasions my basic agreement with this program -- in large part because it rewards the outcomes of the use of health IT and not just the purchase of software and hardware, and because I believe that it focuses health IT on quality improvement where it belongs -- I have also raised the concerns of my fellow practicing physicians across the country, who must evaluate the incentive payments in terms that reflect their real day-to-day struggles to keep their practices afloat financially. Any additional administrative or bureaucratic burden placed upon the already nearly intolerable levels imposed mostly by the private insurance companies and health plans, is not being taken lightly by these doctors, I can assure you.

To be a "meaningful user" of EHR technology will undoubtedly be an easier task for some doctors, and a more difficult one for others. But let's not fool ourselves. Meaningful use criteria include a significant number of new data entry/lookup/calculation tasks be taken on by all participating nurses and physicians, often using new and unfamiliar software programs and hardware devices. Meaningful use is at its core the obligation to collect a designated data set about each and every patient, using computers to store those data, and then assuming the obligation to perform a number of operations upon and with those data. The data include demographics, problems, medications, lab results, allergies, smoking history, and so forth. The operations include electronic prescription writing and refilling; sharing or exchange of the data with other providers for care coordination; reporting of quality measurements to Medicare; making available to patients pertinent personal health information and summaries of their visits; the use of clinical decision support tools and reminders for preventive care; and the recording of all orders for labs, referrals, medications, and radiological studies.

I want to be very clear that, in my opinion, were we to re-design health care in this country from the ground up, I would advocate that this set of data and this level of operational workflow using computerized systems would be nearly ideal as a starting point. Meaningful use puts the focus of health IT on some very fundamental information management tasks that are essential to knowing that the right things have been done for patients, at the right time, and with the right level of resources. It provides the basis for Clinical Groupware to flourish, which implies breakthrough improvement in care coordination and continuity. It is a system that could provide doctors with the tools to act smarter, not just harder, and for them to understand where their gaps in performance truly lie, which is the critical element in starting and sustaining an effort at improvement.

But here's the rub. We're not starting over. We're layering these new requirements on top of an already dysfunctional, highly ingrained and overly-complex system that has shown itself remarkably and stubbornly resistant to reform. And in these circumstances, and for most physicians in medical practices today, Meaningful Use does not appear to them to be a way to practice smarter -- it appears to be a path to just working harder.

Some might argue that today's small medical practices represent a cottage industry that is entirely outdated and ought to be replaced by larger, corporate medical enterprises. They would say that it would be a salutary, even if unintended, outcome of ARRA/HITECH were small practices to be driven out of existence and the doctors, nurses, and staff in them integrated into larger and more productive groups. Perhaps there is some truth to this notion, and perhaps it is even part of the Obama administration's and the ONC/HHS agenda.

However, I would argue that on balance just the reverse is true. Our nation's small medical practices are the "canaries in the coal mine," and their suffocation under the burden of bureaucratic complexity that is non-productive and simply cost-additive is a sign of real danger to everyone else in the industry, not just the smallest and most fragile among us. Forcing the small practices out of business doesn't do anything to relieve the bureaucratic and administrative complexity in the system, it simply moves it to another location, where it will remain a drag on the new and larger units of care. We don't have the numbers, but anecdotally it is evident that some physicians who sell their primary care practices to hospitals do so as a prelude to early retirement and as the last straw in a chain of events that has ended in failure, at least with respect to their expectations for a career as a physician. We may be actually undergoing an invisible shrinkage in our primary care work force right now.

What I would suggest is this: instead of rushing headlong into a clash that further extinguishes the ability of small medical practices to survive economically, and at worst may significantly diminish the nation's primary care capacity at the precise time when we need more of it, the current Congress and White House should work together on a rational trade-off between insurance related hassles and the new work associated with adoption of EHR technology. Our national leaders should understand that unless duplicative, wasteful, and completely non-productive documentation is streamlined and significantly reduced, the nation's small and medium size medical practices will likely sit on the sidelines of ARRA/HITECH -- not because the money is too little, or the technical help offered insufficient, but because they simply don't have the cycles to take on the new paperwork (even if it's computerwork). If that happens Meaningful Use will be at risk of becoming a failed experiment that merely lined the pockets of the highest utilizing, and therefore highest profit, physician groups and hospitals, along with the legacy EHR vendors who they favor.

My guess is that physicians all across the country would applaud an all-out effort by Congress and the Obama administration to simplify administrative/claims workflow and reduce insurance paperwork, and that they would look at the EHR incentive programs with a much less jaundiced eye if they knew that their overhead costs for billing and claims submission were to be cut in half. It will take bold action to bring this about, but it's time to do it. Insurance reform is meaningless unless we drive much of the administrative costs out of the system. And unless we do, asking America's physicians to accept more paperwork isn't realistic.

Are We Adequately Securing Personal Health Information

By BRIAN KLEPPER AND DAVID KIBBE

In a discussion about electronic health records (EHRs) a couple weeks ago, one of the Human Resource team members at a prospective client said, "I don't believe it's possible to secure electronic health data. It's always an accident waiting to happen."

There is some truth to that. More and more, our Personal Health Information (PHI) is in electronic formats that allow it to be exchanged with professionals and organizations throughout the health care continuum. It is highly unlikely that each contact point has the protections to wrap that data up tightly, away from those who would exploit it.

Of course, PHI is among the richest examples of personal data, often with all the key ingredients prized by identify thieves: social security number, birthday, phone numbers, address, and even credit card information. This should give health care organizations considerable pause.

Then consider that, while paper charts contain the same information, electronic files often aggregate hundreds of thousands or even millions of records, information treasures troves for someone really focused on acquiring, mining and making use of the data.

Which is what makes a new health data security survey commissioned by Kroll Fraud Solutions and conducted by HIMSS Analytics, so provocative. As they had in 2008, HIMSS Analytics found that most provider organizations meticulously comply with data security rules and standards. But they're overly confident about the security that compliance actually conveys. Worse, many remain unaware, until confronted by an event, of the devastating implications of even a minor breach.

And the threat is intensifying as the market and technology evolve. In 2010, 19 percent of organizations reported a breach, half-again higher than the 13 percent in 2008. Apparently, both the complexity of the environment and the interest in the data are growing. Security may be diminishing as a result.

And breaches can be hugely costly. A Poneman Institute study found an average cost of $6.75 million for organizational data breaches. This figure is not limited to incidents with malicious origins or even harmful consequences. In January 2009, the Department of Veterans Affairs agreed to pay $20 million to veterans who could show they were hurt when, in 2006, a VA data analyst lost a laptop containing information on 26.5 million patients, nearly every living veteran. The laptop was eventually recovered without apparent data compromise. The VA is now struggling with a new, serious health data breach.

Nor is the impact likely to be financial alone. The larger cost may simply be in the loss of patient confidence. After all, if an organization can't competently manage my data, do I want to hand over management of my family's health?

Perhaps the HIMSS Analytics' study's most important and penetrating finding is that "health care organizations continue to think of data security in specific silos (IT, employees, etc.) and not as an organization-wide responsibility, which creates unwanted gaps in policies and procedures." Nearly 9 in 10 survey respondents said they have policies in place to monitor access to and sharing of health care information. But more than four-fifths of breaches occur in more mundane ways: e.g., lost/stolen laptops, improper document disposal, stolen tapes. In other words, the holes can't be addressed by isolated approaches.

Security is a process, not a product. This means that certification of PHI security must be larger than merely plugging the security gaps in information technology, and must extend to the ways that people access and use information and the information technology.

It is clear that the answers here involve making heath data security an enterprise-wide responsibility, creating highly aware environments resistant to breach in even the most seemingly insignificant interactions. That will demand a significant cultural shift, critically necessary but, as this survey shows, difficult for many organizations' leaders to wrap their heads around.

Brian Klepper, PhD and David C. Kibbe, MD MBA write together on health care innovation, technology and market dynamics.

Value Trumps Price in Onsite Clinics

by BRIAN KLEPPER

Onsite health clinics are new territory for most employers. It can be difficult to sort through the different approaches used by different vendors. Worse, in difficult economic times it’s tempting to “get in” as cheaply as possible.

But like many purchases, you may get what you pay for with clinics, especially if you scrimp. Here are three reasons to favor value over price when considering an onsite clinic vendor:

• An investment. Most employers believe their health plan expenditures are high enough already. For them, a clinic represents an additional expense, and only makes sense if it can provide a return on investment that lowers overall group health and occupational health costs. Ask vendors for data and testimonials that their clinics save money and improve the quality of care.

• Many impacts. Properly configured, clinics do far more than reduce costs for office visits, drugs and lab tests. They can positively impact the chronic diseases that consume two-thirds of a health plan’s costs. They can influence specialty and inpatient care, which the Dartmouth Atlas shows have the highest concentrations of waste. And they can affect the five major areas of occupational health — workers’ compensation primary care, disability management, human resources testing (pre-employment screens, drug screens, Department of Transportation exams), retention/recruitment and lost work time — that, together, cost two to three times as much as a group health premium.

• Total effectiveness results from a clinic’s component medical management mechanisms. Optimizing quality and cost within the complexity of health care requires assembling an array of tools and programs, each targeted to a specific health care problem. Each approach has dedicated costs, but most also produce savings that outweigh their expenses.

For example, incentives such as free office visits, laboratory tests and free standard drugs, mostly low-cost generics, induce employees to use the clinic and help the primary care staff gain more control over the care process. Physicians cost more than nurse practitioners, but are more likely to create a fully realized medical home and have a better chance of influencing downstream care.

Clinical analysis and decision support tools help identify patients with health risks or gaps in care that deserve attention. Onsite, face-to-face disease management programs have a far better chance of influencing chronic disease costs than call center programs.

Modern clinics are a powerful innovation in an employer’s benefits arsenal. But they must be robust to be effective, integrating a variety of proven mechanisms. With those properly in place, the results can be quantifiable improvements in health care quality, cost and employee morale.

In other words, a clinic’s cost may be important. But the value — the benefit you receive for the cost — should be the reason you implement a clinic. It will certainly be how you’ll judge your investment.