Lab Soft News

CDC Releases On-Line Environmental Health Tracking System

The future of tethered personal health record (PHR) products, as in the case of HealthVault and Google Health, lies on the web. The term tethered here means that these electronic records have links to hospital and physician office EMRs such that data from them can be copied to the PHRs. Moreover, web-based PHRs also provide the opportunity to link to other valuable medical information resources on the web. For example, a consumer might highlight the name of a drug or disease in his or her personal health record and launch a search of trusted web resources to learn more about the topic. A recent article (see: CDC Launches Online Health Tracking Network) alerted me to another possibility -- tracking environmental exposures and chronic health conditions on the web. Below is an excerpt from the article:

The Environmental Health Tracking Network [of the CDC] is the first program available to the general public, as well as scientists and health professionals, that follows environmental exposures and chronic health conditions on the CDC's website....The online tool presents information about air and water pollutants and environmental health issues such as asthma, cancer, and heart disease in a single resource. By unifying the health demographic information in a single program, the CDC say it hopes to help scientists make a variety of environmental and health connections that heretofore couldn't be analyzed in one location....To further increase public awareness of the new tool, the CDC released a video advertisement for the Health Network on YouTube, stressing the correlations between environmental and personal health as well as the information now available through the CDC's website. Although 17 local and state health departments currently contribute to the online resource, the CDC hopes to expand the network to all 50 states and develop a complete national picture of public and environmental health....CDC officials said the resource has already had 73 success stories, in which information from the Web site has led to action to control potential illnesses from environmental exposure. The agency cited a Utah case in which a concerned citizen contacted the Utah Department of Health about what he thought was an unusual number of cancer cases in his neighborhood. Prior to the availability of the new software, a multi-year study would have been necessary to collect data. But through the Utah Tracking Program, officials were able to respond in less than a day, telling the man his local cancer rate was no higher than in the rest of the state, CDC officials said.

Bravo! What a great idea and effort on the part of the CDC scientists and public health officials. The home page of the Environmental Health Tracking Network features the following three categories: Environments, Health Effects, and Location. Under Health Effects are the following four categories: Asthma, Cancer, Childhood lead poisoning, and More health conditions. Clicking through Cancer and then Leukemia under Additional Links displays a page captioned Leukemia and the Environment. The site, even in this early stage, provides valuable data. The site is a little quirky and probably designed by an epidemiologist. Once you get the hang of it, you will find a treasure trove of useful health data.

A mash-up is a Web application that combines data or functionality from two or more sources into a single integrated application (see: Web-Based PHR Mash-Ups). The availability of the Environmental Health Tracking Network provides an early view of the potential for mash-ups linking our PHRs with other health resources on the web. For example and in this particular instance, the owner of a PHR could be automatically alerted to local environmental problems such as an outbreak of an infectious disease. Contrariwise, the CDC could use the national network of PHRs for reporting local outbreaks of conditions like flu or food-borne bacterial diseases. This would be similar to the syndromic surveillance systems being installed in hospital emergency departments and used in connection with bioterrorism monitoring.

Providing Patients Easy Access to Physician Notes in Their EMRs

I have been intrigued over past years by discussions concerning patients' rights to view their own medical records. An argument is frequently made by physicians that much of content in a hospital or office EMR is unintelligible, confusing, or unsuitable for patients to view. This may be true. However, many hospitals, on request, will allow patients to view their own medical records while in the hospital. Additionally, patients post-discharge can also request a copy of their chart, generally to provide to other physicians. A recent article takes up this same topic in the context of a project at Beth Israel Deaconess Medical Center allowing patients access to their physician notes in the EMR (see: Patients to get a look at physicians' notes). Below is an excerpt from it with boldface emphasis mine:

One doctor wrote that a patient was acting paranoid. Another typed that she had ordered tests to make sure a patient didn’t have cancer. Such notes, written in a patient’s medical records after an appointment, can be candid and blunt - at times more so than doctors are to patients face-to-face. Amid the national push to computerize medical records and make them more open to patients, one of the most intense areas of debate is whether patients should be allowed to see their doctors’ notes online....But the notes usually aren’t readily available to patients because hospitals and doctors’ groups fear that they will misunderstand medical jargon, take offense at a blunt observation, or worry unnecessarily about a precautionary test. Beth Israel Deaconess Medical Center, however, is about to begin a project called “open notes’’ in which about 100 doctors at the hospital and two other sites will allow 25,000 to 35,000 patients to read their physicians’ notes for a year as part of their online medical record. Researchers hope to learn whether the notes prove more useful than objectionable. They hypothesize that access to doctors’ notes will improve care partly because patients will become more knowledgeable about their treatment and about their doctors’ instructions....[Developers of the project] are developing detailed surveys to give patients, including whether they read the notes and found them useful, and whether they discovered errors.....The ultimate measure of success will be whether doctors and patients want to keep sharing notes at the end of the study....In Boston, Partners HealthCare, which includes Massachusetts General and Brigham and Women’s hospitals, is discussing making “summary notes’’ available to patients but not the full note....Partners is experimenting with providing patients with lab results online as soon as they are available and before the doctor has a chance to review them. The results “so far suggest that the sky does not fall in,’’....

The Open Notes Project will enable all patients enrolled in the study to view the physician notes entered into their medical record. I think that this is a very good idea. It's a good idea because it will cause physicians to be more careful about what they enter into the medical record, avoiding hearsay and off-the-cuff comments. Access to physician notes also provides the opportunity for patients to more actively engage in their own care processes. In fact, I suspect that ad lib narrative notes may have largely outlived their usefulness, to be replaced mainly by structured notes selected from pull-down menus available within the EMR. Such documentation may not be as colorful as some of the narrative comments of past years but will provide overall clearer documentation about the status of a patient. I am obviously very enthusiastic about the Partners HealthCare plan to provide on-line access to patients of their own lab test results (see: Physician Failure to Inform Patients of Abnormal Lab Tests All Too Common).

Do Physicians and Hospitals Want to Make Us Healthier?

A very fundamental issue was raised in a recent note in the HIStalk blog based on a comment from a reader. The topic under discussion is why hospitals and physicians are resisting the conversion to hospital EMRs. The theory being raised is that hospital executives avoid EMRs because they make hospital business operations more transparent and subject to outside scrutiny. Thrown into this conversation is also the idea that treating the sick is more lucrative than assisting the well. Below is the comment and response:

From HIPAAHound: “Re: interesting take on the resistance to electronic medical records [A Pound of Cure: The federal government is about to spend big on health-care IT. Too bad the medical industry has a vested interest in inefficiency]. I have to say I agree with much of this reasoning, most especially where HC costs are increased by for-profit insurance companies looking to avoid paying claims by constantly moving the target for approved claims, thus sending admin costs for providers sky high, and the avoidance of any mechanism which might expose any of these practices to the general public. I am amazed that these practices have not been exposed already in our debate over HC reform.”

Mr. HIStalk response: Bet on it: whoever has the most lobbyists wins. This Technology Review (MIT) article is hardly complimentary: it says healthcare could have already gone digital if it wanted to, but resists to keep its lucrative business model out of the public eye. It also hints an another truism: it takes a lot of sick people to keep the big bucks flowing, so there’s not much incentive to lose customers by making them healthier.

Here's a provocative quote from the A.Pound of Cure article by Andy Kessler linked to in the comment above:

An even bigger threat to the sickness industry's business model is that by allowing automated tracking of patients over time, electronic health records would set the stage for early detection and preventive medicine. Currently, the entire industry is organized around treating sickness, rather than keeping people healthy in the first place. Three-quarters of health-care spending is devoted to chronic care, but the National Cancer Institute and the Centers for Disease Control and Prevention allot just 12 percent of their budgets to research on early detection. Moreover, the payment system is structured around reimbursement for treatment rather than prevention.

I generally concur that physicians and hospitals are most oriented to, and comfortable with, the treatment of disease and not the promotion of wellness. This is largely the result of physician training and the fact that our healthcare reimbursement system does not provide compensation for predictive and preventive medicine or wellness. I do not subscribe to the idea that hospital execs avoid computerization to "keep [their] business model out of the public eye." The business side of hospitals has been highly automated for decades. It is primarily the clinical side of hospital operations that has been resistant to automation and EMR deployment. This is largely the result of factors such as the inadequate outdated computer systems available in the market. resistance on the part of physicians to the shifting clerical duties to them, and failure on the part of physicians to embrace a standardized nomenclature for describing clinical observations and events.

The PHR as a Tool to Enable Consumers to Take Responsibility for Their Own Health

Healthcare consumers need to take more responsibility for their own health, particularly to avoid or ameliorate chronic diseases such as obesity, diabetes, and heart disease. They also need access to the proper tools to achieve this goal. Tethered personal health records (PHRs) enable the transfer of critical health data from hospital and office EMRs to consumer-controlled records. With the exception of some health systems like Kaiser Permanente and the Cleveland Clinic, most providers have not been quick to endorse tethered PHRs. John Moore, who blog over at Chilmark Research, suggests that Microsoft is pursuing an international strategy for its PHR, HealthVault (see: HealthVault’s International Strategy). This will presumably enable consumers to self-manage, to some degree, their chronic diseases and, in so doing, help to mitigate the rising cost of healthcare. Below is an excerpt from his note:

The key driver for all countries is not much different than what we are experiencing in the US.  All are looking to reduce their medical risk profile by providing citizens and physicians better tools to manage health.  Primary objectives include:

• Support telemedicine with device connectivity (HealthVault Connection Center).
• Provide mechanisms/systems/tools, via HealthVault, to allow citizens to better self-manage and where possible minimize chronic diseases.
• Proactively engage citizens in their health by providing them with access to their personal health information leading to better, healthier and more knowledgeable decisions and subsequently, behaviors.

...Finland currently has 90% of its physicians using an EMR, but like most countries Finland continues to see healthcare costs rise.  Therefore, Finland is now looking at HealthVault as a critical component to take their national healthcare system to another level with deeper, direct engagement of their citizens and thereby mitigate cost increases. (In theory this makes sense, but there is no conclusive evidence that indeed this will work. Today, most are going on faith.)

It's interesting that Finland enjoys a 90% acceptance rate among physicians for EMRs but continues to experience rising healthcare costs. My personal belief is that office and hospital EMRs, if well designed, will allow physicians to work smarter and more efficiently but will usually not reduce the cost of healthcare. The reason for this is the very high capital cost of computer purchase and maintenance, including high-priced computer support personnel. In addition, EMRs and LISs provide the opportunity to generate new hospital management reports and perform functions relating to patient safety, quality, and surveillance that were not previously available with manual systems.

As John points out, there is still no firm evidence that patient self-help (see: "Participatory Medicine" and Its Relationship to Clinical Lab Testing), enabled by PHRs, can reduce costs. Nevertheless, I believe that it's worth a try. The challenge with tethered PHR will be convincing/forcing hospitals and physician offices to replicate patient data to patient PHRs. Most office and hospital EMRs are not designed to perform this function. In addition, much of the clinical data in these systems is not organized or phrased in such a way that it can be understood by healthcare consumers. Finally, much of the effort and capital costs to achieve this end on the part of physicians and hospitals would not be compensated under current payment systems.

Microsoft's Amalga/HealthVault Strategy Becomes Obvious

John Moore, who blogs over at Chilmark Research, always presents EMR and PHR issues with great clarity and knowledge. He recently attended the Microsoft Connected Health Conference and posted a blog note about some of the impressions that he gained there (see: The Borg Lives in Healthcare). Below is an excerpt from his note concerning the strategy that he believes Microsoft in pursuing with regard to Amalga and HealthVault, with boldface emphasis mine:

To some extent, that is the impression I walk away with from my attendance at the Microsoft Connected Health Conference.  That indeed, Microsoft and its Health Solutions Group (HSG) has indeed been assimilated by the healthcare sector. Now this is not necessarily a bad thing for Microsoft or the broader market but it does signal some important changes within the organization and more broadly confirms the strategy implied in recent announcements.  Primary among them is Microsoft HSG’s migration from an early consumer-centric strategy to an enterprise strategy.  Yes, HSG will continue to stand behind the consumer’s right to their health data and the consumer’s right to share that data with whom the consumer deems appropriate... [N]o longer is Microsoft interested in drawing the consumer to HealthVault... [R]ather, Microsoft will go to market directly targeting large enterprises, currently providers, ideally selling them a combination package of Amalga UIS [Unified Intelligence System] and HealthVault as in the case of the recent New York Presbyterian announcement.

John is right on all counts but I can't say that any of this comes as a surprise to me. On September 30, 2008, I presented my view of the emerging Microsoft strategy (see: Some Clues About the Microsoft Healthcare IT Strategy). Here is an excerpt from that note:

Microsoft's healthcare strategy is more obvious to me at this time than that of Google and consists of at least the following...elements:

• Develop a hospital EMR with Amalga starting with selected alpha sites as noted ...above. The company will thus be able to determine whether their product is competitive in the U.S. market.
• Sign high-profile deals with major health systems...to offer the HealthVault PHR to patients served by these health systems.

I would like to take some credit for my predictions of nine months ago but I won't -- it was just too obvious. Microsoft's was faced with two options after it purchased the Amalga EMR: (1) sell hundreds of millions of dollars of EMR software to hospital executives with HealthVault as a dangling appendage; or (2) distribute HealthVault to consumers free of charge and with no reliable business model to generate revenue for the company. It was clear to me that Microsoft would be much more comfortable and accustomed, from a corporate culture perspective, to participating in power lunches with hospital executives than working with the more demanding and vocal healthcare consumers. For their part, hospital executive are also most comfortable with bulky, over-engineered software that takes months of training to use properly and may never work as expected. Any after all, this is the type of product that Microsoft surely knows how to deliver. No need to cite product names here.

CCHIT Certification and "Meaningful Use" of EMRs

Meaningful use is a concept that has emerged as basis for determining whether federal funds can be used to subsidize the purchase of certified EMRs by hospitals. CCHIT has established a presence as the key certifying organization. I must confess that I have not been following CCHIT very closely but my instincts tell me to be very suspicious of any organization that is closely linked to HIMSS. In a previous note, I discussed the role of HIMSS as a trade association (see: HIMSS Describes Itself as a "Trade Association" in a Press Release). HIT blogger Dana Blankenhorn holds the same suspicions regarding CCHIT as he opines in a recent note (see: Will meaningful use go down CCHIT rabbit hole?). Below is an excerpt from his opinion piece with boldface emphasis mine:

CCHIT, a creature of the HIMSS vendor group, currently controls certification of Electronic Medical Record systems, and wants its certification to control meaningful use. It has lined up its allies (including consumer groups) to retain that power. Trouble is, as John Chilmark writes, if HIMSS wins its fight then control over defining health IT passes from the public sector to the private sector, which could use it to define out innovation, as it has in the past. As John Halamka notes, there is a reason why the phrase meaningful use is vague. He predicts, “Each year, the definition of meaningful use will be expanded, setting the bar higher and requiring more features and more data exchange.” That’s important. One thing we can be certain of is that, over time, health IT technology is going to change. If you lock in details now, or if you let some private group define meaningful use in terms favorable to current technology, you lose the chance to adapt to change. Conservatives are constantly harping on the idea that, if regulation is to exist, it must be simple, straightforward, and light. Focus on results, and let the market direct the rest.

Certification and governmental regulation tends to favor the large and powerful incumbent companies in any particular industry. That's why big companies tend to favor such initiatives although one might assume that most of them would oppose market restrictions. These companies have scores of personnel who devote all of their time to meeting certification requirements. The more complicated the criteria the better for them because this makes it more difficult for new entrants in the market. HIMSS functions as a trade association and works closely with its larger industry partners to ensure that any certification scheme inhibits new market entrants. And here's the most insidious part of this strategy. The companies can assert with a straight face that they are working to ensure patient safety and information exchange while protecting their market share. [Applause]

Each year, the large HIT companies in search of new hospital clients, will invest more capital into certification and proportionally less in R&D. Meaningful use will soon be equated with the continuing ossification of EMRs. Less capital will be invested in new functionality for their EMR products because it will become more onerous to "certify" as safe any new features. Recall also that all of the major EMRs are highly proprietary by design in order to lock-in hospital clients so that "information exchange" will require a major and costly rework of them. Information exchange has not been a high priority for most hospital CEOs anyway as I stated in a previous note (see: Differentiating Between RHIOs and HIEs):

The primary goal of hospital executives is to increase their admission rates and they have very little interest in making clinical information more portable for patients. Although clinical belongs to the patients for whom it is generated, hospitals generally view it as proprietary to them. The consequences of the broad sharing of patient clinical information is to enable healthcare consumers to shop around among competing hospitals.

Update on 5/25/2009 at 10:15 p.m.

Mr. HIStalk comments on CCHIT thusly:

The Washington Post follows up its somewhat critical HIMSS piece with another that goes after CCHIT. The title is more exciting than the article: “Group Seeks Sway Over E-Records System — Health Association With Ties to Stimulus Lobbying Effort Pursues an Oversight Role.” All it says is that HIMSS created CCHIT, lobbied for big stimulus dollars, and now recommends CCHIT as the EMR certifying body. “Critics in the health-care industry have expressed concern that the certification commission is too close to information technology and health-care companies to be the best judge of what equipment doctors and hospitals ought to buy. Although the group is funded through a contract with Health and Human Services, it is run by a former HIMSS executive and one trustee also is the president of the trade group. Several board members work for technology vendors.”

Steve Ballmer on the Future of Computing: Three Screens and the Cloud

I believe in cloud computing and think that this model will soon be embraced by most industries, with the probable exception of healthcare, and will also rapidly become the norm for personal computing. I have posted a number of notes about this topic. I have also posted a number of notes about smart phones, viewing them as types of mini-computers, and emphasizing their role in e-health and m-health, with the latter "m" standing for mobile (see: Making e-Health Information Accessible with Smart Phones, The Mobile Web and the Future of eHealth).

Nearly all of my own daily computing work takes place in the cloud and I have never worked more efficiently in my life. All of these ideas coalesced in my mind when I heard Steve Ballmer, CEO of Microsoft, utter a simple statement in a podcast that I listened to recently (see: The Future of Microsoft, The Future of Technology). He said the following in a lecture at Stanford: the future of computing involves three screens and the cloud. The three screens to which he refers are PCs, cell phones, and televisions. Azure is Microsoft's platform for the cloud on top of which new applications can be built in this new environment.

For me, It's relatively easy to predict that the healthcare industry will be the last to embrace the cloud. Past history suggests that healthcare has always been last in the queue to adopt new concepts in IT. The reasons for this are numerous and include the fact that the industry is highly regulated, conservative, and suffers serious penalties for mistakes. However, it's still interesting to speculate about changes that may be encountered in, say, hospitals when the norm for computing consists of "three screens and the cloud." The first type of screens that popped into my head in healthcare were the ubiquitous TVs in patient rooms.

Such TVs, wired to provide web access, could provide an opportunity for inpatients to review parts of their own medical records. I would advocate perhaps a 24-hour time lag for patient access to, say, pathology, lab, and radiology reports. This "period-of-grace" would provide the hospital clinical staff a 24-hour window to present critical data to patients prior to their ability to access it. Such access could serve to engage more patients in their own care processes while hospitalized. Consider also, for example, the benefits of allowing patients to view the list of medications they are currently taking accompanied by pictures of the pills. I believe that the error rate when dispensing drugs in the patient care units could decline rapidly if access to such data was available.

Moving LISs Toward Greater Support for Preventive and Predictive Medicine

I have posted a number of previous notes about predictive and preventive medicine (see: Preventive and Predictive Medicine as Components of the Healthcare Continuum, The Relationship Between Predictive and Preventive Medicine). Lab medicine professionals can play a leadership role in predicting disease and monitoring how lifestyle changes can prevent the onset of more serious disease. Think genomic testing, biomarkers, and lipid profiles. John Moore who blogs over at Chilmark Research returned rather depressed from the recent HIMSS conference in Chicago (see: HIMSS’09 & Depression). Here's what he had to say about the event:

 [I]t is clear that the mindset of [the HIT] industry and many of its self-promoting pundits, needs to hit the reset button....We are not, as an industry, focusing on the right things.  Rather than focusing on how to keep people out of the healthcare system, keep them from becoming patients, everything I have seen and heard here at HIMSS is about keeping people tied into the system....I am convinced that the only way we are going to move the needle in a positive direction is to begin handing over the reins to the consumer.  For far too long this industry has kept the consumer in the dark and has not helped that consumer in directly managing their health.  It has taken a paternalistic view that must end immediately.  Nowhere at HIMSS did I see or hear people discuss the consumer (well, there was the occasional marketing education session on how to reach the consumer, but that is just marketing and doesn’t count).  The only perspective on display at HIMSS is that of consumer as patient.  Problem is, that view goes under the assumption that the only purpose of healthcare is to treat people that are already sick.

I am in basic agreement with John about the need for a greater focus on wellness and not disease in our healthcare system. An interesting facet of this discussion is the role of HIT in the promotion of wellness. Unfortunately, I don't believe that most physicians, hospital C-suite executives, or HIT professionals are going to "see the light" any time soon and begin thinking about how to keep consumers healthy. In fact, I can't recall any physicians around me discussing consumers at all. The reason is that the physicians are not selling what many consumers may increasingly want to buy, which will be the means and methods to stay healthy.

If I am correct that the clinical lab industry has a role to play in predictive/preventive medicine, then surely the major HIT instrument of lab professionals, the laboratory information system (LIS) or some extension of it, has a role to play in this enterprise. I presented a "booth lecture" at HIMSS on this topic (see: How Predictive/Preventive Medicine Will Change Healthcare Medicine Will Change Healthcare Delivery and the IT That Drives It) and I am now in the process of discussing with executives of a major LIS vendor the nature of the support that the LIS can provide for wellness.

I suspect that the it would impractical to designate some part of the LIS, in its current form, as a "wellness domain" because many physicians and nurses have little interest in this topic. In the mini-lecture linked to above, I come to the conclusion that the tethered personal health record (PHR) can and should be the repository for copies of lab test results relating to wellness because these records are being developed and maintained by and for the healthcare consumers themselves. Given that PHRs will be web-based, it will also be feasible within them to provide links to wellness resources on the web about how consumers can improve their health and prevent illness using lab test results as guides.

HealthVault Experience at Cleveland Clinic Monitoring Patients with Hypertension

I believe that tethered personal health records (PHRs) will provide a means to enlist healthcare consumers into taking a more active role in the management of their chronic diseases. There is much that can be learned from the experience of hospitals such as the Cleveland Clinic as they deploy PHRs like Microsoft's HealthVault for patient use. I have published previous notes about this product. This topic of home physiologic monitoring was addressed in a recent article (see: Experiences at Cleveland Clinic with HealthVault). Below is an excerpt from it with boldface emphasis mine:

The local Cleveland paper published a good article today that highlights the work between Cleveland Clinic and Microsoft HealthVault....Cleveland Clinic [patients] who are managing a chronic condition, e.g., hypertension, take periodic measurements that are fed, by way of the HealthVault repository to Cleveland Clinic’s EPIC EMR.  Once in EPIC, the physician can track and trend readings and make adjustments to treatment plan as warranted.

(1) Does the use of such systems impact payment/reimbursement schedules?  Is payment reform required to insure that a physician/hospital is reimbursed for such services that typically fall outside the domain of most payment schedules?

(2) How does this type of system fit into the workflow of what is already a hectic schedule for most practicing physicians? Is it primarily the responsibility of the nursing staff to do the day to day monitoring and reporting and bring the physician in when readings exceed certain pre-defined limits, or is it left to the physician to oversee all aspects?

(3) In addition to chronic care cases, what about episodic care?  Such a telehealth system may dramatically drop re-admissions after a given procedure if a patient is monitored post-discharge.  Yes, we all know how important it is to address chronic care and compliance as these are huge cost drivers to healthcare today, but re-admissions is also a significant cost and should not be overlooked.

As usual, John Moore of Chilmark Research is asking all the right questions about a timely topic. Hopefully, the Cleveland Clinic experience will pave the way for other similar initiatives involving patients with chronic diseases who are coached about how to monitor their conditions at home. They then upload the data for review by a healthcare professional at a remote site. This allows earlier intervention and avoidance of both expensive inpatient admissions and added mortality and morbidity. Below I comment on some of the questions raised by John.

• Should health systems or clinics be compensated for the monitoring of patient-generated physiologic data from home settings? Of course. This process differs little from, say, taking a blood pressure reading in a physician's office.
• Is payment reform necessary to allow such payment? For me, the economic value of such a home monitoring program is self-evident. However, I also understand that as soon as payment is permitted for the review of home-generated physiologic data, some unscrupulous providers will immediately try to "game" the system for personal gain. Rules governing such programs obviously need to be put into place.
• What type of professionals need to be involved in such monitoring programs? The answer is undoubtedly specially trained nurses or physician assistants with some physician oversight if a serious problem is encountered. Some of the monitoring obviously can be accomplished using computer rules with alerts integrated into the system for broader coverage.
• It has been already determined that the readmission rate for older patients after various surgical procedures or treatment of medical conditions is high, resulting in substantial additional costs. The rate is about one in five within a month of discharge for Medicare patients (see: 1 in 5 Medicare patients readmitted within month). I suspect that the program for monitoring hypertension was relatively easy to develop and deploy but that other programs will follow in short order.

Who Really Benefits from the Interconnectivity of Medical Records?

In response to my note of last Friday (see: Do Hospitals Really Want Interoperable E-Health Records?), Ole Eichhorn of Aperio and The Daily Scan submitted this comment:

Bruce, this is a great point, I've wondered about this myself. Although "everyone" touts interoperability as a key goal, it seems interoperability between vendors delivers value, but interoperability between competing hospitals is not needed or even desired.

Continuing in this same vein, there is a very insightful interview with Dr. Peter Bach posted on the American Public Media web site in which he comments about interconnectivity and electronic medical systems (see: Network is key to digital health records). Dr. Bach is an Associate Attending Physician at Memorial Sloan-Kettering Cancer Center with a special interest in healthcare policy. Below is an excerpt from the transcript with boldface emphasis mine:

You might think interconnectivity isn't that important, but imagine this: In aggregate, the patients of one primary-care doctor in the U.S. see 228 other doctors in 117 other medical practices each year. There's no way that a single doctor can keep track of all these other doctors' actions with faxes, photocopies and phone calls. So, errors are made, expensive tests get re-ordered, and costs just go up and up. Getting doctors interconnected could fix the problem, but there are some roadblocks ahead. No one agrees on the proper data format. Four years of lollygagging public-private "standards committees" haven't fixed that. The layers of privacy and security to protect records have not been totally defined. Most important, doctors and hospitals don't want it to happen. After all, they've spent a lot of money getting you as a patient, buying ads in the newspaper and creating their brand. You are a revenue-generating asset, made stickier because your records are in their possession. They don't want you to go to another doctor who might be better or cheaper. Hanging on to your records means hanging on to you.

Dr. Bach is right, of course. The next logical step after the deployment of EMRs in hospitals, physician offices, and large multispecialty clinics is to link them together in a network to exchange clinical data. As he correctly points out, such a step will reduce errors and avoid unnecessary duplications of tests and procedures. By and large, the patients themselves are now frequently obligated to relay clinical information from one physician to another but they are often not up to the task for obvious reasons. The creation of such a broad clinical network, of course, will not happen for a very long time. None of the various participants in the provider system, both large and small, really want it to succeed, most don't have sufficient capital to build it, most don't have sufficient IT personnel to install and maintain it, and the current healthcare IT standards are not robust enough to support broad clinical data exchange.

Don't expect much help from the federal government which has no deep and intrinsic understanding of the problem or the solution. It can only turn to experts, many of whom have strong connections to the HIT industry and to the very hospitals which have painted themselves into this corner. As noted above, hospital execs do not have a strong incentive to create networks to share clinical data. When pressured to share such data, they merely respond that they have neither the money nor expertise to deploy such systems -- and they will be right.

By way of contrast, such hospital execs, along with healthcare payors, do have a strong incentive to exchange financial data via networks. They somehow long ago identified both the capital and talent to build them. Keep in mind that the key function of hospitals is to drop patient bills with the creation of clinical data as a bothersome byproduct. JohnSharp reports on Twitter from a HIMSS 2009 payer symposium that 95% of claims are currently managed electronically but only 1-3% of hospitals make full use of an EMR. I rest my case.