IT for Healthcare

RHIO - What does the future hold?

Speaking of their initiative to provide Puget Sound-region physicians health information sharing capabilities, South Sound Health Communication Network's Rick McCormack says, "[W]e don't refer to it as a RHIO because we don't know if the term RHIO will even be around in two years.  It's an emerging form."  We've commented (here) on the evolution of RHIO - both here in Northeast Ohio and across the nation.  Perhaps Mr. McCormack is correct, though, to be skeptical of the term.  What we've proposed is even less RHIO-like than SSHCN's project: "a Web site with portals for physicians and patients within secure communications software" with a $40 per month price tag.  Rather, as we've said before, IPA and PHO that build communities of users around a single platform, i.e. one EHR application hosted by them or a third-party, are creating a de facto RHIO (again that word!) that will grow organically to share information between physicians, clinics, hospitals, and pharmacies.

This makes good business sense and good healthcare sense.  Physician organizations can live up to their mandate by leveraging their members' buying power to get the lowest possible prices for their practices.  Physicians can ensure that they - through their chosen affiliations - make the important decisions that impact their practice, rather than have those decisions dictated by the hospitals to which they refer.  After all, they are independent physicians for a reason.  Finally, patients and physicians alike will benefit from the increased intercommunication within the organization and, ultimately, within the region.

When networks like the SSHCN grow and reach out to other grass-roots organizations, they can interconnect faster, more efficiently, and more economically than individual practices.  By being a part of a hosted (or, if you like, ASP) application community, they also create a viable business model for data sharing.  As mentioned before, NEO RHIO here in Northeast Ohio lies dead in the water because there is no such model.  None of the major health networks has an interest in creating an interoperable data exchange that will also benefit the other networks; no third-party hosts can figure out how to make it economically viable.  In the hosted application model, there is an incentive for the third-party host to build inter-communication into the system through software interfaces: the greater inter-communication their model provides, the broader its appeal and the larger their customer base.

As we've said, it is an evolving process.  There are always new considerations, new ideas.  Undoubtedly this one will change over time.  Right now, though, we believe it is the best way for independent physicians to come together to implement the tools HIT has to offer.  As always, comments, criticisms, observations are all welcome.

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HealthCapable: Your Healtcare ATM Card Provider

Looks like the idea put forward by Dr. Darrell Pruitt in a comment here is gaining more traction nationally.  HealthCapable, a self-described "network of patients and providers using a common tool to share information" - let's call it a RHIO - has been Beta testing the HealthCard, an ATM-style swipe card/PIN combo that keys users into web-based PHR.

Physicians Looking for Info on Dossia Initiative

It looks like some of our earlier critiques of the recently announced plan to implement a nation-wide PHR for employees of five major corporations is starting to catch on.  Carmela Coyle, of the American Hospital Association, points out that the founders have yet to discuss logistics like how the system will be used by providers - a pretty glaring omission, we think.  Coyle questions whether providers will access the information via the web or if patients will "literally carry the information around themselves."  That's likely to work well.  We've spoken with physicians who can't get patients to bring the pre-mailed medical history sheets along with them; what's the probability they'll remember to bring their flash drive with them?

Another point being addressed by is the accuracy of patient controlled information.  According to internist and vice president for the American College of Physicians, Michael Barr, physicians "will always have a question of whether that information is complete information" because patients are allowed to change/exclude certain information:

[J.D.] Kleinke [Chair and CEO of Omnimedix Institute] said patients can request that changes be made on incorrect information, but they cannot change or tamper with what is in the health record. However, patients can choose to exclude certain medical details, such as a prescription or drunken-driving incident, from their PHR, according to [Intel spokesperson Jennifer] Gresson.

That will likely concern physicians already worried about malpractice suits.  The prospect of being sued for a drug interaction they didn't know about isn't going to help make this a popular program amongst doctors.  Interestingly, in view of Dr. Barr's comments, the ACP has officially endorsed Dossia, as has the American Academy of Family Physicians.

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Some CCHIT Rebuttal

Back on December 4, we posted a bit on the inexpensive and small EHR that are opting for CCHIT certification.  Recently, we received a request to post a comment that was being held for moderation.  Long and the short, the comment never got through so I asked the commentor, Dr. Alberto Borges, to send it along directly to me so that I could ensure it posted.  Rather than tuck it back in the comments section, where few are likely to see it we decided to give Dr. Borges his own post.  Here's what he had to say in response to our original post.

YOU STATED>>> "among the list of eleven newly certified EHR "[m]ost. . . are inexpensive products from small vendors. Health IT experts say that this undercuts claims by CCHIT critics that certification is a plot by big vendors to drive small ones out of the market."

 

The fact is that none these EMRs are anything from "inexpensive" or "low-cost", terms usually applied to those EMRs that have up-front costs less than $5000.00 (or less) in the first 2 years. These vendors are also not "small" by any means, unless of course you're comparing them to GE.

 

The process of finding out an actual price of an EMR is like asking the mafia to price out one of their illicit products. Some even claim that their price quotes are even "copyright"! If you call them they offer sale price incentives that can lower a "regular" price, but then they can add additional optional packages that can significantly increase the base price. It is like throwing a dart onto a moving target! On top of these difficulties, they also will have their nag salesmen call back several times, and one once even called me on my emergency cell phone. The EMRs that post the true cost of ownership up front are usually the true "inexpensive" EMRs.

 

Here are some facts that I have been able to obtain from these so-called "small" and "inexpensive" group of newly CCHIT certified products:

1. (from http://www.emrupdate.com/forums/post/3656.aspx) "The quote from Acermed for the above is 58K for all training and conversion of my data now (Medisoft) into there software PMS." - Redneckdoc at emrupdate.com
2. (from http://www.emrupdate.com/forums/thread/58695.aspx) "Medinotes=ChartingPlus and the price comparison table puts it at $7610."
3. (from http://www.emrupdate.com/forums/post/35376.aspx) "Hal's EMR costs for Medinotes+PMS, one physician "Primary Bundle" plus "installation" and "training bundle" and "NDCMedisoft bundle"... ~$18600" [in 2005]
4. AcerMed is 127% of the cost of e-MDs (which puts it at slightly over $19000.00 for a 2 doc, 2 year use) (http://www.emrupdate.com/forums/thread/35301.aspx , and calculation using price matrix)
5. Bond Technologies, 2 docs, 2 years comes out to about $27600 (http://www.emrupdate.com/forums/thread/26506.aspx)
6. Medplexus- one poster at http://emrupdate.com stated that in 2005: "they wanted to charge for each computer I had it on. If I recall, the software was in the 20k range [for one physician, one license]."
7. CPSI- could not get a per-office or per-license cost, but found this out about this vendor: "Cash collections of $20.1 million for the quarter (1st quarter, 2004) on sales of $18.2 million... Total revenues for the first quarter ended March 31, 2004, decreased 9.3% to $18.2 million compared with total revenues of $20.1 million for the prior year." (http://www.cpsinet.com/news/article.php?newskey=125) Of interest, Yahoo has its 5 year stock performance as FLAT, in the $32/$33 range. (http://finance.yahoo.com/q/bc?s=CPSI&t=1d)
8. Abelsoft* is priced up-front at just under $10000.00 for a one physician base license (private communication from vendor).
9. NetSmart*- From their own website: "Netsmart provides comprehensive financial, clinical and management solutions for more than 1,300 organizations, including more than 30 state systems, to help them improve the quality of life for millions of consumers. On 11/22/2006, Iowa Department of Human Services Selected Netsmart Technologies for a $2.5 Million Statewide Software Implementation."

I hope that this clarifies the untrue hype that is being posted by HIMSS/CCHIT. There is no way that a true low cost EMR vendor can afford to pay the costs of this certification process.

 

Sincerely,

 

Dr. Borges

Alberto A. Borges, MD

I've asked Dr. Borges to also elaborate on what products are out there that he does consider a value.  We're very interested to learn more about the expectations of doctors who are unhappy with the status quo.  We don't necessarily disagree with Dr. Borges and his compatriots that there is something wrong with the current state of the industry but we do very much embrace the old saw "you get what you pay for."  If you're paying nothing, in our opinion, that's what you're likely to get.

One last note on the subject of "small vendors can't afford the costs of CCHIT."  Assuming the (wildly speculative) cost estimates of $200,000 over two years (including R&D, programming costs, and CCHIT fees) are accurate and assuming a vendor had a base of 1000 users, the cost to defray over that user community would be $100 per user per year.  We're still waiting for someone to explain exactly why that's too much.  We understand that reimbursements have taken a hit in recent years but considering the value afforded doctors (over the long term, it is true), one would think that $100 a year would be an acceptable expenditure.  Let's hope this debate continues - it's fun and educational!!

Markle Foundation Study: Americans Want EHR

Rick Brady at Healthcare IT posts some of the results of a new survey from the Markle Foundation - a self-described "private philanthropy that focuses on using information and communications technologies to address critical public needs, particularly in the areas of health care and national security."  The gist of the survey: two in three Americans want access to their medical records via an "electronic network."  A high percentage of peopled polled are still very concerned about privacy issues, however, so that continues to be a barrier to widespread adoption.  Check out Healthcare IT for Mr. Brady's analysis; click here to see the press release detailing the survey results.

More Dossia Information Comes to Light

Modern Healthcare Online published an article today that sheds more light on the widely heralded Dossia project initiated jointly by Intel, Wal-Mart, Applied Materials, BP, and Pitney-Bowes.  When it was announced last week, the project was met with a mix of applause and skepticism.  Much of the logistics are still unclear.  The main question - posed here and elsewhere - is how the physicians are expected to interact with the system.  What if your doctor hasn't gone digital?  How does Dossia get the appropriate information into your file?  Whatever else it may be, it clearly is not a comprehensive EHR and is no substitute for one.  Is it expected to drive adoption among doctors providing care to these employees?  Does the combined healthcare buying power of these five - and soon to be more, reportedly - companies give them the leverage to demand that doctors adopt compatible EHR systems or lose their employees' business?

We have more questions than they have answers, at this point; or maybe they have the answers and just aren't saying.  Whatever the case, we'll continue to reserve judgement and keep one eye on this story as it unfolds.  It could be a great boon to the cause of electronic healthcare. . . or another evolutionary cul-de-sac.

Medicare Rate Cut Eliminated

According to Modern Healthcare Alert:

House and Senate negotiators reached a compromise bill that would eliminate a scheduled 5% Medicare rate cut for physicians in 2007 and establish a 1.5% incentive increase for doctors who report on quality measures. A House vote on the bill is expected later today, while the Senate may vote late tonight or tomorrow.

Check out Modern Healthcare for more information

Big Business to Try Hand at EHR

We've been waiting a few days in an attempt to better understand this, but nothing here really makes sense to us.  The short version: Applied Materials, BP, Wal-Mart, Intel, and Pitney-Bowes will join forces to sponsor/subsidize/provide an electronic health record to its employees.  They are doing this because they want to cut healthcare costs in an effort to allow them all to continue providing health benefits to workers.  They won't have any corporate access to records - Omnimedix Institute will gather the information and control the databases.

Some research on the Omnimedix Institute shows that the product/service that will be employed in this endeavor is Dossia, an information aggregator that will server to pull in electronic information to a centralized location.  There is no real EHR - this is, rather, a PHR.  That's not particularly groundbreaking as there are others out there (myPHR, Medem, CapMed) however efficacious they may or may not be.  So while it may make managing your various electronic records easier to manage and it might be a boon to the patient because it's portable - it is NOT an EHR.  It will not provide physicians an interface to enter encounter notes or e-prescribe; it will not reduce (rather will likely increase, in the short run) paper. 

If the providers don't have an EHR application and Omnimedix' Dossia can't pull that e-information,
then how is this going to save time, money, paper, or confusion??  If the doctor continues to chart like they always have and Dossia "gather[s] the information from insurers, pharmacies, doctors and other health care providers," that seems like an extra layer of work and costs added to the process.  How is this supposed to save money, exactly?  How is this supposed to spur adoption?

According to Rick Brady at Healthcare IT it isn't going to help widespread adoption but rather hinder it:

Why this matters: An example of what “market forces” can do in healthcare: create data silos relying on proprietary standards that benefit a minority and increase the difficulty of standards based interoperability in the future. The job to make all of these electronic records talk to each other becomes exponentially more difficult if we don’t agree on the standards to use before we start implementing.

That's certainly an issue we see.  It's more disturbing, however, in that it gives a false sense of progress.  This "bold" initiative is nothing more nor less than one more PHR tool; it's just one being employed (in theory) by a massive user base.  There is already a skepticism among the American people about the value of EHR; feeding that uncertainty through half-measures that pretend to get the job done will not help the situation.

Bottom line: The money spent on this program (some sources say the amount is and will remain undisclosed, other report up to $15 million) would have been better spent subsidizing the adoption of real, functional EHR applications by physicians.  Then American healthcare consumers could see the benefits of actual IT solutions not just the pseudo-benefits of privately gathered patient data.

But, as always, if were missing something here, let us know.  Especially if you think this is a good idea - we'd like to know why.

Top Seven Health Industry Trends for 2007

PriceWaterhouseCoopers recently released this report on the the outlook for Healthcare in 2007.  Among its interesting facts:

• 90 percent of Americans believe greed is a major reason for rising healthcare costs.
• 24 percent of Americans do not believe that having EHR will improve quality of care.
• 17 percent believe sharing the cost of healthcare (i.e., HSA and HDHP) is a very important way of reducing healthcare costs.

According to item number three, it's "Time to walk the talk on technology."  What's more disturbing than the 24 percent of non-believers cited above is the fact that only 34 percent do buy into the idea of EHR improving care - that leaves 42 percent undecided and a total of 66 percent that remain unconvinced.  As the authors point out, these survey results "[signal] the need for massive public education efforts."

There are six other items touched on in the report.  None of them are directly related to HIT but it's still worth a look.  The authors' conclusion: The current state [of healthcare] isn't sustainable and major change is required.  Did they really need to commission a report to come up with that?!?!  Well, at least the meat of the thing has some decent information, even if the analysis isn't exactly paradigm-shifting stuff.

PracticeFusion Unveils Free EHR

Here's a piece of news that may (or may not) strike physicians as the answer to their EHR adoption woes.  San Francisco-based PracticeFusion has announced a hosted solution that CEO Ryan Howard touts as "community-based" - oh yeah, and it's free!  During a recent conversation with Mr. Howard, he talked at length about the slick, intuitive user interface, the intensive client services, and the high-level of interoperability doctors will enjoy with the PracticeFusion model.  After a half-hour conversation - during which I was impressed with both the CEO and the company - I asked, "What do you see as the one stumbling block that concerns you about the viability of your business model?"  There's always one.  Otherwise, there would be no risk, right?  To that, Mr. Howard spoke vaguely and didn't address the question in any concrete way - he had explained during our talk that there were certain things he couldn't discuss at that point and though it wasn't clear at the time, I now see why he didn't answer my question in a more straightforward fashion - because the biggest hurdle to PracticeFusion's success is the one thing he couldn't talk about.

You see, the catch is that the project will be subsidized by the "[sale] of de-identified data to insurance groups, clinical researchers, and pharmaceutical companies."  So the obvious question is, will the healthcare community buy into the model?  Do you, as a physician, have the confidence to explain to your patients that the de-identified data your EHR vendor is selling can never be traced to them or used against them in any way?  Do you, as a patient, feel comfortable with that?  Mr. Howard's answer, "Every healthcare vendor is selling data.  Everyone has this data, but we'll have more of it and it will be real-time and aggregated.  We will be able to help drive the patient community toward better care by providing data on the causes and trends of certain conditions over time."  And the reality is, this is one of the biggest reasons these players (Pharma, Insurance, Gov't.) have been pushing for universal EHR - they want access to comprehensive, inexpensive (compared to gathering it for themselves) medical data for research and development.  De-identifying and using patient data is already a major push in the industry, it was going to happen eventually, PracticeFusion just seems to be the first to figure it out.

We'd love to hear more from everyone out there on this, though.  Would you be comfortable if your doctor was on PracticeFusion?  If you're a doctor, would you feel confident letting your patients know what you're doing?  Let us know.

UPDATE: Rick Brady at Healthcare IT weighs in with this opinion on PracticeFusion's announcement:

Why this matters: You can not truly anonymize healthcare data. The implication is that the health data gathered could (and probably would) be correlated with the other data you have at places like ChoicePoint, resulting in even less individual privacy.