Recent Developments

Quote of the Day:
We are always getting ready to live, but never living.
--Ralph Waldo Emerson

 

Health Train Express has recently become acquainted with a Canadian solution to RHIOs search for the "ultimate" application for their interconnectivity needs.  It bypasses the problems of "governance issues" and the thorny issues of "who owns what".

Many of these issues ignore the primacy of information transfer, efficiency, accuracy, and quality of healthcare delivery in this country.  In addition to that concern, it is not necessary to re-invent a "wheel" that already exists.

What we need has been well established by many consortiums, RHIOs and health information exchanges.  Do we all need all of it? The answer is profoundly "NO".

What about those providers who do not have broadband internet connectivity?

There are many pieces in the mix for a RHIO or Health Information Exchange.  Some of these are already provided by proprietary systems, such as clinical laboratories, hospital portals, secure messaging systems, Hospital PAC systems,etc.

The California Regional Health Information Organization provides a well structured outline and roadmap for developing governance; and also a library,   HIE toolkit  of documents for RFIs, RFPs, and other essentials for vendors, hospitals, providers and IT departments.

SELF CERTIFICATION ???

Groups To Launch No-Cost EHR Interoperability Testing Software

A no-cost, open-source software tool for testing the interoperability of electronic health record systems will be available to vendors March 21, 2008, Government Health IT reports.
The tool, which is being jointly developed by the Certification Commission for Healthcare IT and Mitre, will allow vendors to ensure that their EHR systems can exchange information on patients treated by more than one provider.
The tool, called LAIKA, also will initially support testing of the Health Level 7/ASTM Continuity of Care Document, a core set of patient information including:

• Name;
• Address;
• Health problems; and
• Medications (Ferris, Government Health IT, 11/9).

Mark Leavitt, chair of CCHIT, said, "This project is an important first step in our journey toward testing and certifying the interoperability of health IT systems" (Merrill, Healthcare IT News, 11/9).
CCHIT and Mitre have undertaken this open-source project without government support, Government Health IT reports.
Developers will demonstrate the tool at the Feb. 12, 2008, CCHIT meeting (Government Health IT, 11/9).

Next Article

Readers are invited to send feedback to: ihb@chcf.org

RPM or Remote Patient Monitoring

Microsoft has launched it's Health Vault application.

With this announcement comes a large list of positive and negative reactions in the marketplace.  The most positive aspects are the "commodization" and accessibility of these devices to consumers at affordable prices.

 

RPM data can and should enter the consumer electronics mainstream.  In addition, RPM data should be viewed as just one more type of medical data, similar to lab data, pharmacy data, physician notes, etc., that is equally plug and play.

But...There are Tradeoffs

Depending on whether you are a user or a seller of RPM, you probably reacted differently when reading Bill Crounse's casual reference to devices and services becoming "commoditized".  Regardless of your reaction, he's right.  HV will hasten the already occurring commoditization of RPM devices.

When the RPM market started, many of the devices were priced in the $6-8 K range.  Today prices have dropped to $1-2 K, and will go lower. 

We have all heard stories where RPM devices eventually would become consumer purchases made at Best Buy and Circuit City, and that prices would be in the range of other consumer technology purchases.  That day will arrive in 2008 when Continua Alliance compliant offerings begin hitting the street.

The RPM market is moving from

• High unit prices rooted in the industry's early focus on medical device markets and business models
• Proprietary devices, proprietary IT,  non-interoperable data
• Low unit volume, moderate margins per unit
• Competition based on the vendor lock-in through high changing costs

To:

• Low unit prices as the technology evolves toward consumer markets and consumer business models
• Intereroperable devices, common IT platforms, and interoperable data
• High unit volume, low margins per unit
• Competition based on value and service

Where exactly commoditization and HV come together is not clear. The efforts of Continua will bring to market multi vendor interoperability, true plug and play connectivity. Microsoft can deliver plug and play interoperability with your personal computer, but little else.

 

What do you think?

Economic Advantage????

This news from iHealthbeat:

Do we have a choice about EHR?

 

October 17, 2007

Boston Health Network Requires All Physicians To Adopt EHRs by 2009

Partners HealthCare System in Boston is requiring all of the physicians in its network to adopt or agree to adopt electronic health records by Jan. 1, 2008, or else they will be removed from the network, Tom Lee, CEO of Partners Community HealthCare, said, Modern Healthcare reports.
Partners expects to lose between 15 and 20 primary care physicians this year because of the mandate, and it could lose some patients if those physicians stop referring patients to Partners hospitals, Lee said.
To retain their network status, about 5,000 physicians in the network will be required to adopt either Partners' or GE Healthcare's EHR or sign an agreement that they will adopt EHRs during 2008. However, by Jan. 1, 2009, any physician without a connection to the network EHR system will be removed from the network.
Mario Motta, a cardiologist in the network, said the mandate is a "two-edged sword" because the benefit of EHRs is higher reimbursement rates from insurers, although Partners is not providing any funds to help physicians adopt the systems.
Lee added that funds are available to improve Partners' EHR system and to train physicians on it (DerGurahian, Modern Healthcare, 10/15).

Microsoft Health Vault

from iHealthbeat,

"Microsoft has launched its HealthVault program, which offers consumers online personal health records. The company hopes that individuals will let health care providers directly transmit prescriptions, test results and other medical information to their HealthVault accounts. PHRs will be stored in a secure, encrypted database, and patients will be able to set the privacy controls"

Seeing this post I raced to find the "Vault"... First of all, it is complicated to set up, requiring a download of the basic program, and then and number of "connect" interfaces.  It is not designed for patients to enter their medical history, so it is not a true PHR, or personal health record. In addition, the patient must download a number of drivers for "devices".. These devices, so far include

"Healthy Circles", icePHR (In Case of Emergency),  these also interface with a blood pressure transduce, glucometer, spirometer,

There are several other websites one must go to to setup, enter, and read the data. Microsoft has developed a number of  "partners", which I will not mention here, just advise the reader to go to www.healthvault.com  Microsoft also has an interconnect program called "connect IQ", a portal that almost looks like a HIE, or RHIO.

For the patient, especially an elderly patient this will be difficult to setup, and use.  It will require a nurse or technical assistant to set it up and make it operational.  There will also be considerable expenses for the remote monitors.  The site also states that providers will be able to transfer medical records to the PHR as well. If all of this can be managed it does develop some slick looking tables and graphs of blood pressures, glucose levels,pulmonary function tests, and probably eventually a probe that will report CBCs and blood chemistries.....all from home.

The big question is will payors reimburse for all of this...Will this become part of P4P ?

This is not a patient oriented design.  Even for me it was a long pathway to download and figure it all out.  Setting up the actual vault took some time to complete, and then it was still an empty shell.  But then again I am only a doctor......more later....

The "Monkey on your Back"

I think one of the issues most providers are grappling with in regard to HIT and EMRs in their office is not only the initial investment of capital, but the ongoing "relationship" between the practice and the vendor(s).  Will you have a "tiger by the tail?"

The daily operation of the practice will be entirely dependent upon your PMS and/or EMR system. Witness the recent "crash" of the entire West Coast VA CPRS system. A recent iHealthbeat article quoted that it was the worst incident effecting quality and safety of care in the VA system.

The vendors have their "business model" for profitability, and they are not about to let providers interfere with that fact.

Keep in mind we are in the early phase of EMR and  HIT "buildout"

There will initially be a "bubble" as providers invest in EHRs, RHIOS, etc  Eventually the acquisition rate will flatten out. With diminishing returns will the vendors jack up maintenance contracts and costs for updates.

About 18 months ago Allscripts began offering a  "free eRx system which operates as a portal application. It is necessary to enter patient information in the system the first time it is used for a new patient.  Allscripts now offers "a bridge" to connect it to your PMS. They don't say much about interfaces for  EMRs.  Most of the interfaces cost about 300 dollars initially and 240 dollars each year afterward.  One interface was quoted at 695 dollars. There  are  many with "custom" as the interface quote.  Now I can see an upfront charge for an interface, but an annual charge is something else, unless there are some other changes in software after the initial installation. (sounds like Microsoft)...Windows "Live". I wonder what the rest of you thinks about this?

Whose Network is it, Anyway??

The San Francisco Chronicle featured an article highlighting Health 2.0 and the wave of consumer (patient) oriented web sites.

DailyStrength.org people can choose among 500 support groups - from celiac disease to pulmonary fibrosis - create an online journal to chronicle their disease and send electronic hugs to other members.

ZocDoc.com lets patients book physician and dentist appointments online, similar to the way OpenTable.com allows diners to make online reservations for restaurants

RateMDs.com takes a page from consumer rating sites like Yelp and RateMyTeachers.com - a popular site that allows students to "grade" teachers and administrators - by allowing patients to anonymously praise or pan their doctors.

Dubbed the YouTube of health care, ICYou.com allows patients to share their stories through online video clips.

Other Web sites, such as PatientsLikeMe, offer people battling devastating diseases the ability to discuss and track in great detail the treatment options other patients in their disease group are trying.

OrganizedWisdom.com: Aligns doctor-reviewed and user-generated health content to help people make decisions.

ReliefInSite.comRelief in Site. com: Helps patients record and track their pain and medications and share it with their doctors, nurses, pain specialists, therapists, friends and family members

And I like this one the best:

NursesRateDoctors.com: Recruits nurses to give their candid assessment of doctors........for the surgeons who throw instruments.....

It seems Health Information Networks are developing in ways which we could not imagine.

 

Today  I came across a focused PHR solution for Lasik surgeons. Safeguard your Sight

Many times patients undergo refractive surgery on their eyes, and require enhancements or cataract surgery at a later date. Often times it is with a different ophthalmologist and the prior records are unavailable.  Ophthalmologists are able to upload their "data" before surgery, and after surgery. The data resides on a server. Patients can access this information for a fee and give the results to the new surgeon. 

Featured Interview

This week I had an unplanned interview with Heather McGuire of Within3.   It started out for me as a "show and tell" regarding RHIO development and my "new" self sustaining business model, which frankly still is not a proven model.  Heather reciprocated and introduced me to  Within3. The site is based upon social networking of research scientists and clinicians. In order to gain access one must be recommended by a peer.  Members are thoroughly vetted to be listed on their site.  You can see their site by clicking on Within3 above.  The site has a search function as well.  You can search by disease and it will take you to a number of authorities on the subject, not only that but it will search Pubmed and bring up their articles as well under their name. The site also has their curriculum vita and other interesting things about that person.  There is much more to the site, but I will point you in that direction to find out for yourself.  It is still in early beta....but the concept seems exciting.  If successful, this will continue the revolution in search methodology.

Part II - Science of Spread Change

I left off last time.....

Sarah Fraser is a consultant to health care organizations in the U.K. She points out "that innovators are not normal people, and look for and enjoy change, while most people are wary of change. " For this reason innovators are poor messengers for spread change. The majority of the people are those that hold the organizaton together, go to work at 7AM and not to a conference. They care for patients from day-to-day. If innovators cast aspersions on this group, then spread change is dead. Spreading innovation must also reduce costs, and there must be a return on investment for the organization that is making change. The organization (or stakeholder) must see financial gain for adopting the "new thing".

The article (which I highly recommend to IT people, vendors, RHIO developers and the like) goes on to discuss

Pilotitis
Low Hanging Fruit Syndrome
Unworkable Universal Solutions
The fallacy of the "tipping point"
Accepting Roger's categorizations of people, ie early, late, laggards
Spreading improvement requires continuous measurement
Without leaders....there is nothing
Implement good ideas is better than spreading good practices

I highly recommend this monograph which can be found at:
http://www.chcf.org/documents/chronicdisease/TheScienceOfSpread.pdf

The Science of Spread

Quote of the Day:
Resentment is like taking poison and hoping the other person dies.
--St. Augustine

 

Batten down the hatches....this post is going to be rather long, not a sound byte.  Thomas Bodenheimer  M.D.wrote for the California Health Care Foundation a treatise on this subject which bears reexamination at this juncture in the development of Health IT and the proposed NHIN. Dr Bodenheimer is on the faculty at UCSF.

He summarizes the literature on "spread theory" by Everett Rogers (1962), and Malcom Gladwell's "Tipping Point" . Paul Plesk cites Rogers and Gladwell "to argue that once 10-20% of the target population has adopted an innovation the tipping point has been reached."  Plesk than goes on to discuss "stages of change", "precontemplation", contemplation and action, followed by maintenance.

It can be said that EMRs and RHIOs, and NHIN are in all phases of Plesk's analysis of "Spreading Good Ideas for Better Health Care"

He offers several tools that might help improvement champions that analyze the systems and individuals that make up the spread target population....more later

Health 2.0 Conference Results

Three years ago I had no idea how blogging would provide a platform for everyone and anyone interested in health care. The spectrum of participants ranges from physicians, payors, patients, political pundits, and others.
This forum lies outside the framework of "officialdom"; It has become the water cooler and allows much intercourse. Early on there were some disputes and "retaliation" against employees when their opinions reached "management".....However I believe freedom of speech issues prevailed as long as there was no libel or slander involved.

This year's Health 2.0 was planned for 200 participants, and over 400 registered. The introduction piece was very impressive. I am providing the link here. Health 2.0 Intro-http://www.icyou.com/events/health-2-0-conference?folder=All

The video by scribemedia was truly impressive: http://www.scribemedia.org/2007/09/20/health-20-conference/


While most reporters waxed on enthusiastically, the San Jose Mercury News threw some cold water on Health 2.0, most of which was unwarranted. They criticized health 2.0 and the blogs as not being well grounded in 'business models'. While some blogs do generate revenue, most proponents of health 2.0 blogs or health blogs in general did not nor want to have a rigid business model....I am also sure some will develop entrepeneurial motives or at least there blogs will network them into "greener" pastures.

I also think that unrecognized is the fact that Web 2.0 applicatons are rapidly being deployed for EMRs, Practice management systems, and other applications for healthcare. These applications do away with the heavy cost of capitalizing for hardware, ie servers, etc. A monthly subscription fee covers maintenance, upgrades, and technical support.

Without a doubt the environment of health blogging is one of free speech, enthusiasm, and just plain "glory" at seeing one's words printed on the world wide web. It is a great "equalizer."

Alternate Road to Health Information Exchange

Saturday, September 22, 2007

Roadmap (Alternate) to Health Information Exchanges
RHIO and HIE development is a highly complex undertaking and not for the weak of heart. As I was driving into Los Angeles the other morning I encountered one of the routine "sigalerts". For those of you who have never been in California and live in a rural area I will explain this is a system of alerts from the Callifornia Transit Authority whereby notifications are sent out by television, radio and internet about blocks in traffic due to "events" such as accidents, toxic waste, police activities, construction activites, etc. Recently my oldest son, who has rapidly passed me by in the world of high tech (he has smaller thumbs than I do) and I were in the car together and as we bogged down and did not move for several minutes, the GPS asked if we wanted to plot an alternate route, and suggested about five different ways around the thrombosed artery.
I believe that the current roadmap is flawed as designed and hoped for by several agencies with good intent. Our Health Train Express is now in a "sigalert status" The problems with "roadmap" is that requires funding from unknown or difficult and confounding sources such as grant making organizations ranging from county to state and federal and combinations thereof. Often times these grants are tied to the momentary "political expediency" of the moment, ie, Katrina, Homeland Security, Bioterrorism, and even "Global Warming"
Often and most of the time it is totally dependent on the whim of the moment of legislatures both federal and state, impacted by competing budgetary priorities of peace and war. education, immigration issues, and more.
The "road not taken" as Robert Frost so aptly stated requires a minimalist approach with obtainable goals that step through the process. Rather than swallowing the whole cow, we must take small bites, chew an digest each piece individually. This rather graphic and seemingly unrelated metaphor sums up a new roadmap.
It is difficult for providers and hospitals to grasp the RHIO concept because it is rather like dropping an Atom Bomb. It overwhelms most executives who are fully engrossed in just running their institutions on a day to day basis.
Developing one functionality that would maximize a return on investment in one area as a demonstration without disruptive technology gives an HIE a "foot in the door" When a user (provider or hospital) subscribes to this service for a relatively small sum the revenues derived and create cash flow for the HIE as a revenue cycle. The single functionality must demonstrate it's own cost effectiveness and ROI in less than one month. It must be demonstrated as successful in a regional pilot program. It must be self funding, elective and non binding without contractual obligation, and also offered as a 30 day free trial........more later

The view from Here

Just a reminder to take a look at my "parallel blog" at http://anyviewfromhere.blogspot.com