Roadmap (Alternate) to RHIO and HIE

 

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 on this later........

Surfing on the Labor Day Weekend

The long labor day weekend is upon us all. I plan to spend mine with my feet up, and with a cold drink sightseeing on the hot sands of the Southern California beach.  I even invested in a cell card, so I can now find the internet whether I am floating on my raft, in a dark hole, in a green swamp, or whatever. I realize I am surrounded by   the "can you hear me now" guy and the helicopter flying overhead (Verizon).

As far as health information exchange goes, this weekend, my network is down....

The Caboose

I suppose the health train express should not have a caboose because that implies the end of the train. However I missed an important addendum from Mike Leavitt's blog which he writes as he travels through Africa, attempting to analyze Africa's challenges, clinical overload, a far cry from the paperwork overload providers face in our country. Mike makes some comments about HIE and RHIOs, the subject of which motivate my original blog. The post which follows here is an important link for you to understand what has been done and what will take place over the next five years. Don't miss the TRAIN !!!

http://www.hhs.gov/healthit/community/background/

from Mike Leavitt's blog:

"Today we had an important meeting at HHS related to electronic medical record standards. The development of standards for interoperable health information systems is one of my most significant goals. I believe the standards required to make this electronic medical records system work have to be collaboratively developed among various stakeholders. About two years ago we created the American Health Information Community for that purpose. Rather than try to write much about it I will ask one of my colleagues to insert a link here to the AHIC website: http://www.hhs.gov/healthit/community/background/
People have been talking about interoperable systems for years but the standards to make them work haven’t materialized. So, those who invest in electronic health records are isolated. Many others put investment off, waiting until the systems mature.
This is an extraordinarily complex problem but the biggest challenges aren’t technological; they’re sociological, i.e. conflicting economic interests and turf. AHIC has successfully created a place and process to sort through them in an orderly way. We are starting to make serious progress which you can read about on the website.
Our plan from the beginning has been to get the standards development process started inside the government and then once it is functioning create a non-profit entity that operates under a highly democratic governance system so the progress can be accelerated and perpetuated. I call the transition moving from AHIC 1.0 to AHIC 2.0.
The government will have to be the biggest participant in the process, but to get these things right, the entire health sector has to be at the table in a meaningful way. The federal government will not only be the biggest participant but we have also committed to use the standards developed there. The President signed an Executive Order last August making clear that all the federal agencies, including Medicare, Medicaid, the Veterans Administration, and Department of Defense etc. will adopt the standards. We need to insist those we pay do the same thing, over time.
Today we held a meeting with interested people and organizations to invite their help in creating the non-profit entity and its governance.
The last several years I have become rather interested in collaboration as a large scale problem solving tool. I’m persuaded skillful organization of collaborations is a 21st century skill set. It is a close cousin to network theory. In fact, I think collaboration is the sociology of network building.
Our world is intuitively organizing itself into networks. Networks require standards to operate. The skills to navigate the creation and governance of networks constitute the next frontier of human productivity. Organizations and societies that learn to solve complex problems using these skills will begin to out pace their competitors.
The development of AHIC 2.0 is a significant venture. I’m optimistic it can produce a vitally important institution but it will require our best statesmanship to overcome the natural tension of competing economic interests and turf.
If readers have a chance to look through the AHIC website, I’d be interested to hear your thoughts."

Hot Weather and HotTopics

Stop, don't click away just because you think you have arrived at the wrong site. As I promised there were going to be some fresh changes at Health Train Express. Not only has Elvis left the building, but so too has Health Train Express.

Every summer at this time of August I mention how fast the summer has gone by. Well, just when I think it's over...it's not. The forecast for the next week is 100-107 degrees. As Yogi Berra has said "It ain't over until it's over".



So too is my forecast about P4P, RHIOs, and EMRs. No one can easily predict the outcomes in this arena. However it certainly fuels entrepeneurial minded providers, third party administrators and a variety of industry vendors into a fury of Category 5 storms.



One of my favorite blogs is that of Phillipa Kenneally, The Entrepeneurial MD. She regularly hosts podcast interviews at her site, which can be found at http://trusted.md/ Her guests are often "out of the box" innovators with examples of where many physicians go when they are not seeing patients.



Richard Reece's blog, medinnovation now has a link on my site . This retired pathologist living along the banks of Long Island Sound will give you much food for thought from his experiences and knowledge base of 30 years of clinical pathology experience, much of which has nothing to do with looking through a microscope.



We will be taking a two week break until after Labor Day, when we will return to continue our new "look" to our blog.

Transitions

Fellow bloggers:

When I first began “blogging” about three years ago I intended it to be a newsletter for a RHIO that I was heading up in my area of the country. About a year ago I chose to rename it “Healthtrain Express”. The term recently coined by others came to my mind in 1989 (that definitely dates me) It was in the pre-DRG, pre RVU, pre managed care (ie, the “golden days”) that my residents often wistfully mention..
I often tell them that no “age in medicine” is trouble free. It’s the nature of the “beast”.

Healthtrain express conjures up the rapid changes that constantly occur in medicine. For those of you who have read “Future Shock “ by Alvin Tofler , this has always applied to medicine. I highly recommend this reading.

It also denotes a vehicle with a tremendous amount of inertia, barreling down a “track” . If you are on the track you had better be moving fast enough to stay ahead of the train. If you are stationery, then you must either move aside or be “smashed”.

Returning to more specifics of our “age in medicine” we see the predictions and evolution of pay for performance and reporting, health information technology, the methodology of reimbursement change, including CMS intention to not reimburse for “poor outcomes” or those due to “poor care”. Medicine will continue to be increasingly directed by third parties, consumers, and political and social planners. Most of whom have never treated a patient. This one issue frustrates most physicians, although it has become a fait acompli, I know it continues to “gall” most doctors.

Physician-hospital relations continue to be in a state of flux. Gone forever in most areas is the leadership of the medical staff as it pertains to the board of directors, or trustees of the hospitals. In some rural areas this may remain intact, unless the hospital is part of a larger financial “holding company”. Creative financing has allowed many hospitals to continue operations with “leaseback arrangements” for management, and other issues.

Looming on the horizon is radical change in hospital accreditation organizations.
The JCAH authority is about to be undermined by pending legislation and some hospitals chose to use alternative accreditation sources This may or may not be a good thing, given that operating requirements have radically changed for hospitals.

For those of my readers you may notice on the sidebar the expansion of medically related blogs. Over the next month this list will be expanded. This is going to involve a significant amount of my time selecting and moderating my personal favorites.

I am also extending a personal invitation for co-authors to contribute to “healthtrain express”. Please email me if you wish to do so. email gmlevinmd@gmail.com

GML

Change in Direction

For the past three years I have been beating the drum about the development of HIE and RHIOs. I have not come to any final conclusions about the destiny of this "visionary" prospect. There are a great deal of positives and negatives regarding HIE and EMRs.
I will deal with some of the negatives first.

1. Most providers complain about the complexity and bureaucracy of practicing medicine, in regard to regulatory requirements, the hurdles of reimbursement, and exponential increases in business overhead.
2. The burden of Health IT may outweigh the benefits.
3. HIT is very expensive
4. Automation and the impersonal nature of IT does not really fit in to the paradigm of medical care. Despite patient enthusiasm for all things technical most providers are reluctant to introduce an infrastructure that will make them dependent on third parties.
5. Most physician providers operate on the basis of accountability, reliability, and a one on one relationship with each patient. IT is not going to improve the patient relationship.
6. Medical care has always been a unique portion of our economy, and recently outside forces have forced change, some good, and some very detrimental to patient care.

Positive:
1. The introduction of web 2.0 has greatly expanded patient education, and allows patients to ask more relevant questions.
2. Web 2,0 also introduces transparency and allow for "error checking" on the part of patients
3. Web 2.0 also increases the providers outreach for reliable information instantly at the point of care.
4. Most providers who have installed EMR speak positively about having it, and "would not go back to the old system" (my comments are that they could not even if they wanted to, because of their heavy investment in the system.

That's my meager summary after three years, it is not all inclusive.

Beginning next week Health Train Express will change direction. Look for a change in content first, then a change in the front end. I hope to maintain the title "Health Train Express" however our domain name may change.

Mike Leavitt Sec HHS joins blogger world

HHS Secretary Leavitt Launches Blog To Boost Health Care Discussion
HHS Secretary Mike Leavitt this week launched a blog to foster public discussion and exchange ideas on health care issues, The Hill reports."If I can do it justice, we will continue," Leavitt said, adding, "If not -- we won't." Leavitt, who plans to write all his blog entries himself and read "as many of the comments as time allows," said he will "wade in a little deeper into blogdom" this month.Unlike some blogs, all comments will be screened prior to being posted, The Hill reports.One day after his first blog posting, Leavitt already had received more than a dozen comments, including one that had to be removed because it was inappropriate or offensive, according to a spokesperson (Retter, The Hill, 8/15).

News from Rhode Island

Providence, RI —July 30, 2007—Rhode Island is now one step closer to implementing a health information system that will allow physicians, with their patient’s permission, to access important patient health data from a variety of sources when and where it is needed. The State has chosen Electronic Data Systems Corporation (EDS), and its subcontractor InterSystems Corporation, to build and integrate the necessary technology and software.
National and local efforts have been underway for the last several years to computerize medical records and develop secure methods to share records electronically. Governor Carcieri has prioritized making health information electronic for the majority of Rhode Islanders by 2010. “Anywhere, Anytime Health Care Information” is one of five elements that make up the Governor’s health care agenda.
“We can now begin the important work of building a secure Health Information Exchange, which will result in a more cost-effective health care system by reducing unnecessary tests and potential medical errors,” said Governor Carcieri.
The Rhode Island Department of Health (HEALTH), working closely with community partners, providers, and other key stakeholders, will oversee the development of this interconnected, interoperable system. HEALTH has engaged a wide range of consumer advocacy groups, health care attorneys, and others to ensure the system protects patients’ privacy and addresses the needs of both health care consumers and clinicians.
“With the creation of a statewide Health Information Exchange, doctors will be able to look up their patient’s critical health information, giving them a more complete understanding of their patients and allowing them to provide higher quality, safer, more coordinated care,” said Director of Health, David R.Gifford, MD, MPH.
Following an RFP process, HEALTH selected EDS as the technical vendor to build the system’s technology. EDS will subcontract with InterSystems Corporation for its HealthShare software. Through a three year, federally funded, $1.71 million dollar contract, EDS and InterSystems will build the core components of the system, including giving authorized health care providers access to comprehensive lab results and medication history for their patients. Initially these data will come from Lifespan, East Side Clinical Labs, the Department of Health State Laboratories, and SureScripts (a national company that administers the network connecting physician offices and pharmacies for e-prescribing). During the course of the contract, the system may be enhanced to include additional data sources and types.
EDS is a leading global technology services company, with a local office in Warwick. The company has extensive experience working for the State of Rhode Island, such as serving as Medicaid’s fiscal agent. For more information about EDS, visit www.eds.com
InterSystems Corporation, a software company headquartered in Cambridge, Massachusetts, provides software for connecting healthcare information. For more information about InterSystems Corporation, visit www.Intersystems.com.
Editorial Contact:

One Step Forward Two steps Back

Report: Health IT Bills Will Not Affect U.S. Health Care
Congressional measures to boost health IT adoption would not go far enough to make a significant difference in U.S. health care, according to a Commonwealth Fund report released Thursday, Government Health IT reports.The report, which analyzed major health IT and other health-related bills introduced between 2005 and 2007, found that none of the bills "would commit the funds and central leadership required to realize the potential benefits of a health information system.""There's just not enough funding to get us to a paperless health system in five to 10 years, in my judgment," Commonwealth Fund President Karen Davis said, adding, "If the U.S. is to close the health information technology gap with other leading countries, it will need a strategy and commitment of requisite funds to achieve its promise."Davis said the federal government should subsidize health IT adoption for safety-net providers and the development of regional health information organizations. "The basic problem (with the legislation) is that giving small amounts of money -- compared to the $3 trillion in U.S. health care spending -- and setting standards is not going to be enough to accelerate the adoption of health IT," she said.Davis said the report's findings are applicable to the Wired for Health Quality Act of 2007.The bipartisan Wired for Health Care Quality Act of 2007 has won committee approval and is awaiting action from the full Senate. There is not yet a companion House bill, but Rep. Patrick Kennedy (D-R.I.) is planning to introduce a comprehensive health IT bill after Labor Day, according to his policy aide, Michael Zamore (Ferris, Government Health IT, 7/26).

Despite this bleak appraisal of federal mandates and lack of follow through we see progress in private entrepenurial ventures to fund HIE. Local initiatives and buy in by stakeholders remains the elemental ingredient for success. One has only to look at the success of Healthbridge in Ohio, which has been operational for almost a decade. The key ingredient is focus and dedication by those involved over the long term.

Curing Healthcare: Knowledge, Standards and the Healthcare Crisis: Part 10

Curing Healthcare: Knowledge, Standards and the Healthcare Crisis: Part 10

The Train Coming Down the Track

Is your information technology structure from the ‘90s? 1890??

In the next five years we will see a catalytic innovation take hold, and I don’t just mean electronic medical records, personal health records, or web 2.0 applications.
In the past several months we have seen several states release morbidity and mortality statistics from hospitals performing certain procedures. Most of these were selected based upon their high per capita cost. The figures are prominently announced and displayed on easily found web sites. This of course is quite controversial and is resulting in angst of both hospital administrators and physicians alike. Payers want the most “bang” for their “bucks”, that is to say the best possible outcomes for beneficiaries. (i.e., they are not going to pay for “bad results”.
Providers and hospitals have seen this coming for quite some time, but the impact of seeing this data displayed publicly is immeasurable. For those providers and hospitals on the top tier, this gives them a significant advantage when contract talks begin.
Internal quality assurance, outcome measurements and daily updates will be necessary to stay even with
Change management is one key for successful transition to healthcare 2.0. The significance of the paradigm shift in the early 1990s is not lost on health care institutions or the establishment of the RVU for determining reimbursements for services by providers. The lag in understanding the “strategic” shifts which occurred then caused thousands of practice business failures and also hospital shut downs. Even the sea-change of practice management firms could not stave off bankruptcy and/or operational demise. The drive toward multiple levels of management, i.e., IPA, MSO, and HMO with all it’s subsets of responsibility between patient, provider and hospital serves as a rationing method. The new system will not allow for this paradigm.

Consumer advocacy groups have arisen, and are and will be playing significant roles in “health change”.

Perhaps California was the “poster child” for bad things, the emigration of thousands of providers to other states, the cacophony of IPA closures, health plan demise, and the changing nameplates of groups, hospitals and others in the health industry.
It is a fairly simple analysis. (The have’s and the have not’s) The have not’s will not be providing health care in five years.

Not only will having EMR be critical but also additional systems that will enable chronic disease management by “remote control’ and telemedicine. Leveraging the capability of the medical staff to care for SNF patients, and at home chronic patients will enable providers. Payers must come to terms with reimbursements for these modalities, since the ultimate outcome will be to reduce hospital in patient and readmissions as well as needless office calls. Remote telemedicine is here with devices that can provide audio visual contact using dial up technology. Remote sensing of BP, Pulse, and Glucometers is already available, and many more are in development. Other peripheral include the Prothrombin time Micro coagulation System, telephonic stethoscope, digital scale, and pulse oximeter.

Payers have been reluctant to share in the development costs of these systems. Change management must analyze the short term ROI, rather than long term ROIs. Most businesses want to see results in three months ( a business quarter).Successful transition therefore will require carefully focused change implementation in limited areas and progress as each gains ROI. (Randy Moore, American Telehealthcare)

Reality Check

I recently navigated over to the "TOP 100 HEALTHCARE BLOGS" ranking, and found that my blog was down in the 300s. The top 3 were "Random Acts of Reality" "Medgadget" and "Bad Science"
I also noted that technorati seemed to play a significant role in popularity of the "winners"

In the past I have written a great deal about health information exchange and RHIOs. From what I learned in the past three years I have altered my course and given up on the idea of "warp speed" and will depend upon "Impulse engines".

There certainly appears to be no impuslivity as it pertains to EMRs nor HIEs.

I sent out letters this past week regarding the "NEW PLAN" to bring EMR and HIE to our region of Southern California. Today is a clear day and I can look out over most of it and see all the way from Mt Wilson to Mt San Gorgonio and San Jacinto. As an aviator I can say
"CAVU". A properly paced mirror or antenna on anyone of these peaks would serve as a "beacon" for the hub of a health information exchange. If TV and Radio stations can do that then why not health information? Would this be a "disruptive technology" or a "catalytic innovation"

Funding seems to be a barrier to implementation of EMR and HIE. Why not an excise tax like the 911 excise tax on phone bills to provide emergency services? Certainly health care is important enough to our society that there lies a real basis for this to fund EMR and health IT. It spreads out the fiancial support to almost everyone evenly.

For those of you in our local region who read this I hope you will respond to my letter and email regarding the HHS grant for HIE. Hopefully your administrative assistant did not file it in the round file. Personally I tire of the voicemail trees and the voicemail...

On another note. one of my colleagues wanted to test the capacity of his servers. He posted a comment about "Daniel Radcliffe Naked". Within one day Google had picked up this post and his site hits went up by 10000 hits/day.

The name of my new post shall be "Daniel Radcliffe Naked" in the Health Information Age.
BTW for those of you over age 40 Daniel is the actor who plays Harry Potter.

From the desert to the sea

Your willing sevant.

Google me

Google Health (GH) could be the event of the decade in advancing health care reform — not just healthcare information technology (HIT) reform,
The "ultimate" PHR????
Google Health (GH) could be the event of the decade in advancing health care reform — not just healthcare information technology (HIT) reform, but health care system reform. GH promises simultaneously to create AND dominate the market for next generation personal health records (PHRs). There is nothing else in our solar system or in the entire universe like it.
II. GH’s Anticipated Technology Model
We’ve been provided a number of clues about the technology model that GH is likely to develop:
Patient centric
A personal health URL
Automated data mechanisms to gather and store PHI
Interoperable technical standards: XML and the Continuity of Care Record (CCR) standard
A user interface
Appropriate security and confidentiality measures
Value added functionality (over time)
What do you think???