2009: A Year of Surprises and Change for the EHR Technology Market

DAVID C. KIBBE and BRIAN KLEPPER

2009 began with a bang for legacy Electronic Health Record (EHR) vendors, promising strong sales and windfall profits on the heels of stimulus package incentive bonuses initially worth more than $19 billion to doctors and hospitals. But things changed dramatically along the way.

Here ten surprises and notable events that have impacted the EHR market:

The NHIN and the Health Internet: A Matter of Cost, Control and Timing

DAVID C. KIBBE and BRIAN KLEPPER 

There is growing tension within the Obama administration's health team over who will control health data exchange: everyone (including consumers and their doctors), or just large provider organizations. The public debate will be framed in terms of privacy, security, and the adequacy of current exchange standards. But what really matters is who gets to make decisions about where health data resides, how it can be accessed, how much exchange will cost, and how long it will take for exchange to become routine.

Will Business Force Reform Back To The Drawing Board

BRIAN KLEPPER and DAVID C. KIBBE

Until now, non-health care business has been noticeably absent from the health care reform proceedings , and quiet about the bills' impacts on their management of employee benefits, on cost, and on the larger issues of global competitiveness. Where have the voices been of the powerful business leaders who will pick up much of the tab?

They've finally surfaced, and now we'll see whether they have the will to bring reform back on track. They certainly have the strength. The question is whether this salvo by the business mainstream could force Democrats to reconsider and revise the content and structure of their proposals.

Saving Health Care. Saving America

BRIAN KLEPPER, DAVID C. KIBBE, ROBERT LASZEWSKI and ALAIN ENTHOVEN

So far, Congress' response to the health care crisis has been alarmingly disappointing in three ways. First, by willingly accepting enormous sums from health care special interests, our representatives have obligated themselves to their benefactors' interests rather than to those of the American people. More than 3,330 health care lobbyists - six for every member of Congress - contributed more than one-quarter of a billion dollars in the first and second quarters of 2009. A nearly equal amount has been contributed on this issue from non-health care organizations. This exchange of money prompted a Public Citizen lobbyist to comment, "A person can reach no other conclusion than this is a quid pro quo [this for that] activity."

Why Standards Matter (2): Health IT Enters a New Era of Regulatory Control

DAVID C. KIBBE and BRIAN KLEPPER
 
The recent history of electronic medical records in ambulatory care, or what we now call EHR (electronic health record) technology, can be divided roughly into three phases. Phase I, which lasted approximately 20 years, from about 1980 to the early 2000's, was an era of exploration and early adaptation of computers to outpatient medicine. It coincided with the availability of PCs that were cheap enough to be owned by many doctors, and with the increased capacity of off-the-shelf software programs, mainly spreadsheet and database management systems such as Lotus, Excel, Access, and Microsoft's SQL, to lend themselves to computerized capture of health data and information.

Health 2.0 2009 - Key Health 2.0 Issues for Reform

Will Republicans Be Spoilers or Problem-Solvers on Health Care Reform

BRIAN KLEPPER and DAVID C. KIBBE

In theory Congress' return from recess next week could offer a new beginning to the health care reform process, giving everyone a chance to take a deep breath and recalibrate the components of change.

Nine months into the wrangling around a new Administration, the talk-show right has seemingly hijacked the discussion on health care, Democrats' signature issue, with the standard tools that demagogues have always used: leveraging popular prejudices with oversimplification, hyperbole, and distortion. The die-hard GOP faithful's leaders - Gingrich, Palin and others (see this off-the-deep-end speech by Rep. Mike Rogers (R-Mich)) - are of course playing spoilers, independent of the cost. They hope to goad centrist voters into abandoning the Democrats so they can retake power. Witness South Carolina Republican Jim DeMint's comment, "If we're able to defeat Obama on this, it will be his Waterloo. It will break him."

Health Care Reform's Deeper Problems

BRIAN KLEPPER and DAVID C. KIBBE

Congress' health care reform debate has highlighted how American governance is broken and the difficulty of addressing our national problems.

Take, for example, whether health care is in crisis at all. Conservative commentators argue that America's health system is fine, that our excellent care simply costs more than other countries' poorer quality, and that most uninsureds can afford coverage. 

They ask why we should revamp a great system for the two or three percent of Americans who get less.

This misrepresents reality, though.

Why Standards Matter (1): The True Meaning of Interoperability

DAVID C. KIBBE and BRIAN KLEPPER

Americans are generally skeptical of words that otherwise intelligent and articulate people can't pronounce.  "Interoperability," like nu-cu-lar, is one of these. After a while, these words can take on a mystique all their own.

But interoperability is a hugely important word in the context of today's ongoing debate about the use of EHR technology by physicians, hospitals, and patients too. The federal government is going to provide billions of dollars to encourage today's fragmented health care providers to convert from mostly paper to mostly computerized information systems. It is critically important for these systems to talk with one another. We want health data to flow between and among these systems and to be, well, interoperable.  And it isn't now.

Finally, A Reasonable Plan For Certification of EHR Technologies

A caution to readers: This post is about methods for certifying Electronic Health Record (EHR) technologies used by physicians, medical practices, and hospitals who hope to qualify for federal incentive payments under the so-called HITECH portion of the American Recovery and Reinvestment Act (ARRA). It may not be as critical as the larger health care reform effort or as entertaining as Sarah Palin, but it WILL matter to hundreds of thousands of physicians, influencing how difficult or easily those in small and medium size practices acquire health IT. And indirectly for the foreseeable future, it could affect millions of American patients, their ability to securely access their medical records, and the safety, quality, and the cost of  medical care.

Three weeks ago, on July 14-15, 2009, the ONC's Health IT Policy Committee held hearings in DC to review and consider changes to CCHIT's current certification process. The Policy Committee is one of two panels formed to advise the new National Coordinator for Health IT, David Blumenthal. In a session that was a model of open-mindedness and balance, the Committee heard from all perspectives: vendors, standards organizations, physician groups, and many others. 

Why Congress Should Consider Bob Laszewski's Health Care Affordability Model

Over the last few months, I have become increasingly disheartened over the prospects for meaningful health care reform.

First, the process is terribly conflicted, and it shows. In the first quarter of 2009, the Center for Responsive Politics reported that the health care industry contributed $128 million to Congress. Now that the tide has turned, this has gone mostly to Democrats who, as it turns out, are just as receptive as their Republican predecessors.

A Dream of Reason

BRIAN KLEPPER and DAVID C. KIBBE

The dream of reason did not take power into account...Modern medicine is one of those extraordinary works of reason...But medicine is also a world of power.

-Paul Starr, The Social Transformation of American Medicine, 1984

Today's unveiling of a Declaration of Health Data Rights is an important action, long overdue, that represents a collaborative effort by a group of health care professionals - activists, entrepreneurs, technologists and clinicians - all colleagues we hold in high esteem.

The Declaration's several points arise from a single, simple premise: that patients own their own data, and that that ownership cannot be pre-empted by a professional or an institution. And there lies its power, especially in the context of early 21st Century health care. It is a transformative ideal that currently is not the norm. But we join our colleagues in declaring that it should be.

The Health Industry's Achilles Heel

BRIAN KLEPPER and DAVID C. KIBBE

"You never want a serious crisis to go to waste.
- Rahm Emanuel, White House Chief of Staff

Timing matters. The health industry has demonstrated steadfast resistance to reforms, but its recently diminished fortunes offer the Obama Administration an unprecedented opportunity to achieve meaningful change. The stakes are high, though. The Administration's health team must not miscalculate the industry's goals, or waver from goals that are in the nation's interest. The two are very different.

An Open Letter (4) to the New National Coordinator for Health IT: Bringing Patients Into the Health IT Conversation About "Meaningful Use"

DAVID C. KIBBE and BRIAN KLEPPER

The Obama health team at HHS and ONC are gradually establishing the rules that will determine how approximately $34 billion in ARRA/HITECH funds are spent on health IT over the next several years. But there is a "missing link" in these deliberations that, so far, has not been addressed by Congress or the Administration: how the patient's voice can be "meaningfully used" in health IT.

An Open Letter (3) to the New National Coordinator for Health IT - The Elephant in Health IT's Living Room

DAVID C. KIBBE and BRIAN KLEPPER

In the first and second parts of this series we talked about how and why there is no universal definition for the term "EHR." Instead there is a legitimate, growing debate about the features and functions that "EHR technologies" should offer physicians seeking to qualify for HITECH incentive payments. We explored the layers of network technology, suggesting that federal regulators should "separate the data from the applications."

An Open Letter (2) to the New National Coordinator for Health IT - Opening the Aperture of Innovation

DAVID C. KIBBE and BRIAN KLEPPER

One of the important decisions before Dr. Blumenthal and his colleagues at ONC and HHS is whether the national health information network will be one of closed appliances that bundle together proprietary hardware, software, and networking technology, or one of open data exchange and management platforms in which the component parts required to do medical computing can be assembled from different sources. If the former direction is chosen, power and control will be concentrated in the hands of a very few companies. If the latter, we could see an unprecedented burst of disruptive innovation as new products and services are developed to create the next generation of e-health services in this country.

Will CIGNA Remake The Health Plan Marketplace

BRIAN KLEPPER

First published here on the Health Care Blog

America’s health plans are floundering. If their job has been to provide the nation’s mainstream families with access to affordable care (let’s leave quality out of it for the moment), they have failed miserably, though they were very profitable along the way, at least until Q1 2008. In 2008, the Milliman Medical Index – an estimate of the total cost for health coverage premium and out-of-pocket costs for a family of four – was $15,609. Now it is almost certainly above $17,000, more than the total income of more than one-third of American households.

To many health plan execs, these are simply market dynamics that must be accommodated through new product and service designs. I just attended a health plan conference where the overarching themes were the transition away from group to individual coverage, and the use of incentives and touch points like texting, email, and ergonomic Web interfaces to cultivate member competency, loyalty and retention.

Is The Health Care Economy Downsizing?

BRIAN KLEPPER and DAVID C. KIBBE

First published here on the Health Care Blog

More than at any time in recent memory, powerful forces are buffeting the health care sector. We are in the midst of profound upheaval, driven by market and policy responses to the industry's long-term excesses. We can already see evidence that the dysfunction of our traditional health system is accelerating. It also seems clear that the center cannot hold indefinitely.

Dog Eat Dog
It is useful to remember that the health care industry's different stakeholders are adversaries. While they clearly share a common understanding that a wholesale meltdown is possible, there is little real motivation for collaboration and no unity. Independent of role, the industry as a whole has been focused on, and extremely effective at, securing dollars from purchasers: government, employers and individuals. But each silo within the industry has been separately focused on growing its own slice of the health care pie. In every niche, there are courteous conceits - access, appropriateness, efficiency and value - reserved for the good manners of public relations. But these are meaningful in practice only if they do not conflict with the professional's or the firm's economic performance.

Five Recommendations For An ONC Head Who Understands Health IT Innovation

DAVID C.  KIBBE and BRIAN KLEPPER

First published on The Health Care Blog

Now that the legislative language of the HITECH Act -- the $20 billion health IT allocation within the economic stimulus package -- has been set, it's time to identify a National Coordinator (NC) for Health IT who can capably lead that office. As many now realize, the language of the Bill can be ambiguous, requiring wise regulatory interpretation and execution to ensure that the money is spent well and that desired outcomes are achieved. Among other tasks, the NC will influence appointments to the new Health Information Technology (HIT) Policy and Standards Committees, refine the Electronic Health Record (EHR) technology certification process, and oversee how information exchange grants and provider incentive payments will be handled.

The AMA Wins A Round Against Accountability and Patient Information

BRIAN KLEPPER

On January 30th, a 3-judge DC appeals court overturned a lower court decision that would have forced public release of Medicare physician data. Writing for the majority in a split 2-1 judgment, Circuit Judge Karen LeCraft Henderson declared that
“The requested data does not serve any (freedom-of-information-related) public interest in disclosure. Accordingly, we need not balance the nonexistent public interest against every physician's substantial privacy interest in the Medicare payments he receives.”

But in a strongly worded dissent, Judge Judith Rogers, the third member of the ruling panel, found that the request by the consumer group, Consumer Checkbook, represented “a commanding and important public interest in disclosure of the data.”

Five Shovel-Ready Health Care Reforms

BRIAN KLEPPER and DAVID C. KIBBE

Microsoft Health Vault's leader Peter Neupert has a wonderful blog post that makes two important points really well. One message is that health care reform is about the outcomes, not the technology. We should think expansively about which technologies to invest in, based on the results we want to get.

The other message is the economic stimulus package is different than the reform effort. It is moving at hyper-speed through Congress, and it may be difficult for staffers and other advisors to sort through and incorporate what may seem like opposing Health IT views against a backdrop of traditional ideology and extremely forceful special interest lobbying.

Welcome to Health Wonk Review (HWR), 1/09/09

Brian Klepper

First Published on THCB

Well, here we are at the beginning of 2009. On TV we’ve learned that the unlimited spending and brilliant, if socially pathological, heroics of Dr. Gregory House, unfailingly saves his patients from unknowable complexity and the abyss of death.

Meanwhile, the rest of health care, aided largely by really excellent lobbying, continues to be buoyed, defying the relentlessly corrosive gravitational pull of waste, corruption, and a tanking economy.

Still, health care's troops are beginning to feel, in Tom Lehrer's words, like a Christian Scientist with an appendicitis. Things definitely are not going well, and this longstanding run of great good fortune could be on the downswing. Is it possible that exorbitant pricing and massive waste are NOT entitlements!

Let's Reboot America's Health IT Conversation (2): Beyond EHRs

DAVID C. KIBBE and BRIAN KLEPPER

First Published on THCB

Yesterday we tried to put EHRs into perspective. They're important, and we can't effectively move health care forward without them. But they're only one of many important health IT functions. EHRs and health IT alone won't fix health care. So developing a comprehensive but effective national health IT plan is a huge undertaking that requires broad, non-ideological thinking.

As we've learned so painfully elsewhere in the economy, the danger we face now in developing health care solutions is throwing good money after bad. We don't merely need a readjustment of how health IT dollars are spent. We need to reboot the entire conversation about how health IT relates to health, health care, and health care reform. To get there, we need to take a deep breath and start from well-established and agreed-upon principles.Most of us want a health system that, whenever possible, bases care on knowledge of what does and doesn't work - i.e., evidence. We want care that is coordinated, not fragmented, across the continuum of settings, visits and events. And we want care that is personal, affordable and increasingly convenient.

Let's Reboot America's HIT Conversation 1: Putting EHRs in Context

DAVID C. KIBBE and BRIAN KLEPPER

First Published on THCB

On Dec. 19, we published an Open Letter to the Obama Health Team, cautioning the incoming Administration against limiting its Health Information Technology (IT) investments to Electronic Health Records (EHRs). Instead, we recommended that their health IT plan be rethought to favor a large array of innovative applications that can be easily adopted to result in more effective, less expensive care.