I’m in Atlanta for the biggest US conference in health care IT, run by
the Healthcare Information and
Management Systems Society (HIMSS). This organization, along with
the branch of the federal government responsible for dispersing funds
for a medical records overhaul, has to do a huge job in an extremely
short time. I’ll report what I hear (and how I interpret it) over the
next few days, aiming both at people who care in general about the
future of health care at particularly at readers who are wondering
whether their next career move may be into health care.
Although many people have been saying that the medical field would
benefit from a Silicon Valley approach to technology, it’s coming to
seem that even more important would be a Silicon Valley approach to
risk-taking. I’ll look at the events that created this imperative.
Where the pressure comes from
Why are most doctors in the U.S., some thirty years after IT became
ubiquitous in American offices, still working with paper records? The
main reason is that they work in small offices instead of large
institutions, as I describe in an
earlier blog about electronic health records. Most economically
advanced nations have centralized, government-administered health care
systems, and therefore electronic records. Large institutions in the
U.S. also have them–the Veterans Administration’s VistA is a famous
example–and more hospitals have made the move than small physicians’
offices.
A crisis in costs and achievements provides a nice impetus for change
(an
article in last Sunday’s New York Times lays out the stakes), but
cold cash does even better. Few things can make an industry perk up as
much as a sudden infusion of twenty billion dollars. Thus the impact
of a provision in the federal stimulus bill (properly known as the
American Recovery and Reinvestment Act of 2009 or ARRA) that mandates
the adoption of electronic medical records.
The framers and implementers of the stimulus bill were both ambitious
and idealistic, but they weren’t naive. They know that the adoption of
electronic health records, like any computer system, can be botched
and can turn out to miss the benefits that it’s supposed to bring. So
in this part of the act, called Health Information Technology for
Economic and Clinical Health (HITECH), they lay out a demanding list
of practices that clinics and hospitals must carry out to qualify for
government money. In other words, HITECH is really about behavior and
workflow, not technology.
What does HITECH call for? Some requirements seem fairly easy to meet,
such as tracking key clinical conditions on patients. Others get quite
complex, even at Stage 1 of the implementation. For instance, doctors
are supposed to use their electronic systems to help check their
treatment plans for errors and suggest best practices, a field called
clinical decision support. Stages 2 and 3 require complex data
exchanges with other organizations, which in turn requires
interoperation among different systems from different vendors. I’ll
return to interoperability in a later blog. Other rules include
evidence-based order sets (which bring up suggested treatment regimes
based on research) and reporting treatments and results to registries
to foster the further development of best practices.
All these requirements are put forward under the buzzword
meaningful use, an ironic choice given that the requirements
aren’t even completely defined yet. Still, whether it’s meaningful or
not, the term has instantly leapt to the forefront of discussion among
vendors and providers, because of the financial rewards attached to
them.
In principle, the meaningful use criteria are good. The government bodies
creating the requirements got stakeholders involved early and often.
It’s well understood that these things are needed to improve care and
reduce inefficiency. As in any major attempt at social change,
doom-sayers predict disaster. (I’m not necessarily saying they’re
wrong; in this case they include CIO
Anthony Guerra and IT
company CTO Evan Steele, both featured at the HIMSS conference.)
But for the most part, the health care industry is lined up behind
meaningful use–or at least behind the promise of the money that
health care providers will be paid to implement it. Grumbling among
vendors and practitioners focuses on the timetable for implementation,
not on the practices themselves.
If you’ve gotten the impression from this summary that Congress and
the Administration have bypassed all the political bickering around
health care reform bills and implemented it under the guise of a
financial recovery, I’d say you’re right. HITECH doesn’t directly
address the health care industry or other controversial issues such as
how to pay doctors. And those issues still need to be resolved. But
HITECH does try to reform the health care system around better
practices.
So the HIMSS conference is taking place at the height of a suspenseful
moment in U.S. health care history. The Administration has released
proposed final rules, but they’re in the middle of a 60-day comment
period. Meanwhile, working from the drafts that have been released
all along, vendors are feverishly bringing their tools into
conformance and claiming (how could they not?) that the tools will be
ready soon for adoption.
The pressures extend to other players all throughout the health care
industry. A certification body called the Certification Commission
for Health Information Technology (CCHIT) is design certifications for
vendors’ systems as well as the hospitals and individual providers who
adopt them, matching the meaningful use criteria “no more and no
less,” as said today by the outgoing CCHIT chair, Dr. Mark Leavitt.
The pressure will then be on the providers–and here is where I’m
seeing the most resistance.
Suspicion and silos
Given that many clinicians never adopted electronic systems, and
others who did regretted doing so, we don’t have to be surprised to
hear that some don’t think it will work or don’t believe that they can
make the change.
It would seem that heath care IT is hot right now. HIMSS is sprawled
across three buildings in the Georgia World Congress Center (whose
address completely confuses Google Local, by the way). Getting from
one place to another between sessions means forcing my way through
hundreds and hundreds of attendees. To walk from one corner of one
show floor to the other would take several minutes. I picked up half a
dozen magazines on health care IT.
But even here–among people who paid to attend a health care IT
conference–dissent can be felt. There’s a lot of anger at electronic
systems and their vendors, complaints ranging from high costs and
inflexible templates to user interfaces that slow down busy staff and
problems with data exchange. A few observers claim that HIMSS and
CCHIT are just vendor-controlled consortia who want to milk providers
and walk away with government money. I must say, though, that debate
here ranges across many points of view. I was impressed to see an
HIMSS book on patient-centered records, which–if made the basis of
health care–would produce a bigger revolution than anything discussed
so far. (I’ll explain why in another blog this week.)
Although attendees want to make the move to electronic records, many
talk about other people who won’t. And a typical session on clinical
decision support was devoted, not to ways of using electronic medical
systems, but to persuading the attendees that electronic medical
systems would be worthwhile.
The timetable does seem like a forced march. Even though the systems
that meet the meaningful use criteria are still under development–and
so is the certification–providers will be rewarded as early as 2011
for installing them and using them heavily. (The records have to be
used for 80% of some practices in order to get the money.) And each
year that providers wait before meeting the meaningful use criteria,
they get less money. A stick also accompanies the carrot; providers
that accept Medicare and Medicaid will actually be penalized if they
don’t demonstrate meaningful use.
Furthermore, implementing the rules will require the hiring of more IT
staff and telling clinical staff to take time to serve on committees.
These considerations contributed to a declaration
by a consortium of Chief Medical Officers that the timetable was
too aggressive. Some Congressmen have recently made the
same request, so you know someone has been talking to them.
But many others in the field–including the vendors, confident in
their ability to deliver, and some hospital managers in the forefront
of implementing electronic records–urge the government to stay the
course. Their attitude is that the need is great (because health care
costs are rising so precipitously), the schedule is demanding but
still feasible, and “if not now, when?”
I stated earlier that HITECH was more about behavior and workflow than
technology. The push to implement the meaningful use rules brings
this to the fore. Old silos between IT, doctors, and other staff won’t
work; neither will silos between doctors, billing, labs, and other
departments.
Providers trying to achieve meaningful use must talk to their staff:
not just doctors, but also nurses, technicians, and anyone else who
touches a record. They have to examine their workflows and be willing
to admit when they don’t conform to health care standards or are
inefficient. They have to make some of the same mistakes offices and
factories made when they computerized in the 1980s, and learn from
those mistakes. To some extent, implementing an electronic system is a
bottom-up activity.
That’s why I say that a Silicon Valley approach to risk-taking is even
more important for this field than a Silicon Valley approach to
technology. I’m not so concerned with the famous Silicon Valley
tolerance for failure. Health care is not a social network, and
failure there has serious consequences. I’m more interested in a
Silicon Valley willingness to cross organizational boundaries and to
encourage people’s opinions on things where other people are the
recognized experts.
Overall, I don’t think the money offered by HITECH will really drive
the decision to change. I think providers will move as they hear of
others running awesome applications to make life easier–and save
lives. I’ve stopped using the phrase “killer app” in the health care
field for obvious reasons, but the standards, protocols, and storage
mechanisms won’t have much impact until applications follow.
So I’ll end with a nod toward a company for which I have a fond spot
because it happens to be the first health care
company I talked about in a blog, over six seven years ago. Vocera is still going strong, providing
mobile devices with health care applications to over 600 sites.
Medical staff can issue orders, call for help, or scan medications
using these tiny clip-on devices.
Although Vocera doesn’t work on the immensely popular iPhone, it does
have partnerships with the makers of several other handhelds,
including the Blackberry and one from Motorola. It collects scads of
statistics about things such as the number of contacts made and the
success of speech recognition software, to help sites judge its
effectiveness. I find it an example of the kind of product that will
drive electronic medical systems, because it will please not only a
Chief Medical Officer, regulator, or insurance claim processor, but
someone doing clinical work on the floor of the hospital.