How to deal with Deb Peel

For those of you following the battle over Privacy rights in Healthcare, today's post by Lygeia Ricciardi on The Healthcare Blog is a must read.

Ms. Ricciardi suggests that factual responses to fear mongering often don't work because our response to fear is often stronger than our response to reason. She writes that one way  to counter alarmists like Deb Peel is to offer your own alternate scary scenarios:

If it’s fear you’re after, we hardly lack material:

- How about being given a drug you are dangerously allergic to?

- How about receiving a radical misdiagnosis—and the treatment to match?

- How about enduring prolonged, unnecessary pain?

- What abut the cures not found, or contagions not contained?

But, the post continues, a better way is to also use holistic, moving stories. Look for this battle to heat up in the coming months as more companies monetize de-identified data. Alarmists must not be allowed to derail progress.

The Best Care Anywhere?

I'm reading the second edition of Philip Longman's classic: "Best Care Anywhere". The book is a fascinating read into the story behind the VA's transformation from a case study in Government mismanagement to a model of modern medicine with manageable costs and outstanding outcomes.

The book offers some surprises, and I need to research them more.

• One story concerns Beth Israel New York and Duke Medical giving up promising studies into better patient outcomes because the programs were not profitable. This highlights the disconnect between incentives and goals that everyone talks about. I imagine other hospitals aren't any different and these two should be lauded for at least trying outcomes-based programs.
• The other bigger story for me was the apparent success of the VistA EMR system which is Open Source. There are emerging companies like WorldVistA, vxVista, and others following a "Red Hat strategy" of wrapping maintenance, enhancements, and support around VistA. Could this be an alternate world to the commercial EMR vendors?

See also the RAND Corporation's research brief on quality of care at the VA from 2005. Apparently, the VA's success isn't new.

IT Priorities and Government Mandates

With the release of Stage 1 Meaningful Use guidelines two weeks ago, it is increasingly evident that these rules will drive IT agenda at most providers. A  new survey today by Embarcadero technologies seems to confirm this. I also read about a HIMSS leadership survey from a few days ago that stated Meaningful Use was listed as a priority by 42% of respondents versus 27% for other clinical initiatives.

On the other side of the debate are commentators like Paul Romer who believe Meaningful Use does not contribute towards better patient outcomes. Mr. Romer writes:

Meaningful Use, if used as a way to obtain incentive money is at best meaningless, at worst, without numerous other initiatives; it can disrupt your business. It seems to violate the dictum, “Do no harm.”

Stakeholders in the healthcare IT world need to develop a position on whether Meaningful Use will set the agenda for Providers. This question affects the very core of their strategy.

Ingenix Buys Picis

Many of you must have seen the announcement this morning: Ingenix acquired Picis. In a previous life, I was a management consultant and through that experience, I have some familiarity with M&A. It's always interesting to investigate the back story that's never included in a press release.

On the surface, the acquisition makes sense if you believe analytics will quickly evolve beyond its current claims-data world. That certainly seemed the trajectory of the industry until recently. However, many observers believe that Stage 1 Meaningful Use (MU) will dominate the Healthcare IT agenda for the next few years [1] and I tend to agree with them. If  that's true, then Ingenix may have moved too early and made a bet that would not pay out for quite some time. Also, the commentary on HISTalk suggests revenues at Picis have grown less than $7M over the past few years and that the "$1B in 3-4 years" comment in the press release is dubious at best.

My personal impression is that Ingenix has made a speculative bet in the hopes that this merger will make sense a few years out. Part of the rationale may be the belief that if they pick up Picis before the stated synergies are operational, they may be striking a bargain.

As with most acquisitions, time will tell.

>>>UPDATE: Since I posted this, I came across this analysis from ZDNet that suggests this acquisition could be a positioning to improve Ingenix's ability to sell consulting and coding services. From the article:

But Ingenix hopes that its presence in the ER and ICU can give it an entree to sell consulting services and coding resources, as well as a play in the growing area of Health Information Exchanges (HIEs) — moving EHRs among hospitals and doctors under the emerging NHIN Connect standards.

<<<
[1] There are some notable dissenters who believe MU is not all it is cracked up to be

"EMR Enablement" from Iron Mountain

Close on the heels of Kodak's announcement recently of a new health records solution, Iron Mountain this week released its "EMR Enablement Solution" to link historical and modern (electronic) records as hospitals climb the adoption curve of EMR systems.

The press release states:

While EMR systems promise to improve patient care and cut treatment costs, healthcare organizations are uncertain how to implement digital records using existing resources and without disrupting patient care. The Iron Mountain EMR Enablement Solution makes the paper-to-EMR transition easier and faster for hospitals by helping them identify which records to digitize and which to destroy.

This solution is geared towards hospitals and emphasizes outsourced document management, in sharp contrast to Kodak which appears to target smaller practices using existing staff for in-house scanning. Iron Mountain has a very large customer base and claims the solution is already operational at many of its clients, including Lahey Clinic.

Seinfeld and the Move Towards Patient Engagement

Today's Wall St. Journal has an article on patient access to physician notes. It reminded me of a sketch from Seinfeld from several years ago, where Elaine is trying to get a hold of her medical charts because she thinks the physician's notes are not fair to her. Turns out, you can legally request physician notes and some hospitals like Beth Israel Deaconess Medical Center in Boston are piloting a program to make such data more accessible.

In case you haven't heard enough about Meaningful Use this week, I'll just add one more insightful analysis: John D. Halamka believes that patient engagement is actually one of the more challenging aspects of Meaningful Use Stage 1.

Step 1 in the path towards patient-centric healthcare. Clip from Seinfeld included below.

De-Identified Patient Data and The Right to Privacy

"It's personal. It's private. And it's no one's business but yours.......Privacy is as apple-pie as the Constitution."

And so began one of the most important essays on Privacy in recent times. The essay was authored by Phil Zimmerman, the author of PGP--a public source encryption program that broadened access to secure electronic communication. And yet, scholars will tell you that, despite Mr. Zimmerman's "American as apple pie" comparison above, the US Constitution does not include an express right to privacy [1]. The Bill of Rights does, however, acknowledge the need for privacy and the US Supreme Court has firmly implied such a right through numerous rulings over the past century.

Healthcare records were not always afforded the same level of privacy as today. The road to HIPAA--today's governing legislation on healthcare records--was long and paved with some spectacular cases of misuse of personal health information. In recent times, HIPAA has strengthened privacy protections and emphasized enforcement. The penalties are steeper and the access terms are stricter than before.

The challenge with HIPAA, as with any other legislation, is to balance individual interests with those of society. For example, an individual has a self interest in protecting his or her health records from prying eyes. Yet, aggregate health information is extremely valuable to analyze trends, predict disease migration patterns, link treatment to outcomes, etc. The personal privacy protections from HIPAA make it difficult to get these societal benefits. The industry's approach at de-identified data appears to be a good compromise, but privacy advocates such as Deb Peel of Patient Privacy Rights have strongly clashed with industry advocates like Matthew Holt, the author of The Healthcare Blog on this subject.

For a recent example of how privacy alarmists can derail efforts to improve healthcare see this article. The issue described here was the selling of de-identified patient data by a free, hosted EMR system called PracticeFusion. The sale of de-identified data enables PracticeFusion to provide a free service to 30,000+ small physicians, but, the company's practices has privacy advocates up in arms.

Some of you may recall Facebook's Mark Zuckerberg claiming privacy was dead. Zuckerberg, of course, was referring to personal privacy in the context of what you do or share online and he was probably not thinking as much about personal health records. Are these two related? Will changing outlook on personal privacy affect how we view health information?


[1] a fact noted by Mr. Zimmerman later in his aforementioned essay.

Analysis of the Final Rule on Meaningful Use

Inga from HIStalk provides a helpful summary of the changes between the preliminary and final rules for  Meaningful Use. Also John D Halamka has posted a very nice summary slide deck for those who need to present a synposis of the changes. Finally, Keith Boone's colleague, Dan Sepulvada helped compile a table summarizing the differences between the preliminary and final rules.

Two quick observations are below; look for a separate post in the coming days on how these new rules affect document management, particularly Release of Information.

• Across the board, the final rules are a lot less ambitious than the preliminary ones. This is mostly a good outcome because we still don't know the behavior these rules will motivate. More* on this at the end of the post. 
• The preliminary rules were written with an assumption that medical records will be mostly electronic by 2015. Several studies suggest this goal is not realistic, so it will be interesting to hear whether these rules will indeed prevail or whether there would be further changes down the road. A Bass Diffusion model applied to physician EMR systems by Prof. Eric W. Ford and others claims true adoption will take a decade longer than anticipated. And that's the optimistic scenario!

I look forward to hearing your thoughts in the comments section below.

*Why less ambitious rules may be a good thing: Rob Lamberts at The Health Care Blog draws an analogy between Meaningful Use rules and those in No Child Left Behind--another well intentioned legislation that introduced undesirable behavior on the part of the actors (the teachers). One would rather have rules that are realistic than those that are so strict everyone has to find workarounds.

Kodak-Medco Data Partnership

This week, Kodak announced a partnership with Medco Data to provide conversion of paper-based charts to digital files. There are a number of local vendors currently serving this space, so the entry of a major brand like Kodak appears to validate the belief that EMR adoption improves when there is continuity with historical records.

The press release states:

"Conversion of paper-based patient charts represents a critical consideration for practices implementing EMR/EHR systems. Scanning charts prior to the installation of an electronic records system can significantly improve the chance of a successful adoption."

The product is targeted towards physician practices and ambulatory care. It emphasizes the ability for existing staff to perform scanning work.

It will be interesting to see what physician practices and ambulatory care EMR systems, particularly AllScripts, do to better integrate paper and electronic medical records.  Stay tuned.

EMR or EHR?

EMR (Electronic Medical Records) and EHRs (Electronic Health Records) refer to two very distinct concepts. Unfortunately, government officials, vendors, respected journalists, and consultants have used these terms interchangeably in order to refer to EMRs.

HIMSS Analytics provides clarity on the meaning of these terms:

• Electronic Medical Record: An application environment composed of the clinical data repository, clinical decision support, controlled medical vocabulary, order entry, computerized provider order entry, pharmacy, and clinical documentation applications. This environment supports the patient s electronic medical record across inpatient and outpatient environments, and is used by healthcare practitioners to document, monitor, and manage health care delivery within a care delivery organization (CDO). The data in the EMR is the legal record of what happened to the patient during their encounter at the CDO and is owned by the CDO.

• Electronic Health Record: A subset of each care delivery organization’s EMR, presently assumed to be summaries like ASTM s Continuity of Care Record (CCR) or HL7 s Continuity of Care Document (CCD), is owned by the patient and has patient input and access that spans episodes of care across multiple CDOs within a community, region, or state (or in some countries, the entire country). The EHR in the US will ride on the proposed National Health Information Network (NHIN). The EHR can be established only if the electronic medical records of the various CDOs have evolved to a level that can create and support a robust exchange of information between stakeholders within a community or region. While some forms of early EHRs exist today in limited environments, it will be difficult to establish effective EHRs across the majority of the US market until we have established clinical information transaction standards that can be easily adopted by the different EMR application architectures now available.

John at "EMR and HIPAA" argues that this distinction is irrelevant and that these terms will always be used interchangeably. He writes:

"My favorite in the EMR world is when people go crazy if you use the term EMR and not EHR. Let’s just get over it. The doctors I talk to really are. They use them interchangeably to mean everything that you might technically consider an EHR."

What do you think?

Meaningful Use Criteria Announced

The Department of Health and Human Services (HHS) and the Office of the National Coordinator for Health Information Technology (ONC) has released the long-awaited announcement on meaningful use. See news article.

Also, see the New England Journal of Medicine's Perspective on the new rules, authored by David Blumenthal and Marilyn Tavenner