Tuesday, August 31, 2010

How Long Will It Take to Adopt EMRs?

One story that got a lot of press last week was Prof. Aashish Jha's research update on the adoption of Electronic Medical Records. Prof. Jha has observed that only about 12% of US hospitals have a fully operational EMR at the end of 2009 and only 2% would have complied with Meaningful Use guidelines release this July that determine whether Providers can receive Federal incentives starting next year. 

Common sense suggests that electronic medical records should have much wider adoption, particularly since most sides agree that a properly implemented EMR improves patient care. After all, as one advertisement by United Healthcare recently noted, "your Pizza delivery guy stores your orders electronically. Why can't your doctor do the same?" The reality is that EMRs have not been widely adopted because there are many counter forces:
  • Medical information like health status is not as determininistic as, say, financial data. There is no unique score, or set of scores that can uniquely pin point the state of your health in a way that two reasonable, independent observers would always agree. In banking, there is no ambiguity on your bank balance when it is viewed by two separate observers. Similarly, your Pizza preferences are, in general, mostly deterministic and can be described in a way that is interpreted in the same way. I buy this argument, but it doesn't explain it all.
  • Some commentators have suggested that medicine is viewed as an art by an older generation of physicians and as long as that group makes decisions for the medical community, EMRs and other metrics-driven tools are likely to remain on the backburner. This is an artful argument, but again, it cannot explain the widespread inability of Providers to adopt EMRs. Some (more cynical?) observers have even claimed that the Providers don't want EMRs because it allows them to preserve inefficiencies and make more money.
  • The most compelling reason for the lack of adoption is simply that the benefits of EMR accure to those that don't pay for it. Put in other words, those that have to pay for EMRs aren't the ones that benefit the most. So, cash strapped hospitals are not very likely to want to make a huge IT investment if they don't see direct returns of some form. The Federal goverment has recognized this misalignment of incentives and much of the HITECH funding through Meaningful Use attempts to address this deficiency.
So, if you believe this logic, it would stand to reason that EMRs will see a much more rapid pace of adoption as Federal incentives kick in. Prof. Jha's paper seems to make a similar conclusion.
For more on the topic, Prof. Eric Ford and others published a bass diffusion analysis applied to EMRs. This study was published in 2006 and concluded that EMR adoption would take a decade longer than the 2014 target set by the Bush Administration as part of E.O. 13335 that established the ONCHIT. I have yet to see an update on this study, post Meaningful Use incentive payments, but the paper is still worth a read for its analysis of buying behavior in the medical community. Specifically, the paper examines the similarity in buysing behavior between healthcare IT and consumer goods, given that both are influenced by the coefficient of imitation (doing what key opinion leaders do) than coefficient of innovation (buying the latest and greatest). Heady stuff.

Tuesday, August 24, 2010

Ingenix...yet again

In several recent posts, I have tried to determine the grand strategy behind Ingenix's recent acquisition spree.

For a much more comprehensive analysis, see today's HISTalk Investor's Chair briefing.

So, what's your take on the real story behind all this momentum? What is Ingenix (and United Healthcare by extension) trying to do?

Monday, August 23, 2010

Using Crowdsourcing Principles for CDS

One of the emerging challenges for Clinical Decision Support systems is the problem of how to describe the data that is input into the rules engine. For a detailed description of this problem, see Keith Boone's Standards Activity Around Clinical Decision Support.

Of course, with Meaningful Use still in Stage 1, the emphasis is currently on data capture rather than clinical decision support. Healthcare IT has an article on how Google's IP from its failed Wave product may be of help in digitizing hard-to-read physician notes.  Most providers today perform some form of scanning of physical files; the approach proposed in the article essentially involves principles of "crowdsourcing" where a complex translation is farmed out to a large number of people that work on tiny bits of the problem, usually only for a few seconds each.

When the focus shifts towards CDS in Stage 2 of Meaningful Use, a similar crowdsourced approach could be used to create CDS rules databases. Hosted EMR vendors like athenahealth are most likely to be in a position to mine their databases for such an effort.

Thursday, August 19, 2010

Best Care Anywhere Reviewed by Andy Oram

For those of you that read my review of Best Care Anywhere, please see Andy Oram's comprehensive and insightful read: The Software Behind the VA's health care transformation.

Andy ends the post with a call for help:
If you'd like to learn more about VistA, help to add features so it can become the nation's electronic health record system, or just meet the fascinating people who work with it, check out the WorldVistA community..... doctors are moving quickly to install electronic record systems ..... To play in this space, VistA needs both more promotion and.... changes to simplify deployment and configuration.

Monday, August 16, 2010

Ingenix Continued

I've reported on this blog that Ingenix bought Executive Health Resources not too long after picking up Picis. Well, they've done it again: Ingenix announced yet another acquisition at close of business today: Axolotl, an HIE Services providerIngenix was rumored to be entering the HIE space and HISTalk reaffirmed it this morning. This acquisition confirms it.

With a string of recent acquisitions, UnitedHealthcare is inching closer to its vision of becoming a Kaiser-like end-to-end provider with a focus on outcomes. This also appears to be a pragmatic shift away from some of the more fancy predictive modeling approaches that hold promise but do not deliver near-term results.

Organizational Models Behind Healthcare Delivery

In a review of the China Study, I wrote about how Healthcare discussions often revolve around insurance, treatments, technology, operational excellence, etc. but not as often on driving factors like lifestyles, choices, etc. As a product manager, I'm often confronted by similar questions on strategy; for example, can organizational culture be a source of sustainable advantage? Are we overly focused on business models, technology leadership, incumbency  when we should also think about how are teams operate and how members relate with each other?

Today's HISTalk mentions how Epic, the leader of the EMR vendor market if you measure momentum, focuses not on hiring candidates with the best experience but instead selects those with the right traits, qualities, and skills. HISTalk states:
"Epic emphasizes that many hospitals can staff their projects internally, choosing people who know the organization. However, they emphasize choosing the best and brightest, not those with time to spare. Epic advocates the same approach it takes in its own hiring: don’t worry about relevant experience, choose people with the right traits, qualities, and skills, they say."
Top-tier management consulting firms like BCG, Bain, and McKinsey have always known this. As a result, these firms test candidates on scenarios (or "cases") to evaluate how a candidate would think in a particular situation rather than evaluating the candidate on behavioral questions (that can generally be memorized). Other companies in other industries are catching on. Netflix famously released it's Freedom and Responsibility Culture reference guide that emphasizes context over control.

How much time do you spend on your organization's team dynamics? What methods do you use to select candidates?

Wednesday, August 11, 2010

Data Classification

John Moehrke has a comprehensive post on Data Classification. As privacy and security considerations are codified within electronic medical records, standards are essential. There are three areas that I see these standards playing a transformative role, but I'm sure there are others:

  1. HIE Consent Management: There are seven services needed for the creation of HIEs. Many are still under development but the least developed area amongst these is most likely patient consent. See Private Access--one of the potential technology providers in this space.
  2. Release of Information: Much of the business of release-of-information, estimated to be a $1B market [1], depends upon the proper redaction of sensitive information from medical records. Codifying privacy preferences will eventually allow automated release-of-information processing. Mature data classification techniques may enable a disruptive technology to upend this market, which is currently dominated by HealthPort with a $250M annual revenue stream.
  3. Data De-Identification: De-identification is currently a somewhat manual process if you want data that retains some degree of usefulness. HIPAA requires a person with knowledge of general statistical principals to certify that reverse engineering of identity is not easily possible or it requires the removal of 18 fields that remove personally identifiable information. Data classification takes us one step closer to automated de-identification.

While on this subject, see Keith Boone's contention that redacted documents should not be considered the same as the original document and hence should not retain signatures that were used to sign the original.

[1] market sizing from HealthPort, Inc. S-1 filing with the SEC, 2009

Monday, August 9, 2010

Gold Rush Redux?

The Boston Globe's story this weekend on Athenahealth CEO Jonathan Bush confirms what is becoming increasingly apparent: the EMR revolution is indeed a gold rush and federal incentives will define the agenda in Healthcare IT for the foreseeable future. A survey of news items in HIStalk also lists several stories supporting this conclusion.

If you compare the current environment to the pre-bubble days of the internet, you could assume we are in 1994. Netscape has not been launched yet, but there's a wide expectation of a revolution to come. Web 2.0 proponents will claim that the first wave of the internet did not produce productivity improvements comparable to those from Web 2.0 technologies. Similarly, skeptics might believe this gold rush will not truly transform healthcare IT, but it will set the stage for an eventual revolution in technology, patient engagement, and evidence-based medicine.

Whichever way you look at it, participants in the market will adapt their strategies in order to profit from this environment. News satire site, The Onion had a memorable headline a few years ago:  "Recession Plagued Nation Demands New Bubble to Invest In." I think that call is being answered.

Friday, August 6, 2010

The China Study

One of my good friends who is a senior-level executive at a major national Payer (and sometimes an industry source for this blog) recommended The China Study. It sounded like an odd title for a book on health and nutrition so I was eager to find out what it said.

The book is authored by T. Colin Campbell, who has spent his career in science. This book isn't an opinion piece, it's a fact-based reporting of the correlation of several lifestyle factors on health outcomes. The book criticizes the "scientific reductionism"--the practice that assigns outcomes to single variables rather than considering the systemic nature of influencing factors.

The author shows, for example, how the presence of carcinogens themselves do not lead to as many cancers as carcinogens in combination with complex proteins (such as found in non-plant sources like red meat). The China Study itself is the analysis of relationship between diet and disease for about 100 communities in China that were relatively isolated and with differing diets and disease outcomes. This provides a snapshot of the effect of varying amounts of diet components in a manner that was not possible before.

The conclusion I have drawn from this research is that there's a large unexplored theme of modifying diets to improve patient outcomes. Much of the debate in Healthcare revolves around insurance, Healthcare IT, cost-reduction, technology innovations. So little time is devoted to the source: the foods we eat and the lifestyles we lead.

Wednesday, August 4, 2010

Ingenix buys Executive Health Resources

Ingenix is continuing its buying spree. Just after acquiring Picis two weeks ago, Ingenix is now adding medical necessity compliance and physician medical management solutions for hospitals by purchasing Executive Health Resources. In a blog post this morning, John D Halamka suggested that Ingenix may also be looking at entering the HIE space. If that's true, expect additional M&A activity on that front.

Is there a theme here? Some commentators have suggested that Ingenix is putting together the elements of a Kaiser-like solution. For example, Dana Blankhorne at ZDNet writes this about United Healthcare, Ingenix's parent:
It’s trying to be more like Kaiser. That is it wants to control the hospitals and clinics it pays money to and see that they’re managed efficiently. Kaiser does this directly. It owns hospitals and clinics. UnitedHealth plans to do this indirectly, through Ingenix.
Kaiser Permanente has an good track record of outcomes vs. dollar spent. One would expect it to have an overwhelming share of the market. Yet, it has garnered just a 24% share in California while failing to gain traction in other states (e.g. 5% in Georgia). Commentators believe this is because Kaiser limits patients freedom in choosing how they receive care

The success of the next Kasier-like solution will be affected by how much choice it enables. I wonder what UnitedHealthcare thinks about patient choice?

Monday, August 2, 2010

Public Health Data

Google makes it really easy to visualize large amounts of data. In the chart below, I've modified an example from the Public Data Explorer website: the chart compares Life Expectancy at Birth with Fertility Rates and the bubbles represent GDP of that country. I've only shown BRIC countries, the US, Canada, Cuba, Afghanistan and Somalia.

Click "Play" above. 

Notice how Somalia's life expectancy falls dramatically in the 1990s due to the ravages of war. Also, it appears there's an inverse correlation of fertility with GDP. Not entirely surprising. What is surprising is how much the other countries are catching up (to the US) in terms of life expectancy. When you layer the fact that the US spends a lot more on Healthcare than most other countries, it's easy to think we're not getting better outcomes for more investment. 

Perhaps, that's another obvious conclusion?