Tuesday, April 27, 2010

Physician Plans for Adoption of Health IT Systems

A recent study on physician plans for adoption of health IT systems found that ARRA and hospital incentives will drive rapid adoption, with 80% of physicians under 55 year of age (and 58% overall) planning to implement an EMR within the next two years.

Healthcare Technology News sat down with Greg Parston, the lead researcher and director for Accenture’s Institute for Health and Public Service Value. 

HTN:  This study is focused on the 10 and under physician market in US?

Greg Parston: That’s correct.

HTN:  The physicians have pretty aggressive plans.

Greg Parston:  Because of what’s happening with incentives provided by ARRA and sometimes being provided by hospitals we are at a tipping point.  There have been many physicians who appear to have been looking into what EMR can do for them.  They’ve been reluctant for many reasons that we identified in the study. But because of these incentives and in part because they can anticipate minor Medicare reductions for non-use, they are becoming more interested. The indications of aggressiveness, if you can call it that, are pretty astounding.

80% of physicians under the age of 55 we talked so say they are going to adopt an EMR system within the next two years and that’s a pretty big shift.  Right now we’re talking about a physician population of about 15% using on EMR and now we were talking about much bigger numbers within 24 – 36 months. 

 HTN:  There’s always been a prediction that the EMR adoption was right around the corner. 

Greg Parston:  Physicians have been looking.  It’s not as if they’re coming to this totally uninformed.   Many practices have been taking a look at different kinds of systems.  They’ve been considering the benefits.  They’ve been talking to people who have a system today.  I don’t think they’ve been doing enough of that. But they’ve been doing enough of it to indicate that they been thinking about it.  So if we’re talking about 58% now, a good portion of that would have been thinking about adopting it in the coming years.  What ARRA has done is to provide the tipping point to make a much larger percentage of small-group practices decide that they're going implement a system.  But also because of the deadlines it’s brought their plans closer.  You’re right to say that there was a time we thought this was going to happen and there was going to be a big surge.  What ARRA has done is to provide the added push and the timetable for that. 

What’s most interesting is the difference in attitude amongst those physicians under 55 and those over 55.  These systems are not inexpensive.  For very small packages it’s a sizable amount of money.  For the older guys they’re there taking a look at when are these reductions going to come in.  How much is it going to cost me?  When am I going to retire?  Those sorts of questions are making them in some cases perhaps a bit more skeptical of it.  More wary of it.  More reluctant.  When you take a look at the younger guys, 2015 (when the penalties kick in) is still within their working lives.  They’re taking a look at how they can avoid any penalties now and put in place a system which potentially has great benefits for them. 

HTN:  Your study cited a key driver for EMR adoption being federal legislation - 61% cited penalties for non-adoption and 51% cited federal incentives.

Greg Parston:  You can’t just look at their reaction to ARRA.  You also have to take a look at their reaction to the potential of local hospital subsidy.  Many local hospitals are offering support of one type or another and some of that support is actually financial.  There’s also aftercare – we’ve heard of doctors who have had a systems crash and have waited up to three weeks for the geek squad to fix it.  Hospitals are offering 24x7 services.  Hospitals are offering training.  Hospitals are offering assistance in transition from written records to electronic records. All of those things along with ARRA are providing a basket of benefits for clinicians. 

And while the study does cite the penalty as the single most importat thing, when you combine the benefits of both the government and their potential networked hospitals, these incentives seem to be the overwhelming influence.

If doctors move to full functionality EMR systems, however meaningful use is finally defined, and if they negotiate well with their local hospitals this could be a rather inexpensive investment for them.  As they’re thinking about this, they’re thinking about how they could network in to hospitals.  This brings them advantage, not just in terms of billing but in terms of patient flow through their referrals.  In another study we found that 75% of the American public want their doctors to have electronic medical records and that must put pressure on practices as well.  They’re sitting there saying:  “This looks pretty good - I can get up to X thousands from the government to put in the system and my local hospital is willing to put in training and support for me - Now is the time.”
HTN:  The study found a strongly held belief in the value of an EMR system to the practice.  The summary in the study was about changing the way the practice works for the better.   I hear various arguments:  Are the majority of of practices using it just to comply with billing and payment requirements for reporting outcomes?  Or are they really into this for better patient care? What is your insight on how this changes the way the practice works for the better?

Greg Parston:  Patient care came up but it wasn’t the top. What was top was trying to develop more streamlined administrative systems within the practice.  And that’s fine.  These guys run businesses and they’ve got to make sure that those businesses are giving them the kind of support and administrative ease that allows them to focus on their patients. 

When we ask doctors who currently have systems whether the systems benefitted them, 90% said they did.  There wasn't any one thing that was identified as the overwhelming benefit.  Doctors use these systems in various ways for various advantages in various places.   Places that have used systems for a very long time like Kaiser Permanente have learned how these systems can not only streamline administrative practices but can also streamline and improve the quality of the patient care process.  There are organizations that really know how to use the EMR.  I’m not sure that doctors who are in small practices are cognizant of all the potential benefits and changes possible with an EMR system in place. 

HTN:  The study noted the exaggerated perception of the difficulties in using EMR systems.  How did that manifest itself?

Greg Parston: It manifested itself in the fear and hesitancy about the systems.  There is another important observation here that came out of the research.  Many of these physicians self-report themselves as being less conversant and less comfortable with computer and Internet technologies than their predecessors.  So the first wave who are already using it – the 15% who are already there - they identify themselves as more IT literate.  Some develop these systems because they want to be on the edges of modernity.  You and I have friends that have every piece of technology around the house because they have to have it.  There are doctors like that too.

The next generation if we can call it that – the people we were talking in that 58% (or under 55, that 80%), they’re more fearful.  They don't feel as comfortable with these technologies.  They certainly don't feel able to service it themselves.  So they raise bigger questions about how difficult is it going to be implement it or how difficult it’s going to be to get service.  Am I going to find that it’s going to crash and am I going to run into real problems in my practice?  Those questions don't come from looking at the systems.  Those questions come out of their own personal lack of total comfort with new technologies.  That’s something that’s going to have to be overcome through learning more and through use of these systems.  And here I think that vendors and hospitals that are trying to network doctors in can be of enormous help in providing much more education and support and understanding to make them much more comfortable more quickly. 

HTN:  What was the timing of your survey?  Was this pre- December 30, before the meaningful use rules were issued? 

Greg Parston:  Yes it was.  It was also right during the height of the health reform legislation.  We had been timing this study to occur in the Autumn and we took a judgment about whether or not we should do it during the midst of that debate.  We decided we should because people would be even more cognizant   and sensitive to the issues.  Healthcare reform legislation is going to change American healthcare.

HTN:  What do you think would be the impact of the meaningful use rules on physicians planning to adopt an EMR? 

Greg Parston:  There’s 600 pages there and I only know one person who’s read all 600 hundred. And they’re still being modified as we speak.  Meaningful use is essentially about trying to get people to use the system to full functionality, cognizant that people are concerned about privacy issues and lots of other things.  Meaningful use will drive people to take a look at what they get from that next step of functionality.  By linking the incentive payment to increased meaningful use physicians will begin to explore more. 

They’re not going to jump all the way into whatever the top level of meaningful use is simply to get the money.  But knowing that the money is there, they’ll begin to explore further the edges of their systems.  And they’ll begin to think about how they can use them in a new ways. 

I’ve already mentioned Kaiser Permanente.  There’s a quote in recent article about Kaiser Permanente – about how the system can actually change things - about how doctors will use these technologies to adapt their practices.  The quote goes something like this: that if you give a lumberjack, who’s been using an ax his whole life, a chainsaw and he starts hacking at the tree it’s not going to help him. It's only when you begin taking a look at how this chainsaw works and what a difference it can make that it can make a difference in his life.  I think that’s the same with an EMR. 

This is a new technology that’s going to allow people to do lots of different things.  Meaningful use is a carrot as well as an instruction about how you can learn how to use the chainsaw in the way it was designed to be used. 

HTN:  You mentioned the striking impact the health reform legislation will have.

Greg Parston:  It’s going to force people to take a look at what we mean by connected health.   I don't mean that in a technology sense. I mean it in the sense of really connecting agencies together to try to deliver value for the public in health terms, not just in health service terms.  And that’s pretty exciting to me.  This legislation will unleash a whole new part of the market on the demand side.  And there are people on the supply side that are very good at innovation and thinking about how they can serve the needs of people who have not been served before. And a lot of that isn’t episodic acute care.  I think we could see a very different health system in two decades from what we've got now.  What we’ve got now is one that largely focuses on episodic transactional care.  I think we can get something which is much more about helping me deal with my health through the continuum of my life.

Greg Parston is the director of the Accenture Institute for Health & Public Service Value. Prior to joining Accenture, Dr. Parston was the chairman of the Office for Public Management, a nonprofit organizational development company that he co-founded in 1988 and led as chief executive until 2003. Dr. Parston has consulted widely with top managers, focusing on governance, strategy and change and has worked as a manager in the public, private and not-for-profit sectors. Until taking up his current post, he also was a director of the Priory Group, responsible for public service partnerships.

Thursday, April 22, 2010

NHIN Direct Addressing Specification

Guest author and member of the NHIN Direct Implementation Group John Halamka provides an update on:

The NHIN Direct Addressing Specification

Every Tuesday, the NHIN Direct Implementation Group holds a teleconference to update the entire team on the progress of the technical workgroups. This week, we discussed the completed addressing specification.

As I've said many times in my blog, the most important standards implementation problem to solve right now is transport, not only the basics of transmitting data securely but also transaction orchestration and the constellation of supporting functions such as addressing the messages.

In previous blogs, I've described one way to solve the addressing problem - give every patient a voluntary opt in "Health URL" that they could use to receive all healthcare data from hospitals, offices, labs, and pharmacies.

For use cases such as sending data from provider to provider, hospital to provider or provider to public health we need some similar approach to ensure data is delivered to the right place.

The NHIN Direct Addressing specification proposes five ways to do this - secure email addressing (SMTP plus TLS), REST, SOAP, and the HL7 routing schemes XCN and XON.

First, two definitions. A "Healthcare Internet Address" is made up of a Health Domain name and a Health Endpoint Name

Health Domain Name
A Health Domain Name is a string conforming to the requirements of RFC 1034.

A Health Domain Name identifies the organizations that assign the Health Endpoint Names and assures that they correspond to the real-world person, organization, machine or other endpoint that they purport to be. For example, my organizations (BIDMC and Harvard Medical School) could control nhin.bidmc.org or nhin.hms.harvard.edu

A Health Domain Name MUST be a fully qualified domain name, and SHOULD be dedicated solely to the purposes of health information exchange.

Organizations that manage Health Domain Names MUST maintain NHIN Direct Health Information Service Provider (HISP) Address Directory entries for the Health Domain Name, as specified by the Abstract Model, and corresponding to rules established for concrete implementations of the Abstract Model. Organizations that manage Health Domain Names MUST ensure that transactions are available for Health Endpoint Names, either through proprietary means or following the Destination role transactions of the Abstract Model. Organizations may take on the HISP role or assign this function to another organization playing the HISP role (such as GoDaddy does for hosting regular email on behalf of other organizations).

Health Endpoint Name
A Health Endpoint Name is a string conforming to the local-part requirements of RFC 5322

Health Endpoint Names express real-world origination points and endpoints of health information exchange, as vouched for by the organization managing the Health Domain Name. For me, that could be a person such as Dr. John Halamka, an organization such as BIDMC Emergency Department or an aggregation point such as BIDPO Quality Data Center. Here are examples of each address type

Jhalamka@nhin.bidmc.org for health information exchange (not regular email) directed to me at BIDMC

REST (example of a possible format)

1_0 refers to the REST API version.

SOAP (example of a possible format)

the person or organizational endpoint would be specified in the message itself.

1_0 refers to the SOAP API version.

HL7 XCN (extended composite ID number and name for persons)
urn:nhin:nhin.bidmc.org:jhalamka^Halamka^John^D^DR^MD^^&NHIN OID&OID

The XCN representation could be used in multiple contexts, including the intendedRecipient in an XDS/XDR web service call or in an HL7 2.x message to refer to the sender or receiver of a message (e.g., in a PV1 segment)

HL7 XON (extended composite name and identification number for organizations)
Beth Israel Deaconess Medical Center^^^^^&NHIN OID&OID^^^^urn:nhin:nhin.bidmc.org:emergency_department

Note that XCN and XON are included for compatibility with the IHE XDR spec, NHIN Document Submission, and HITSP T31.

Imagine if every EHR could send data to every other EHR using a simple addressing mechanism like Email, a consistent REST implementation or a well described SOAP WSDL. Interoperability would follow rapidly because novel packages of data will be sent to support real business needs without any barriers of how to get the data from endpoint to endpoint.

The NHIN Direct process is working well and builds upon the work of the past. It does not compete with, diminish, or in any way represent a replacement of the hard work done by so many people over the past years in HITSP, IHE, and the SDOs.

I'll continue to provide NHIN Direct updates as reference implementations with running code are deployed. Massachusetts, through NEHEN and the Massachusetts eHealth Collaborative has volunteered to test these techniques with other surrounding states. Let the testing begin this Summer!

Friday, April 16, 2010

Chronic Disease and the Internet Access Gap

Adults living with chronic disease are disproportionately offline in an online world.  The internet access gap creates an online health information gap.  Only 62% of adults living with chronic disease go online, compared with 81% of adults who report no chronic diseases.

Lack of internet access, not lack of interest in the topic, is the primary reason for the gap. When demographic factors are controlled, internet users living with chronic disease are slightly more likely than others to access health information online.

More than any other group, people living with chronic disease remain strongly connected to offline sources of medical assistance and advice such as health professionals, friends, family, and books. However, once they have internet access, people living with chronic disease report significant benefits from the health resources found online.

The report, “Chronic Disease and the Internet,” surveyed 2,253 adults, 36% of whom are living with chronic disease (heart conditions, lung conditions, high blood pressure, diabetes, cancer).

51% of American adults living with chronic disease have looked online for any of the health topics included in the survey, such as information about a specific disease, a certain medical procedure, or health insurance. By comparison, 66% of adults who report no chronic conditions use the internet to gather health information.

Thursday, April 1, 2010

Health Wonk Review: Special Edition on Health Care Reform

"The unfinished business is done."

Health care has never been so center stage and so enmeshed with policy and politics.  It took 100 years, starting with Teddy Roosevelt's 1912 presidential campaign. Seven presidents tried including two Republicans and five Democrats. 

Who won? Patients won't be denied coverage for pre-existing conditions (eventually) and are no longer subject to lifetime caps.  Physicians will benefit from the coverage expansion and increasing fees for Medicare primary care. Government trims the rate of growth of the deficit. Small business gets a tax break. Students can stay on their parent's plans until age 26. Seniors see the close of the Medicare prescription drug doughnut hole.  And hospitals receive payments for more of the care delivered. 

Not all of the "winners" improve access/health/costs:  Pharma doesn't have to negotiate for drug prices. Payers will still find reasons to deny care and are permitted medical loss ratios of 80-85%.  

The Debate

Did it go far enough? Could a public option have done more to hold down administrative costs and improve access and health?  Mad Kane skewers the "something is better than nothing" half-a-loaf theory with an hilarious limerick.

And in the aftermath of the bill's passage, Republicans warn of no cooperation for the rest of the year. You can just imagine Mad Kane's sharp witted riposte - - check it out in Addled Threats posted at Mad Kane's Political Madness.

Louise at the Colorado Health Insurance Insider reports that the Colorado and other Attorneys General are questioning the legality of the Health Insurance Mandate.  Basically, they’re saying that the federal government doesn’t have a constitutional right to compel citizens to take part in any specific market – including health insurance.

Health care reform unconstitutional?  Get over it. David Harlow's Health Care Law Blog spells it out. 

David Williams at Health Business Blog makes the case that  health reform would not have made it through Congress without unwitting help from Republicans.  "My biggest chuckles have been with Republicans complaining about Democrats using unfair processes and not accepting the will of the people."

Bob Vineyard lays out the questionable economics of the tax penalties for non-insurance in We Have Ways posted at InsureBlog

Austin Frakt at The Incidental Economist asserts that individual mandate penalties are adequate.  Some claim that health reform's penalties for failing to purchase insurance are lower than those in Massachusetts and therefore invite gaming of the system. Those claims are false.

Jared Rhoads at the The Lucidicus Project ("All Talk, No Debate") argues that there was never a principled debate around healthcare reform. Too much bickering. Ya think?  Also, at The Lucidicus Project:  21 brief thoughts and observations, Thomas Sowell-style, on health reform.

Jaan Sidorov at Disease Management Care Blog does a back of the computer monitor calculation and divides the $940 billion price tag of health reform by the number of lives that were reportedly being lost for lack of health insurance.

Minna Jung at Health Reform Galaxy Blog reminds us that the job of educating people about what did just happen in the health reform debate, and what will happen, is not over, not by a long shot.   

Anthony Wright at Health Access Blog spotlights a study showing that health services provides states with their best bang for their buck in terms of job creation and/or retention. Health care does much better from a "jobs per billion" metric than tax hikes or cuts.

Joe Paduda at Managed Care Matters endeavors to anger people on both sides of the political spectrum with this two-parter:  Unsustainable, irrational, unaffordable health reform and Flip flopping on the mandate - Gingrich's hypocrisy.

John Goodman's Health Policy blog contends that health reform won't reign in government spending, as the legislation will require just about every non-elderly person in America to buy health insurance, the cost of which is going to rise at twice the rate of growth of their incomes.

Tinker Ready at Boston Health News reports on the Brown and Romney dance around Mass Reform.

Jeff Goldsmith at Health Affairs Blog reviews the performance of the Obama administration during the recent health reform debate through the lens of David Blumenthal and James Morone's book Heart of Power.

The real work begins

Anthony Wright at The New Republic's "The Treatment" blog writes the real work now begins.  The work of health reform doesn't just continue, but explodes at the state level. In California, bills are already moving on issues from rate regulation to a public health insurance option.

As a great example of the impact on the states, Mike King at Georgians for a Health Future describes the work in front of Georgia in response to the health reform legislation. 

David Harlow at Health Care Law Blog interviewed Don Berwick about 18 months ago. As Don heads into the post of CMS Administrator, it is a timely window into the thoughts of the person who will be responsible for implementing a great deal of the health reform law.  Neil Versel at FierceHealthIT thinks Don Berwick will embrace IT as long as it improves quality. Ken Terry at BNET Healthcare believes that Don Berwick's big vision will make him a political target.

Dr. Sheldon Horowitz at the Health Reform Galaxy Blog reports on a Rx for primary care. Improving Performance in Practice (IPIP) is devoted to helping doctors in primary-care practices improve the quality of care they provide and encourages them to work with support staff to ensure their time is well utilized.

Vince Kuraitis at e-CareManagement blog recaps pilots, demonstrations and innovations in the health reform bill.  Just what are these demos and pilots in the PPACA all about? Vince was boggled by the sheer number and complexity, and shares his findings.

Fred Lee presents Crowded Hospitals And Mortality posted at Healthcare Hacks. In certain cases, patients admitted to crowded hospitals stand a 5.6% higher risk of dying.

Ethics and Economics

The law of unintended consequences strikes again: Erik Turkewitz at the New York Personal Injury Law Blog contends that the health reform bill will be a big benefit to personal injury victims.

Jon Coppelman at Workers Comp Insider explores the dynamic tension with employers and payers:  "it would be nice to think that the pending expansion of healthcare benefits to nearly all Americans might make this cost-shifting problem go away. Alas, the game of 'pin the tail on the payer' has only just begun."  He also presents Dueling Shrinks: Uncompensable Depression.

Jason Shafrin at the Healthcare Economist describes some recent work evaluating proposed changes to Medicare's hospital wage index..

Roy Poses at Health Care Renewal presents a sobering report on The Settlement and Conviction Round-Up: Friday Frequent Flier Edition. 

For your reference

Silicon Valley Blogger provides an overview of Health Care Reform Bill: How It Affects You posted at The Digerati Life.

Shannon Wills presents 100 Great Twitter Streams to Stay on Top of Health News posted at Radiography Schools. An outstanding list of sources in 140 characters or less.

Raymond Fernandez20 presents 25 Little Known Ways Everyday Technologies Are Affecting Your Health posted at Online BSN.

Clay at the Health Crazies compiles resources on how each state’s health stats stack up. 

Joel Ohman at Healthcare Insurance Providers graphically presents the health reform time line.  You'll want to keep this close by for easy reference.  It's reproduced below.

Health Care Reform
Infographic by HealthInsuranceProviders.com

Next Health Wonk Review will be hosted by David Harlow at Health Care Law Blog.