"What health care needs is process innovation, not product innovation."

Wow- I love it, this is a simple but great explanation of where we should focus on innovation in healthcare (from Dr. Devi Shetty, a cardiac surgeon and efficiency expert in India). To clarify further: we actually know how to do a lot of things very well (e.g. prevent infections, manage diabetes, cure many cancers)... but instead of trying to make sure we follow these processes 100% of the time, we seem more intent on coming up with the newest product or service that will only be incrementally better than the last one (and which may actually be used by less patients because it is more expensive)!

As it turns out, much of the time, all we need to do are create some easy and cheap process improvements which simply enforce the standards of care we all accept- and we would get much better bang for our buck than any new medication or device! This was highlighted by Dr. Atul Gawande in "The Checklist", an article about Dr. Peter Provonost's simple checklist procedure to prevent line infections in the ICU - which saved a significant amount of lives and money... and yet which has not yet been widely accepted because that is not how American's like their innovations! As Dr. Gawande describes:

The still limited response to Pronovost’s work may be easy to explain, but it is hard to justify. If someone found a new drug that could wipe out infections with anything remotely like the effectiveness of Pronovost’s lists, there would be television ads with Robert Jarvik extolling its virtues, detail men offering free lunches to get doctors to make it part of their practice, government programs to research it, and competitors jumping in to make a newer, better version. That’s what happened when manufacturers marketed central-line catheters coated with silver or other antimicrobials; they cost a third more, and reduced infections only slightly—and hospitals have spent tens of millions of dollars on them.

A more recent WSJ article reviews Dr. Shetty's experience and philosophy about how increasing volume can save money and improve quality:

The approach has transformed health care in India through a simple premise that works in other industries: economies of scale. By driving huge volumes, even of procedures as sophisticated, delicate and dangerous as heart surgery, Dr. Shetty has managed to drive down the cost of health care in his nation of one billion.

His model offers insights for countries worldwide that are struggling with soaring medical costs, including the U.S. as it debates major health-care overhaul. "Japanese companies reinvented the process of making cars. That's what we're doing in health care," Dr. Shetty says. "What health care needs is process innovation, not product innovation."

In the healthcare innovation program I help lead (the Szollosi Healthcare Innovation Program), we have used a similar philosophy to come up with some simple process improvements which have started making a difference. The ExpectED project created a web-based tool which formalized the hand-off from outpatient physician to the Emergency Department. Further evolutions of this project have moved this formalization into our EMR system.

Meanwhile, the Inflection Navigator system allows physicians to send a single order which then triggers a cascade of processes related to one of the defined "inflection points" we are studying (Cancer, Hematuria, Atrial Fibrillation). These processes (including radiology orders, specialist consults and patient education) are carried out by a team of people knowledgeable about each of their separate duties. The result is a more efficient and more consistent process for both patients and physicians.

So as Thanksgiving rolls around, let's rejoice in the fact that there is plenty of innovation left to do in healthcare... much of it right before our eyes!

If HITECH Does Not Work, What are the Options to help with EMR Adoption?

The HITECH incentive plan (estimated at around $38 billon) was established to provide up to $44,000 to every outpatient physician who uses a "certified" EMR in a "meaningful" way (as well as $2-$3 million to each hospital). While its spirit has good intentions, I don't believe they will create a significant amount of new adoption in the outpatient arena because
- The amounts are too low (most systems cost much more to implement).
- There are severe shortages of qualified staff to help physicians convert from a paper to computerized system - a challenging task that includes IT knowledge, workflow redesign and general change management skills.
- The EMR systems are just not very good - both in form and function. See earlier blogs of mine about poor EMR Usability, from April and August, as well as a nice report by Dr. Peter Basch on the problems with current systems. Also check out a new podcast on EMR Usability in which I, and an IT Usability expert, discuss this topic in detail. Finally, here is the HIMSS WhitePaper on EMR Usability: http://www.himss.org/content/files/HIMSS_DefiningandTestingEMRUsability.pdf

So let's review two reasonable options - which are not mutually exclusive:

Change the Underlying Healthcare Reimbursement System
The government could forget the "on-time incentive" idea, and instead focus on long-term reimbursement changes that support quality and efficiency. As we know, our current reimbursement system mainly pays for the volume of "face-to-face visits". EMRs usually slow providers down, although can help them increase their coding levels for higher reimbursement. At best, it's a draw. What if the reimbursement system were instead based on quality (e.g. Pay for Performance) and efficiency (e.g. take care of patients, whether face to face, email or phone)? An EMR has much more potential to help here - by using decision support, establishing registries, and allowing for easy electronic communications. In other words, the government can just help set the reimbursement guidelines to focus on quality and efficiency, and then let the market work on optimizing care in line with that.

Create a Single Healthcare Data Platform
For a fraction of that same $39 billion dollars, the government could rather easily create a single data model and warehouse upon which all other applications can reside - thus solving standards and interoperability issues, increasing adoption, and creating a free market for the "best applications" out there. In fact, a conspiracy theorist might even suggest that the government assumes the current HITECH plan will fail...and thus they put a clause in the plan that says if there is not significant adoption by 2015 - the government can release some type of universal EMR...maybe the universal health database is what makes the most sense?

Several of us have been talking about this "iPhone" like platform in the past year, and here is a link to an interesting meeting that happened in May 2009, which resulted in the following: Ten Principles for Fostering Development of an “iPhone-like” Platform for Healthcare Information Technology
http://knol.google.com/k/kenneth-mandl/ten-principles-for-fostering/9x9jzgucudo6/2# .

And here are some videos from this meeting:
http://www.itdothealth.org/multimedia/2009-hit-platform/#videos

Pulling Forward the Benefits of HIT - Federal Comments

The government is asking for "the public's" input on how to "Pull Forward the Benefits of HIT". I'm a bit confused as to how much they want input on that general topic vs. just how Standards play into it; as well as whether to just post a comment or do something elsewhere... so, I just posted a comment and we'll see if this changes their mind completely :)

Comment Posted to their site 11/03/09
My perspective comes as a practicing PCP (Internist) who has used an EMR since 2002, as Medical Director of Clinical Information Systems for a large primary care group, as a past Medical Director for an EMR company, and active consultant in the EMR space.

I’m all for using EMRs meaningfully, and second, I’m all for rewarding physicians! However, I believe (as many do) that our current crop of EMRs are far from perfect and I have to question whether we could spend that $36 billion a better way than by rewarding mediocre vendors whose products are poorly adopted and poorly used (see the National Research Council’s recent report via this short press release, and this full PDF of the report: http://books.nap.edu/openbook.php?record_id=12572&page=R1). Rather, for a fraction of that money, perhaps we should consider creating a national EMR framework upon which vendors could build their applications (yes- sort of like the iPhone). This then solves interoperability immediately, and lets the vendor compete on applications and user interfaces rather than on all wasting time/money trying to replicate databases which limit their ability and creativity in building what we really need. More thoughts on this topic: http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20090430/REG/304309994/1029&nocache=1#

However, if we do keep the current definitions of Meaningful Use, then my three main talking points would be:
1. E-Prescribing: make this definition broad enough to reward providers who use their EMR to create and print out scripts, don’t limit to just electronic transmission to the pharmacies, as that is not yet a perfect science.
2. Interoperability: reward based on ability to share data in a group or with a hospital, but don’t require regional or national sharing at this point, that is way beyond the means of most providers and vendors.
3. Data reporting: reward based on producing the reports, whether from the EMR, an EDW (Enterprise Data Warehouse) or similar. Most EMRs are bad at report writing, and other tools are needed.
More details on all three at: http://www.histalkpractice.com/2009/08/25/drlyles-meaningful-discussion-about-meaningful-use-82609/