Sunday, March 28, 2010

Why I Blog...

Last month, a friend and fellow blogger asked me why I blog... and I had to stop and think about it for a second, but it became quickly clear to me there are two main reasons:

1. So that I can document my ideas and experiences in a single repository, which I can then refer to later. Sometimes these are thoughts stirred by the current climate or an experience I've had. Other times I am directly "responding" to articles I have read - and thus this blog allows me to save a link to the article and why I thought it was particularly good or at least thought-provoking.

Although I mainly am just creating these blogs as a placeholder for ideas I want to think more about at another time... It turns out that I often use them as a source to explain myself more quickly to others. So if I get an email asking about my thoughts on EMR adoption or usability or the new healthcare plan, I can provide a quick summary and then a link to my blog which has details. In other words, although it takes some time to write the blog, if I can re-use it in these ways, I can actually be more efficient.

2. Writing helps me take some whirling thoughts and put some order into them - forcing some definite structure. In other words, it helps me generate a clear product that both I, and others, can understand and ideally use in some way.

So while I mainly write for myself, if these blogs stimulate thoughts, ideas and motion from others- then all the better. Last month, my little blog actually was recognized in the list of "Top 50 Healthcare IT Blogs", which I really appreciated (of course, maybe there are only fifty of us?). So hope everyone out there is enjoying reading along!

Monday, March 22, 2010

Healthcare Reform (well, at least Insurance Reform)

The Change Doctor Blog has to comment on this important moment in our country's history... On Sunday night, the House passed “The Patient Protection and Affordable Care Act,” a landmark health care reform bill. This legislation, along with a crucial package of specific improvements, aims to lower costs and expand access to millions of Americans. It's been a long road, but the echo of "Yes, We Can!" rings a bit louder this week.

While it is not ideal, we are at least closer to reaching what I believe is both an ethical and financial imperative in making healthcare insurance affordable to every American. A good summary of this bill is found in this MarketWatch article. Also check out:

But let's not kid ourselves- the race is far from over. We need to realize that this is just "Insurance Reform", meaning that it makes insurance companies act as they should act: like risk pools who do not get to cherry pick who is in their pool (i.e. no more exclusions based on past history). At the same time, it makes the game fair for insurers by pushing everyone to get insurance - thus making sure that young, healthy adults don't get to completely opt out of the system. There are nuances, but that is the core part of what is happening - and it will take a few years to get into full effect.

What this does NOT do is stop the spiraling cost of healthcare related to increasing illnesses, tests and treatments... in a system that predominately rewards Volume over Value. In other words, the second part of this movie is "Reimbursement Reform", in which the government helps shift reimbursement of quality and efficiency over simple volume. For example, in the current volume-based system, a Primary Care Physician (PCP) makes money by seeing as many patients as possible in their office. The result is increased cost for patients and insurers, and a shortage of PCPs to do all this work. In a value-based system, a PCP could oversee a team of nurses who manage a much larger group of patients - taking care of the stable ones via phone and web-based services, and only needing to see the sickest and most complicated patients in the office. The result would solve both the cost and access problems we face!

Fortunately, this issue is not lost completely in this insurance reform bill. Atul Gawande, MD, correctly points out in a December 2009, New Yorker article, that the current bill does provide some ability to "test" new reimbursement ideas. Let's hope that those tests quickly prove some ideas which can then be extrapolated... because otherwise we will look back on a collapsed healthcare system in a few years and point to all these problems we know about, and say we wish we had done reimbursement reform sooner.

Saturday, March 13, 2010

The Dawning of the EMR as a Platform...allowing us to "get the health care that we build"

Joe Flower continues to be one of my favorite healthcare writers. In a recent article in HHN Online, he talks about the heroes in healthcare who are constantly trying to improve the system. I love the quote on which he ends his article:

As Aristotle famously shaped it, "We are what we repeatedly do. Excellence, then, is not an act, but a habit." We will not get the health care that we want. We will not get the health care that we deserve. We will get the health care that we settle for. We will get the health care that we build, where we are, with the tools that we have, with the courage and compassion and collaboration and hard insistence on excellence that lies within us.

At the recent HIMSS conference, I think we began to really see the first signs of an important paradigm shift in the EMR world which will help make this ability to build a better healthcare system more feasible. Specifically, we saw the rise of the "Ecosystem" or "Platform" - terms which will become the buzz word of the coming year as vendors are starting to "open" up their systems (e.g. via APIs, or other technical and business transparency).

Stepping back, the historical scenario for an EMR vendor is to sell you all three tiers (database level, application/functionality level, and user interface level) as a tightly integrated unit. The upside is they should all work well together, the downside is minimal ability to customize one layer without having to get involved with the other layer because they were so tightly linked. For example, if you wanted to display vital signs in a different way in your user interface - you would also have to change the underlying data model and application abilities. We can refer to this as the "Tyranny of the Three-Tier Architecture".

Unfortunately, what we have seen are quite bad user interfaces from the EMR vendors and minimal ability for real life users to improve upon them. The result has been poor adoption of EMR systems, as well as multiple instances of "unintended consequences" from poorly defined user interfaces. Fortunately, the EMR vendors must have realized this was the case (or they are getting spooked by the new crop of HIE vendors and system integrators who are trying to take their data and allow for more customized user interfaces).

So at HIMSS, I found that many EMR vendors are now allowing at least some ability for users or third parties to create new widgets and user interfaces to "put on top of" their EMRs. We are still pretty early in this phase, but eventually- the hope is that this will become analogous to Apple creating the "iPhone Platform": The EMR vendors will ideally compete to create the best platform which will then allow for some true innovation at both the application and presentation layers, or alternatively brand new vendors will come along to create platforms which take what is needed from legacy systems while allowing for others to build on top of them in a unified environment (e.g. GE's new Qualibria). Either way... the ideal result will be an Ecosystem where we can indeed Build the Healthcare System we need and deserve.