Well,
it’s Spring, 2014. Most of the dirty snowpiles are gone here in Boston &
I’m hoping we’re done with Winter finally (although it’s supposed to snow
tonight). It’s been a tough few months, though, for healthcare reform. Even
with the debacle of the ACA website launch behind us & over 5 million
people signed up for care under the act, there are still many issues &
events that call into question some of the underpinnings of the reforms we are
working toward. A non-inclusive list would consist of:
- Idaho - The U.S. District Court (Idaho) found that the acquisition by St. Luke's Hospital System of the 40-provider primary care medical group, Saltzer Medical Practice, violated federal anti-trust law[1] since the combined organization would control over 80% of the primary care physicians in the area. The court acknowledged that the acquisition was done in order to improve the ability of St. Luke’s to provide primary care, & that it in all probability would improve primary care in the area, but that it was still illegal. If upheld, this has all sorts of implications for ACOs & other new forms of healthcare organization consolidation.
- Black Book Survey - A new Black Book Survey[2] reported in Government Health IT found that 95% of payers, 83% of hospitals & 75% of providers thought that publicly funded HIEs had flawed business models & provided no meaningful connectivity. So much for public information exchange.
- CCHIT's recent announcement that they are ceasing to do certification of EHRs.[3] Their new CEO cites the complexity of Stage 2 certification & the "vagaries" of ONC's Stage 3 timeline & content. Apparently their Board felt that there was no sustainable business model remaining in certification. If their assertions/assumptions are true, then Stage 2 & Stage 3 are in for a rough road.
- IDC Health Report - IDC Health Insights has just released a report on 2014 healthcare IT trends.[4] It basically says that first generation (Stage 1 & 2) meaningful use of EHRs has "failed because even if providers qualify for Stage 2 MU, they still do not have the tools they need to actually improve outcomes & reduce costs. Specifically the report talks about EHRs (& MU) not realistically addressing: provider-to-provider connectivity (including eReferral), provider-to-patient connectivity, patient-to-patient connectivity, care management & transition, medication reconciliation, analytics for revenue & cost management etc. In short, EHRs must become an application & data platform to layer additional necessary capabilities on. To the extent that this is done successfully, HIT will continue to provide value. The report highlights many other areas including: use of private cloud, privacy & security, consolidation of healthcare organizations (see first bullet above), but the EHR "predictions" are most relevant to us for this purpose.
&
finally:
- A study published in the Journal of the American Medical Association (JAMA)[5] looked at 32 NCQA PCMH certified primary care practices & found very limited improvement in quality (improvement in 1 of 11 quality measures assessed) & no significant change in utilization or cost of care over three years. The authors’ primary conclusion was: “These findings suggest that medical home interventions may need further refinement.”
OK
– I’m ready to give up… not really. What should we make of this litany of
issues, problems & unexpected results?
First,
it’s important to understand how early we are in many of these reforms. The
HITECH Act , Title VIII of the American Reinvestment & Recovery Act (Public
Law 111-5) was published in February 2009. Supplementary payments from CMS for
meaningful use of certified EHR technology began in 2011 & we are only at
the beginning of the fourth year of such payments & just at the beginning
of Stage 2 of meaningful use. The adoption curve for EHR technology is
necessarily difficult, as it requires alignment of clinical practice with both
new software technology & new workflows for provider-patient interaction.
There are other important factors for why this adoption is difficult &
they’ll be discussed shortly.
The
National Committee for Quality Assurance (NCQA) first published criteria for
Patient-Centered Medical Home qualification in 2008, & we are about to go
to the third version (2011, 2014) of those criteria. Currently about 7000
primary care practices (10% of those in the U.S.) are recognized by NCQA as
PCMHs, but that means that 90% are not.
Health
information exchange organizations have been around well over a decade. They
predate the Office of the National Coordinator (formed by Presidential Executive
order in April 2004), the HITECH Act (February 2009) and were originally formed
to provide economies of scale for costs and to improve clinical outcomes
through data sharing. According to the eHI 2013 HIE Survey[6]
there are about 315 HIEs in the country & half of those reporting were
financially viable in 2013 (& so half are not). There were many other
issues including technical (substantial difficulty of interoperability &
data acquisition from multiple (EHR) sources) & organizational (lack of
cooperation &/or data sharing among HIEs).
Finally,
ACOs… The Patient Protection and Affordable Care Act (PPACA) requires, under
Section 3022, that a Medicare Shared Savings Program (MSSP), be established
which is intended to improve quality of care while containing costs. The
program began in January 1, 2012. Groups of providers, healthcare organizations
formed Accountable Care Organizations (ACOs) in order to qualify for payments
or shared savings by managing and coordinating care for Medicare
fee-for-service beneficiaries. We’ve had two years of experience with ACOs
during which time the model has evolved as the issues associated with shared
risk have become apparent. Accountable care (basically capitation) has become a
focus of HIE evolution as the exchanges try to evolve to more sustainable
business models – whether this is a more sustainable model, however, remains to
be seen.
We’ve
had between two & four years of experience with these reforms (meaningful
use, HIE, ACO), & we know several things from many years of study &
experience with technology adoption. Thing 1 – You can incent technology
acquisition, but you cannot incent technology adoption; & Thing 2 –
Technology adoption depends on the alignment of the new technology with both
organizational culture & the work being done. Any substantial difference in
either means that either the technology will not be adopted (used) or that it
will be adopted (used) imperfectly. In any case, adoption will take much longer
than anticipated or planned.
I’ll
look at meaningful use in this post & cover each of the other reforms in
future posts… IDC Health Insights has issued two reports recently that are
pretty damning of meaningful use as currently defined. The one I’ve already
cited on HIT Provider Predictions for 2014 & a report on ambulatory EHR[7].
The first report controversially states that first generation EHR technology,
& by extension the meaningful use effort associated with it, has failed.
Current EHRs are not engineered for post-reform healthcare models. The levels
of interoperability, connectivity, usability & usefulness they provide are
just not effective enough for the expense they incur, both financial & in
terms of the change required to use them. As long as EHR technology & the
incentive programs associated with their adoption are based on billing &
our current reimbursement system, the use of EHRs will be seen as a financial
necessity, not as a clinical advantage. It needs to not only be seen as both,
but to actually be both. The second report lists a set of issues with current
EHRs for ambulatory practice (in the real world, the issues are not so
different for hospital-based practices). These issues are focused around the
loss of productivity after adopting an EHR. The survey found close to 60% of
ambulatory providers were neutral to very dissatisfied with their EHR & the
two biggest complaints were that it took substantially longer to document
patient encounters (including the system inadequately representing provider
notes), & that many fewer patients were able to be seen (because of the
first issue). Additionally, providers complained about poor reliability &
usability, inefficient (& ineffective) workflows, poor integration with
mobile devices & a variety of other problems. IDC Research Director Judy
Hannover stated (in the second report), "Despite achieving meaningful use, most office-based
providers find themselves at lower productivity levels than before the
implementation of EHR. Workflow, usability, productivity, and supplier quality
issues continue to drive dissatisfaction and need to be addressed by suppliers
and practices."
To continue in this vein (did I actually say
that), David Blumenthal, former National Coordinator of HIT (ONC, HHS) now
President of the Commonwealth Fund gave an interview in The Atlantic (19 March
2014)[8] where he
said, "there are substantial costs in setting up and using"
health IT systems.” He added, "Until
now, providers haven't recovered those costs, either in payment or increased
satisfaction, or in any other way." Blumenthal went on to say "The
disincentive to adopt HIT is related to the brokenness of the health care
market." He said, “]f the medical market functioned like the
car industry or the computer industry or the service industry, with true
competition based on quality and price, providers would have adopted electronic
records long ago." This insight that healthcare, for all of the talk
about market incentives & market forces acting in it, is not really a
market is important, & one that I’ll return to in another post.
These disincentives combined with the fact that a
bit greater than 50% of healthcare organizations are planning on replacing
their current EHR vendor in the next 12 months clearly indicates that we have a
long way to go to align EHR use with actual meaningful use. What could be done
to facilitate this alignment? Here’s a list (non-inclusive & also to be
returned to in future posts):
- Nathan Myrvold, former CTO of Microsoft & (unfortunately) current patent troll, made the distinction between usability & usefulness. Regardless of how technically usable EHRs are (& they provably are not), this is not a major impediment to adoption, so long as they do something useful for their target audience. Once EHRs provide capabilities that providers find useful in their interactions with patients (& not just necessary for more effective billing), effective adoption will not be an issue.
- Many other industries (as David Blumenthal points out) have struggled with the adoption of new technologies in the past 25 years. Two that I have worked in directly are automobile manufacturing (General Motors) & aerospace (Boeing, McDonnell Douglas). Each of these industries underwent very disruptive workflow & work process redesign during the 1980s-1990s as they adopted new information technologies. These re-engineering efforts led to increased productivity & lower costs – exactly the outcome (along with improved clinical outcomes) we want to see in healthcare. This work has not, for all the rhetoric of EHR adoption & meaningful use, been done in healthcare & it needs to be. Re-engineering of both the business & clinical work processes is necessary in order to be able to adopt & productively use new technology – otherwise you are just “paving the cowpath”
- Vendors must also revise & redesign EHR products based on usefulness & not primarily on meeting meaningful use criteria. Current products are neither really useful in a clinical sense nor meaningful in the sense of the Triple Aim. If CCHIT is right, & there is no sustainable business model in meaningful use certification, then vendors must reexamine the design, including both the user experience & the product functionality to ensure that their products facilitate the Triple Aim. Providers must insist on usefulness & alignment with redesigned workflow as features of future EHR products
- HHS just released its 2014-2018 Strategic Plan[9]. It emphasizes Stage 2 & Stage 3 Meaningful Use as the primary HIT effort during this time. HHS & the ONC need to revisit this plan in the light of these, & other current opinions, issues & criticisms regarding EHR use & meaningful use. I recently heard both Marilyn Tavenner (Administrator, CMS) & Karen DeSalvo (National Coordinator for HIT, ONC) speak at the HIMSS14 conference. Both emphasized staying the course on meaningful use (although Dr. DeSalvo’s message was more nuanced). A re-exmination of this strategy is necessary if HIT, as envisioned by the relevant government agencies, is to provide real progress in improving clinical outcomes, improving population health & reducing per-patient costs.
PCMH is next, then HIE/ACO…
[1]
http://www.ag.idaho.gov/consumerProtection/pendingActions/stLukes.html
[2]
http://www.prweb.com/releases/2014/01/prweb11503131.htm
[3]
http://www.cchit.org/press-releases/-/asset_publisher/l7V2/content/2014-01-29-business-transition?redirect=https%3a%2f%2fwww.cchit.org%2fpress-releases%3fp_p_id%3d101_INSTANCE_l7V2%26p_p_lifecycle%3d0%26p_p_state%3dnormal%26p_p_mode%3dview%26p_p_col_id%3dcolumn-2%26p_p_col_pos%3d1%26p_p_col_count%3d2
[4] U.S. Healthcare Provider IT
2014 Top 10 Predictions: IT Priorities for the Post-EHR Era http://www.idc.com/getdoc.jsp?containerId=HI244741,
accessed February 20, 2014.
[5] Friedberg, M.W. et al.
2014. Association Between Participation in a Multipayer Medical Home
Intervention & Changes on Quality, Utilization & Costs of Care.
311(8):815-825. Accessed on 15 March 2014.
[6]
http://www.ehidc.org/resource-center/surveys
[7] Business Strategy: The
current State of Ambulatory EHR Buyer Satisfaction. IDC Health Insights (Doc
HI244027). November 2013.
[8] See iHealthbeat: http://www.ihealthbeat.org/articles/2014/3/21/blumenthal-says-realizing-promise-of-ehr-adoption-will-take-time.
Accessed 18 March 2014.
[9]
http://www.hhs.gov/strategic-plan/introduction.html
