EMR Risk & Opportunities Map

Medical information is rapidly moving from paper records to electronic formats and new sources of information are being added. The electronic formats provide opportunities to capture, store, share and use information in new ways. These new ways create risks and opportunities.

Most of the elements identified and discussed here have been identified and discussed by others. What is new, is a broader view of more elements at the same time and their interdependencies.

It is these interdependencies that pose risks and create opportunities.

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THE MAP

EMR: Free? Really!

Free is a marketing term that typically evokes a mixed set of reactions ranging from an optimistic “You have my attention, tell me more,” to a cynical “There’s gotta be a catch,” to a pessimistic “There’s no such thing as a free lunch.” All three of these showed up when I heard about a free electronic medical records system offered by a company called Practice Fusion.

Their Web site referenced the book Free: The Future of a Radical Price, which includes an analysis of “How can healthcare software be free?” So I read the book. The basic theme is that costs of data storage, transmission, and processing are falling so fast—on the order of 50% per year–that the costs associated with “bits” of data (as contrast to “atoms” or physical stuff) are heading for zero. With atoms, revenue usually has to be associated with cost. With bits, revenue can be loosely related to costs or even independent of costs.

At the level of a private or small group medical practice the typical evolutionary path for medical records is from paper to site-specific computer to networked systems. Most of the software being sold today is site specific which means the doctor has to pay the up-front costs and networks will be added on. But, only some of the value accrues to the doctor and there is little or no broad agreement about what the networks will be or how they will be managed.

Practice Fusion sees the value in both the local data and data that is networked. Their basic premise is that by providing an EMR to a doctor the doctor’s data will be in a format consistent with the data of all of the other doctors using their system. With the appropriate consents and controls in place, the data can then be networked among subscribing doctors with full compatibility. Subscribing Doctor A can send a patient’s data to Subscribing Doctor B without translation, formatting or delay. Doctor A can send data to other doctors who do not subscribe to Practice Fusion with a similar level of ease or difficulty as using a site-specific system. Data can also be forwarded to billers and insurers.

With appropriate consents and controls in place, the data from multiple practices can be de-identified, consolidated, and shared with public health agencies and medical researchers to further increase its value at a very small increase in costs. Data can be sold at a higher price because it will be in a standard format and in larger quantities. A researcher, whether a not-for-profit institution or commercial company that needs 1,000 records will be able to go to one place and quickly get records of a known quality. Practice Fusion will recover its investment and cost from advertising (optional to users) and the sale of the data.

Practice Fusion has placed itself in the enviable position of having a cost structure that is getting less expensive and a revenue stream derived from data that is becoming more valuable over time as it gains longitudinal range.

Free presents the following hypothetical model:

Medical associations conducting research on specific conditions require longitudinal health records for a large set of patients. Depending on the focus of a study (think white, middle–aged, obese males suffering from asthma) each patient’s anonymized chart could fetch anywhere from $50 to $500. A physician typically sees about 250 patients, so Practice Fusion’s first 2,000 clients translate to 500,000 records. Each chart can be sold multiple times for any number of studies being conducted by various institutions. If each chart generates $500 over time, that revenue should be greater than if Practice Fusion sold the same 2,000 practices software for a one-time fee of $50,000.

[Practice Fusion is now reporting, “… 30,000 users across all 50 states and US territories.”]

Free is an option worth considering. Does that mean you should sign up? No.

The normal business process for selecting a system is to do a high level search and assessment to narrow the number of candidate systems for further study. The fact that free makes sense just means that a Practice Fusion system, or others like it, qualifies as a first round candidate.

The next step would typically be to prepare a cost/benefit study among the top few candidates. Because one of the systems is no-cost, the focus for the next step should be based largely on benefits.

Moving medical records from paper to a computer system provides opportunities to reduce office costs and improve both administrative and medical services to your patients. Benefits will include those directly related to the creation, storage, use, and networking of records plus those related to administration such as the non-medical part of patient records, appointments, billing interfaces, etc.

If you have already done your homework, now is the time to look at the benefits of a no-cost system. If you haven’t done your homework, check with other doctors and see what systems they recommend—both positive and negative. Get vendor documentation for other systems and acquaint yourself with the benefits those systems offer. Make a list of must have, like to have if cost is reasonable, and nice to have. Also, a list of things to avoid (negative benefits.) Now go look at a no-cost option and compare the benefits.

If a pair of shoes doesn’t fit, they aren’t worth taking home even if they are free. If a system doesn’t provide the benefits you need, don’t waste time considering it further. You do not want to change your practice to save money on a system. You want a system that will allow you to get the benefits at the lowest cost in terms of dollars with no negative impact on performance.

If a no-cost system provides the benefits you need at least as well as a for-cost system you have your answer. If two systems have comparable benefits, the cost/benefit analysis will always be better for a no-cost system than one where you buy it or pay a license fee.

If a no-cost system meets you minimum requirements and a for-cost system provides better benefits, you need to judge whether the better benefits justify the cost. They may. If a free pair of shoes fit but are not your style you will probably get more value out of a pair you like even if you have to pay for them. It is sort of the same thing with a computer system.

As a place to start, free is definitely worth considering. Be certain the vendor has a business model that makes sense. If it does, the next step is to get more information and be certain the system really meets your current and long term needs. But, that’s material for another blog post.

A footnote: On May 14, Chilmark Research, one of the healthcare blogs we follow posted a blog titled Where’s the Beef about another company that is offering a free service. That company claims it will be “generally available” in August. “Imagine our disappointment when we clicked on the [site] to find very few concrete details as to what the platform would offer …” Free is a good place to start but the real test is whether or not the system provides the services, protection, etc., you need. Thanks Chilmark for helping us make the point that it takes more than just free to make a system attractive.

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EMRs & “The Cloud”

I ran across a Webinar from March 4, 2010 the other day about “the cloud.” The presenter was Steve Ballmer, CEO of Microsoft. It changed my understanding of where the cloud is and where we are going. He didn’t address EMRs specifically, but it easy to see how the cloud will be part of the solution to networking EMR and health information to make it useful, reduce costs, and improve outcomes. Excerpts from the transcription:

So, I’m going to give a little bit of perspective on the cloud really from the standpoint of people who get a chance to use it, to drive it, to shape it, to make something of it. …

First principle, the cloud creates opportunities and responsibilities.

The amount of invention that needs to happen is high. The world is still not a perfect place in terms of the commercial infrastructure. Yes, you can create a Web page and put on an AdSense ad. But, we certainly haven’t fulfilled the sense, the opportunities to create technology that empowers the creator. …

Immediately people get nervous, particularly when you talk about advertising. They get nervous, what about my privacy. And that’s why I think we have to talk about the opportunities and the responsibilities. The responsibilities for creators, for business people to respect the consumer, to build technologies that really do allow the user to be in control. … And yet I think we have a responsibility, all of us, not just to socially respect the user, but to build the technology that will protect the anonymity, the privacy, the security of what I say, who I say it to, where I go, what’s important to me.

Second dimension of the cloud: The cloud learns and helps you learn, decide and take action

The world is a large, complicated place. So, the first thing that got built to help people navigate was essentially directory services, search services. People built tools to help you navigate and find information, pull it all together, et cetera. And yet, we’ve got to go further than that. The cloud needs to learn about you and it needs to keep learning and figuring things out about the world that has been described virtually.

It’s great to know about 83 million Web sites on the planet, but if you’re actually trying to find something specific … I’ll put my hand up, as part of the U.S. healthcare debate I decided I should actually understand what we spend money on as a society. Try that one out for size. Pick any search engine you like and go give it a whirl. You’ll get a bunch of links, you’ll find a bunch of data, you’ll probably try to cut it, copy it, paste it, but you won’t be able to just sort of describe maybe like a simple, little chart that you would like to see populated. How much money do we spend on healthcare, how much of it gets spent on older people, younger people, poorer people, richer people, people in the last year of their life.

It’s only about eight numbers, there happen to be eight numbers that you can’t learn by following the public debate. But, there were eight numbers that I felt as a citizen I ought to know. But, the ability of the cloud to actually learn from all of the data that’s out there, and the ability of the cloud to learn from me what I’m interested in is not what it will be two, three, four, five years from now.

I happen to be a numbers thinking guy, I would create that little healthcare thing as a little spreadsheet. I would want Excel to just go get that stuff from the cloud. And so this notion of learning, learning about me, learning about the world, making conclusions, and then helping me to decide and take action, I think is a very big idea.

The cloud itself needs to learn. It’s got to collect new data. It’s got to sense new data. It’s got to represent the real world, and keep getting smarter and better, so that it can help me learn. … [demonstration using maps and photos to bring information from multiple sources together, including real time sources, e.g hospital, doctors, labs, pharmacies, personal health records.]

I hope the demonstration does a couple of things. Number one, I hope it kind of wets your whistle for some of the kinds of things that can be done. And number two, it really helps bring together this notion about learning about the world, how do we learn from others, how do we pool the data that’s available on the Web to learn about the world, and then map it and make it of interest to somebody in real life.

Third dimension. The cloud enhances your social and professional interactions …

Dimension No. 4, the cloud wants smarter devices.

The way in which we can learn about you, the sensors, the cameras, the voice, the gestures, today. This year, we’ll get about 10 billion utterances, speech utterances, submitted to us in the cloud through something called our TellMe Service, which handles call centers, and Bing kind of phone voice response searches, and the like. And so, the ability for the device to participate in connecting to the user, providing a richer interface, to get data back from sensors, and use that to improve the cloud experience on behalf of the users is really quite strong.

Later this year, we’ll ship a thing that we call Project Natal. It’s a camera that comes with the Xbox, and it recognizes you, and your voice, and your gestures. … The great smart device hardware is going to bring together the best of what we think of today as rich clients, and the best of browsers, and the best of a next generation of natural user interface, voice, touch, speech, et cetera, all in one unit. [EMRs and the user interfaces.]

Dimension No, 5, the cloud drives server advances that, in turn, drive the cloud.

Cloud Computing Remarks by Microsoft CEO Steve Ballmer
Paul G. Allen Center for Computer Science & Engineering, University of Washington Seattle, Wash. March 4, 2010

Webinar: http://www.microsoft.com/presspass/presskits/cloud/default.aspx

Transcription: http://www.microsoft.com/presspass/exec/steve/2010/03-04Cloud.mspx

If I Were A Doctor … Impatient Patients

There have been a number of articles recently about the changing relationship between doctors and their patients, or what might be called their “impatient patients.”

As an impatient patient, why should I have be at your office for my first visit 15 to 30 minutes early to deal with paperwork that is essentially the same as I have filled out for every doctor I have ever visited. Give me a standard set of forms. Post them on your Web site and let me download them so I can do this one more time and then just update as necessary for future doctors. You and future doctors are asking for information about me; give me a tool and I will take care of that.

Better yet, help me find them in a place like Google Health or Microsoft Health Vault or somewhere similar. After I make the appointment, I can review the forms, fill them out and send them to you. Have a general medical set, insurance set, HIPAA set, specialty set, etc. In the future I may have to fill out a new form for a new specialist and update a couple of fields but that is easier than filling out every form for every doctor. In any case, let me do it on my free time rather than as part of my appointment.

It could also include a list of recent tests and a history of standard things like my weight, blood pressure, etc. that could be accessed in advance. If my standard form shows that I had a PSA test in 2009 and the reason I am coming for this appointment might make my PSA level of interest, your system (or assistant) could have that information in the office when I arrive.

One of these forms should also give you a list of my other providers in case you need to communicate with any of them before my appointment or want to send them a follow up report. Or better yet, let me know that you can use the list already in my Google Health file which includes specialty, addresses, and phone numbers.

It should include a list of my meds from Google Health or a similar service. This will give you accurate data from my pharmacist that is date stamped so you can see what I have taken and am taking. Almost certainly better than the records I bring with me today. Saves me some more time and you get better data. That will also give you information about my pharmacy of choice.

Send my prescription to my pharmacy of choice. Why should I have to make two trips to the pharmacy? One to drop it off and one to pick it up or wait 30 minutes. I want to make just one stop and not have to wait to pick it up.

We all know doctors run late. You truly have life threatening emergencies. But that doesn’t mean I should sit in your office if I have something better to do with my time — I almost always do even if it is to go someplace private and make some phone calls. (Don’t you hate it when people make cell phone calls in your office?). If you are going to run 30 minutes late, have your appointment system or assistant call me as soon as you know. Ask me if I would like to be notified if you are delayed further, push “1” for yes or “2” for no.

If you get lucky and make up some time and get to your office before I do, take care of the little old lady who was scheduled after me but has been sitting in your office for more than an hour because she doesn’t have a cell phone. She will appreciate it and I will appreciate the reduced impact of your unavoidable lateness.

Stay open to iPhone apps and other tools that will help both of us make better use of our time. Not for all of your patients — that day is probably somewhere in the future. But start using it now. You and I other adventuresome folks can experiment knowing that we will encounter a learning curve to be climbed.

I know you have better things to do than play on the bleeding edge of technology. On the other hand, if I work through the learning curve with one of my other doctors, I will expect you to have it right the first time we use it. And, if I start with you, I will be trained to do it your way. If you are reading this, I would rather work with you.

EMRs: Brass Ring for Insurance Companies

A brass ring is a small grabbable ring that a dispenser presents to a carousel rider during the course of a ride. Usually there are a large number of iron rings and one brass ring that can be exchanged for a prize. An opportunity to achieve wealth or success.

There are values to electronic medical records (EMR) in a standalone system. Those benefits have been available for years and have provided only limited incentives for doctors to use them. There are significant additional values from sharing the information in these systems but most of the networking has been motivated by good intentions, not market forces. This post describes a way to bring a combination of good intentions and market forces together to hasten the adoption of networked EMRs.

This proposal plays on the interests of two participants at the edges of most of the current work being done on EMRs: consumers and health insurance companies. Consumers have been given only limited tools with limited links. Insurance companies haven’t seen, or at least haven’t exploited, the opportunities.

The initial step is for insurance companies to recognize the benefits of better patient care and potential cost reductions through networked medical record systems and then offer two new services, one for consumers and one for doctors.

In neither case will the insurance company access, store, or transmit personal health information (PHI.) In the scheme of doctor/patient relationships there is no reason for the insurance companies to take responsibility for this information and, as a practical matter, the level of public distrust of large corporations is so high that direct participation by insurance companies would probably be more of a hindrance than benefit. The consumer will own their data and any data they receive from their doctor; the doctor will own the data from their EMR system including the data they receive from their patient.

The proposed services for consumers and doctors provide new ways for insurance companies to differentiate their service offerings. One of the reasons for me as a consumer to chose company “A” could be they let me know which of my doctors is able to access my personal health record (PHR) to improve the information available for decisions about my health or, if I am looking for a doctor, which affiliated doctors offer those services.

As a doctor, affiliation with company “A” could give me access to better information about some of my patients and provides incentives for new patients to call me. The insurance company that moves first will gain a first mover advantage; the others will have to play catch up.

The service for consumers will allow me to contact my insurance company and inquire about affiliated doctors and their EMR systems and services. I can then use that information as part of the process of selecting a doctor.

I will also be notified by my insurance company if a doctor I have used in the last n months improves their EMR related services. This will allow me to take advantage of those improvements or allow me to feel better about recommending my doctor to a friend.

From a patient perspective, the primary advantage will be that I can contact my insurance company and inform them that I now have a PHR and specify which doctors will have access to it and under what conditions.From the insured’s point of view it might look like this: I log on to a secure Web page provided by the insurance company (think of a home page for online banking).

• I indicate my desire to participate in the medical record exchange program sponsored by the insurance company and specify the terms of my participation. This could includeAuthorization to send a notice to an affiliated doctor that I have a PHR and want to share information: (a) if the doctor inquires about a covered service, (b) or inquires about a service whether covered or not, (c) or if they have provided services to me during the last n months, (D) or if they are on the following list, etc.
• As part of that notice include the name of my PHR, e.g., Google Health, Health Vault, and provide instructions to gain access.

Options to gain access could include: call me, call a trusted third party in case of an emergency, remind me during my next visit to provide this information, access the insurance company’s secure site and log on to get more information, etc. There are a number of ways the options for access can be expanded to include access to all or parts of my PHR for emergency medical services, or for doctors overseas if I am on a trip, etc. The providers of PHR systems will almost certainly develop additional options.

The service for doctors will allow a doctor to log on to a secure Web page provided by the insurance company (again, think of a home page for online banking) and authorize the company to let current and/or prospective buyers of insurance know that the doctor has an electronic medical records system for his practice and will make test results and medical records available to patients in (a) an electronic format, (b) hard copy, or (c) both.

When any doctor’s office contacts my insurance company to confirm coverage, the company’s response will include information about my PHR if I have authorized the company to share that information.

The doctor will get the same number of messages from the insurance company as they get today. They will get a message about my PHR only when they inquire about my coverage and the message will be a bit longer only if I have a PHR. Doctors who do not have an EMR will get a sense of the potential value of having one and they will be able to access my PHR, print a copy, and add it to my paper file in their office. Whether or not the doctor has an EMR, this is an added service for me and my doctor.

When one of my doctors gets a new or upgraded EMR and is ready to share information, they will have the information they need to get copies of my medical records and to send test results and medical records to me. Neither they nor I will have to register with the insurance company or do anything else to share information. Nobody has to remember to do anything or wait for action by anyone else. A doctor who makes an inquiry about my coverage will get the information they need to access my PHR, get information, and post information.

Doctors who find benefit in the networking capability will encourage their patients to get PHRs and will recommend the services that provide the best interfaces to and from the doctor’s system. Providers of PHR services will have incentives to interface to popular EMR systems. More subscribers will give providers of PHR systems additional incentives to continue developing features and functions. EMR system providers will have incentives to provide interfaces to the leading PHR systems to support their efforts to sell new or upgraded systems to doctors. Market forces will be aligned to support the wider adoption of EMRs.

Solving the problems with America’s medical delivery systems will require a number of changes. This is one that can be implemented fairly quickly without regard to any regulatory requirements other than HIPAA security and with limited investment. Many of the required capabilities are in place already. Required changes to computer systems can probably be accommodated through additions to existing systems rather than costly new system development. Most system and operating changes can be implemented incrementally to spread costs and minimize risks.

Insurance companies that provide these two services will contribute to better medical services and lower cost and earn a public relations brass ring.

One small step for electronic medical records; one giant step for better health care at lower cost.

Healthcare is dis-integrating its information

Significant parts of American business are integrating information through industry wide interfaces and Enterprise Resource Planning systems (ERP). What is healthcare doing? In too many cases, healthcare is moving in the opposite direction and dis-integrating its information.

Electronic Medical Records (EMR) systems are being designed using proprietary solutions with a facility or group focus that limits the ability to share information outside the facility or beyond a limited group. This is providing better and better data that is aligned to the needs of a limited set of providers with little or no regard for the total healthcare needs of their patients. If a patient needs the services provided by our limited group,we can help. If patients need a service that is not provided by our group, the best we can offer are the services that have been available for years – services from the time before computers.

Clinical systems are being developed using proprietary solutions and are silo focused which makes data and processing incompatible even within organizations.

A Google search for “erp systems for healthcare” lead to a list of links. The top ten included nothing newer than two from 2007, two from 2006, one from 2004, two from 2001, three undated and a vendor job board.

One of the links dated 2007 was Healthcare ERP and SCM (Supply Chain Management)  Information Systems: Strategies and Solutions by HIMSS. The summary of findings included:

Healthcare is far different in its expectations for enterprise-wide systems and solutions due to the nature of the business. The concern that errors in the processes and technology can lead to severe and undesired outcomes has far greater impact than any other industry with ERP and SCM needs. That is why it is alarming that while clinical systems and medical devices continue to evolve, thus contributing to greater and more positive outcomes, the current ERP and SCM solutions are built on 20- to 40-year-old technologies, programming languages, and architectures.

Every technology department has experienced integrating their ERP and SCM information systems with proprietary and cumbersome clinical systems, which are defined in specialties and single purpose roles. In addition, the information remains separated requiring several databases and stores, which are incompatible and not designed to work together. The crisis in healthcare has moved from the operating room to the server room with a need for greater response from the ERP and SCM IS vendors. The healthcare environment and the systems that support it have become too difficult for users to fully utilize all the system capabilities. With constrained budgets and limited resources, the entire system to support the hospital’s business administrative needs becomes a conglomeration of excel, post-it notes, e-mails, and bytes. [emphasis added]

Healthcare reform and cost control will require multiple solutions that include more effective capture, integration and application of patient, clinical and operation data. Integration, not continuing dis-integration.

Time to Kill the PHR Term

Language can be magic carpet that takes thoughts to new and interested places; it can also be a trap. This blog has been about electronic medical records—EMRs—generated by healthcare providers. A corollary to that has been a personal version of EMRs from multiple providers that make up a personal health record—PHR for an individual. There is a trap in dealing with the personal version as a collection of information from other records. The PHR is reduced to a record or data rather than becoming a tool that supports the individual’s efforts to improve and maintain good health.

Microsoft Health Vault, Google Health, and similar programs use the Internet and linked tools including iPhones and “smart” medical devices to create the needed tool or “platform” for more than just records. John Moore of Chilmark Research argues that it is time to move from PH-Record to PH-Platform and I agree

Quoting from John’s post:

… where we really get concerned with the PHR term is that in the meaningful use recommendations that were accepted in July.   Under meaningful use guidelines, those obtaining Stimulus (ARRA) funding for adoption of a certified EHR must provide a PHR to their patients by 2013.  Trouble here is how will HHS define what that PHR is?  Last year, HHS [had] the PHR term defined (see below).  This term, we have been told, is what will be used within the context of meaningful use rule making.  If this is indeed true, adoption of PHRs will continue to be lackluster.

PHR, Personal Health Record: “An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed, shared, and controlled by the individual.”

To move beyond the limitations of this definition (and the baggage that goes with it) Chilmark proposes a new term, Personal Health Platforms (PHPs) with the hope that others will pick up the banner moving us beyond where we are today and hopefully get HHS to look beyond the narrow confines of the PHR definition that they have before them.

What is a Personal Health Platform?

Our proposed definition is as follows:

A Personal Health Platform (PHP) is an Internet-based platform that securely stores and manages a citizen’s personal health data, data that may be derived from multiple sources including among others clinical systems, payer systems, self-enter data, and biometric.  The PHP also provides the framework and capabilities to support applications, services and/or tools that a citizen may invoke to leverage their personal health data enabling the citizen to make better, more well-informed decisions regarding their health or the health of a loved one.

The second sentence of that definition is the key differentiator. A PHP does more than simply store the data, it makes that data actionable.

In a nut shell, we keep the records and the communication links and interfaces that create the personal records and we add capabilities that support additional information and make all of the information actionable. That is a result that is worth the effort.

See also: Including patients in EMRs and
What if? What if we expand the definition of EMR?

Proposal to Microsoft & Google

A core element of healthcare reform in its broadest context is cost. The first step in controlling cost is to gain visibility about what healthcare actually costs at a level where action can be taken. Microsoft Health Vault and Google Health are platforms that can provide that visibility for consumers. That information can then be de-personalized and used to provide visibility from multiple points of view including hospitals, private practices, regions of the country, type of procedure, etc.

The problem

If I receive healthcare services that involve more than a single provider I will be billed for services from the primary provider and a host of other providers and services including labs and pharmacies. These will show up as line items on a statement I receive from the provider if I am a direct pay or on a statement from my insurance company. Some will be prompt; some will show up months later. All of them will be printed on paper.

Any effort on my part to analyze this data will require hours to transcribe it to an electronic form and then to assign it to specific illnesses or injuries and then classify it in meaningful sub-categories for analysis. If I find a potential issue it is difficult to challenge it in a timely manner.

Proposed solution

You could provide an interface to providers to capture the data in its electronic form and post it on my personal health record (PHR) as a standard spreadsheet, e.g., Excel. That format would:

• Identify the service provider with a link to a database for more information, e.g., what services does XYZ Medical provide and how I can contact them – an Internet link would probably take care of most providers.
• Provide a generic classification of the services, e.g., hospital, lab, ambulance, etc.
• The date of service
• Some description of the service which could be a billing code* and a standard translation
• Amount billed, allowed, payer paid, I pay

It should include charges that are covered by insurance plus non-covered charges such as non-prescription pharmacy at drugstores and other providers that are subscribers to Health Vault or Google Health. It should allow me to add in costs related to trips for treatment, special clothing or devices not covered by insurance, etc.

It should provide the means for me to assign each line item or set of line items to a particular illness or injury or some general classification of my choosing, e.g., seasonal allergy.

Benefits

• I could accumulate charges related to an incident to get a better understanding of what it cost
• I could explore options for less costly solutions, e.g., clinic vs. emergency room
• I would have more confidence in the accuracy of my charges if I could see them sorted in ways that make sense to me, e.g., see that two charges for the same service or item on the same day were for something that could reasonable occur more than once on the same day
• I would be able to challenge any apparent issues in a timely manner and with a minimum of effort using the data and information in the report
• I would be able to get a sense of the charges that have been invoiced and those that have not
• I would see the value or limitations of my insurance to negotiate for more cost effective insurance in the future.
• I would be better informed about the cost of healthcare and therefore better able to participate in discussions of options and solutions.

Costs

Participation in this service could be part of a provider or payer’s package of services. A translation from their standard formats to yours would have to be developed but we should be dealing with relatively standard data elements as specified by HIPAA and the current work on electronic medical records. The cost per provider or payer should be relatively small.

I leave the cost and benefits of de-personalizing data for broader analysis to you but I suspect that it is relatively small once the data exists in a standard format.

* Related discussion on problems with billing codes initiated by e-Patient Dave on Twitter

Building a Healthcare IT Team

I am a management consultant with experience in a number of industries including HIPAA in healthcare. Electronic medical records (EMR) appears to be an area where I can make a contribution and a living. But, the opportunity is more apparent than real.

Several things I have noticed:

• Widespread concern in the press about the availability of the people who will be needed to implement near-universal EMR.
• Almost all of the open positions I have seen have a strong requirement for hospital or other healthcare provider IT experience.
• Almost all of the positions are for programmers and other “technical” staff; almost no analysts or others skilled in exploring what is really needed and how current technology and advances on the horizon can be put to good use.
• There is no clear definition within the industry of the scope for electronic medical records.

Of course an IT team should include a lot of direct experience in the specific industry. But strong teams are made up of people with diverse and complementary skills and experience. Effective healthcare IT requires a wide range of skills and experience. The quickest way to develop that range is to incorporate experienced people from other industries who have relevant IT experience. As part of a team they will learn the fundamentals and most of the nuances of healthcare quickly. With fresh eyes, they will make unexpected contributions. They will stimulate the discussions about options and solutions. And, they will bring new points of view about IT and the world with which healthcare must interface, e.g., patients who are growing more computer savvy, healthcare related products and services beyond the normal bounds of healthcare such as retail drugstore clinics, online medical advice, and evolving electronic medical devices.

A friend of mine writes business cases for companies seeking early stage investment. A recent client was a group of doctors who wanted to develop and market a computer application related to their specialty for use in hospitals. They asked hospital IT managers they knew for recommendations for system development support. The recommended “experts” in hospital systems development agreed to take the assignment and offered to assess the competition. For openers, they said there was no significant competition. My friend quickly found there was a significant competitor. Failure to know and disclose that to investors could have led to a lawsuit. Well into the development project, my friend asked me to review what was being developed. Even with my limited healthcare background, it was obvious that the requirements analysis process had missed several key elements. They had started coding before they thoroughly understood how the system should deliver value. In addition, substantial parts of what they were building and charging for are readily available in the market and could have been licensed at a small fraction of the cost of development and would have been available much quicker. The “experts” do know hospital procedures and are good coders but they simply do not have the breadth of experience to identify specialized system requirements, assess the competitive market, or the state of the art of assembling existing elements to support the truly innovative parts of a new application.

If you want a stronger species or IT team, deepen and expand the gene pool.

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Inspired by a Twit from HealthcareITJob || How To Build Your Team Now So You Can Play (Not Pay) Later Posted on: 8.20.2009 6:53:57 PM http://tinyurl.com/mzmyxk

Indivo – part of the InnoRx disruption

The Indivo system is cited in The Innovator’s Prescription and showing up in other material I have been reading. It is part of the Children’s Hospital Informatics Program of Children’s Hospital Boston

I started this post to facilitate reference to Indivo. Found much more than I expected. See the link below that includes: Ten Principles for Fostering Development of an “iPhone­-like” Platform for Healthcare Information Technology.”

The Indivo system is essentially an inversion of the current approach to medical records, in that the record resides with the patients and the patients grant permissions to institutions, clinicians, researchers, and other users of medical information. Indivo is a distributed, web-based, personally controlled electronic medical record system that is ubiquitously accessible to the nomadic user, built to public standards, and available under an open-source license. …

Indivo is built to be extended and customized: users can connect their record to third-party applications that enhance the management and analysis of their health information. Indivo accelerates the development of these third-party applications by providing a core set of common features:

• secure storage, categorization and aggregation of health data.
• single sign-on and standards-based data-access delegation.
• a simple, open, web-based Application Programming Interface (API).
• unified user notification. …

Google, Microsoft and Dossia emerged as giant PCHR platform providers all sharing the basic PCHR platform approach. Microsoft Healthvault launched with Indivo open source code in the founding companies. Google later announced the Google Health model, building a platform around the Anvita (formerly Safemed) knowledge base and analytics. [links added]

Am article titled: An “iPhone-like” Platform for Healthcare Information Teechnology
June 18, 2009 argues “for the development of a platform model – similar in nature to the approach of the Apple iPhone – that would support an ecosystem of “substitutable” health care applications.”

The post includes: Ten Principles for Fostering Development of an “iPhone­-like” Platform for Healthcare Information Technology — truly disruptive.