Operating as a non-profit, public-private partnership, Healtheway supports the eHealth Exchange, a health information exchange, serving thousands of providers and millions of patients. Its founding members include health systems, technology vendors, and the American Medical Association.
Healtheway, Inc. the non-profit, public-private partnership that operationally supports the eHealth Exchange (formerly known as the Nationwide Health Information Network Exchange) Wednesday announced its nine founding organizations. Among them is Epic Systems Inc., the dominant supplier of electronic health record software to hospitals.
The organizations will supplement the involvement of the federal government that has coalesced around the eHealth Exchange. Healtheway's nine founding members are:
The American Medical Association
Epic Systems Corp.
ICA, maker of the CareAlign interoperability and informatics software platform
Kaiser Permanente
MedVirginia, the first HIE to go live on the eHealth Exchange
Mirth Corporation, which powers private HIEs
The New York eHealth Collaborative (NYeC)
Orion Health, another HIE technology developer
The Workgroup for Electronic Data Interchange (WEDI)
The founding members' activities are meant to supplement the work of the Healtheway board of directors. Founding members will be charged with exploring new health IT opportunities and providing recommendations to the board regarding issues that would be of value to the full Healtheway community.
"Today's announcement reinforces our commitment to establishing a secure, interoperable nationwide health information exchange network that is capable of overcoming many of the challenging issues facing health information exchange today," said Michael Matthews, Healtheway Board Chair and founding member, and CEO of MedVirginia.
"The founding members each come at health information exchange from a different perspective, and it's that unique perspective we will rely on. We must continue building an exchange that can meet the needs of organizations large and small, in a wide variety of clinical and technical environments."
As part of its charter in operationally supporting the eHealth Exchange, Healtheway is working to expand membership and participation in the eHealth Exchange. Originally formed as the Nationwide Health Information Network Exchange program in 2007 by the Office of the National Coordinator for Health IT, the eHealth Exchange has since transitioned into a public/private partnership. Today the community includes thousands of providers and millions of patients.
Some organizations on the board, including Kaiser Permanente and MedVirginia, have been involved with the eHealth Exchange since its ONC days, Yeager said. Others are newly working with Healtheway, explained Mariann Yeager, executive director of Healtheway, Inc.
The announcement lays the groundwork for members to participate in Healtheway annual member meetings and to vote on formal governance matters that will come before the organization, she said.
Addressing Epic's participation, Yeager noted that the company has been "integrally involved" in Healtheway's work for several years, and is active in a number of eHealth Exchange workgroups.
"For us, it wasn't a surprise, because they've been there every step of the way, supporting their customers," Yeager said. eHealth Exchange participants have been sharing data in production for four years, she noted. The number of transactions on the exchange has more than doubled in the past six to nine months, Yeager added.
One example of the exchange's growth occurred when the 40th participant recently joined eHealth Exchange. That single node in the network added 80 hospitals and 19,000 clinical users in a single day, Yeager said.
More than 110 organizations in 29 states are actively engaged in the process of enabling data exchange through Healtheway, Yeager said. Some growth is fueled by collaboration with the Care Connectivity Consortium, five prominent health systems: Kaiser Permanente, Geisinger Health System, GroupHealth Cooperative, Intermountain Healthcare, and Mayo Clinic.
The primary types of data being exchanged today are documents structured in the HITSP C32 format, as well as unstructured documents, Yeager said. Medical documentation supporting CMS' End Stage Renal Disease Program are also being exchanged, as well as dialysis clinic quality CMS reporting data, she added. Formats supporting an eventual migration to the Consolidated CDA document format are also being exchanged.
The CommonWell Alliance and Healtheway have "an open dialogue," Yeager explained. CommonWell, a joint initiative of Cerner, McKesson, Allscripts, athenahealth, Greenway, and RelayHealth, is developing and planning to demonstrate interoperability among electronic health record systems starting in 2014.
"Anything that the vendor community can do to get providers connected is good, so we certainly recognize the importance of collaborating and working, finding ways to move together," Yeager said.
"Healtheway supports an emerging HIE models task group in which CommonWell participates. When their network is operational, their customers will likely have an interest and a need in exchanging with other health systems and providers around the country, and so if there is more than one network, we should be able to interoperate. It's about making sure we're really trying to maximize connectivity across the country."
Fred Trotter is closing the gap between the needs of patients and providers to see and share data, and the reality of unlocking it from where vendors have stored it. Driven by a passion for transparent access to data, he's just getting started.
Fred Trotter
Patients have caregiver champions. They have physician champions. They have nurse champions. They have payer champions. And, I discovered recently, they have at least one hacker champion.
His name is Fred Trotter, and if you're a proprietary software vendor, you don't want to make him angry.
First, forget any automatic association you have between the word hacker and criminal activity. Some hackers break laws. Most do not. As described in Steven Levy's classic book Hackers, computer programmers are a culture unto themselves, and the hacker ethic states: "Access to computers should be unlimited and total." Ironically, we live now in an age where the National Security Agency has made that its mission. As for hackers like Fred, they know that they won't get too many programming jobs if they totally disregard laws.
But the spirit that has fueled Levy's hackers and Fred himself is making the difference between the yearnings of patients and healthcare executives to see their data, and the reality of unlocking it from where it is stored. Right now the data is locked away in countless proprietary file formats by vendors used to exercising control over their customers by being stingy with the data and "protective" of those formats.
Knowledge, as they say, is power.
Photo: Regina Holliday
At the recent Health Datapalooza IV in Washington D.C., Fred was depicted (in a Regina Holliday paintingon the back of a business suit, no less) as The Incredible Hulk on the cover of a comic book, with the phrase, "You won't like him when he's angry."
But Fred doesn't get mad, he gets even.
Case in point: Fred was heavily involved in the initial design of the Direct Protocol, a form of secure email currently being baked ino every electronic health record software package that aspires to be Meaningful Use Stage 2 compliant. Direct spells doom for countless, expensive interface modules connecting EHR A to EHR B.
Direct required a lot of other cooks in the kitchen, including a few forward-thinking software vendors. "I'm not a committee type," Trotter says. "I don't have time for that kind of thing, unless there's a high impact." Once the protocol got implemented in a few programming languages, Trotter returned to his software development business. That business includes authoring the O'Reilly book,Hacking Healthcare: A Guide to Standards, Workflows, and Meaningful Use, itself something of a hacker bible on the topic.
Trotter also carries the banner for open source implementations of electronic health records. He was one of only two open source developers who testified at Washington D.C. hearings back when meaningful use was being defined. He argued then, and still does, that proprietary software vendors have been using the meaningful use regulations to tilt the playing field in their direction. "Meaningful use [became] yet another barrier you had to cross in order to exclude small, innovative players from the market and have large, proprietary vendors win."
Despite this, despite the overwhelming success of those proprietary vendors, fueled by HHS's billions of dollars, open source EHR software continues to grow, Trotter says. "Open source is really good at meeting and beating standards, as long as [they're] clear, objective and transparent."
Trotter should know. Way back in 2004, he was writing open source medical billing software. Then came Clear Health, open source practice management and EHR software. The list of open-source EHR software is lengthy indeed, including OpenEMR and the Veterans Administration's VistA, now in the public domain.
I don't for a moment think that open source EHR systems are going to replace Epic and Cerner. But they are not going away, and sooner or later, there will come a day when the smaller proprietary software vendors fall away.
When that happens, only the biggest proprietary vendors will still be standing, and because the source code is available, numerous open source projects will live on, and it will be wizards such as Trotter who make them work, much as open source has succeeded in many other corners of IT.
Even now, Trotter says, "the place where open source really pays off for you is if you've got 20 clinics scattered across 10 counties. You can get one open source EHR instance and use it for every single one of them. And the cost benefits of doing that are phenomenal."
As for Trotter, he's on to bigger and better projects, such as creating an open data set that shows how doctors refer to each other. He's working with potential sponsors and unlocking more and more of healthcare's secrets, thanks to the ever-increasing release of data by the government.
This data will allow developers and healthcare executives alike to plot doctors' referral patterns and prescribing habits. Answers to questions you would think are easily answerable lie just around the corner, Trotter says. For instance: Do practices with 10 providers provide better or worse healthcare than practices with 100?
Trotter also wants to see the physician credentialing system reformed, "so you get a doctor who has poor bedside manner who's been sued five times, but is otherwise a great doctor, and he looks bad in the current system. In general, the current credentialing system is not fair. I want to replace that with is essentially some kind of open credentialing 2.0 based on reality, fair to doctors. That may be a pipe dream, but that's what I'd like to do."
So when you finally retire your fax machines and switch completely to the Direct Protocol, or realize that the data you never thought you could access is suddenly being published online by CMS for all to see, or discover a fairer way to evaluate physician performance, think of hacker champions like Fred Trotter.
His visions and those of other hackers helped get us here. Those visions coincide nicely with what patients, providers, and payers often want – transparent access to data.
Don't let vendors paint you into a corner. Instead, dream big. Imagine having the kind of clout Fred inspires. Imagine the kind of technology that unlocks all the information that evens the playing field, and puts us all in the driver's seat of healthcare.
Health information technology is full of promises—and ever-escalating costs. But there's one technology I would bet on right now. That's the technology to accurately, securely, and easily transfer health data information from one system to another.
In the switch from fee-for-service healthcare to accountable care, the old ways of developing healthcare systems aren't working. The escalating cost of care is due in no small part to overspending on hospital capacity, equipment that isn't always needed, over-engineered technology, short-sighted planning and bad hunches.
But there's one technology in particular I would bet on right now. That is the technology to accurately, securely, and easily transfer health data information from one system to another.
Let me give you the top five reasons why a healthcare information exchange should be your top information technology priority.
1. Compatibility: Legacy healthcare systems are not going away. Look around your hospital or medical practice. Before you is more than 30 years of investment in productivity-enhancing, safety-producing information technology. Some of it is easily replaceable, but built into the rest are some of the real assets of how your organization maintains its edge: a series of workflows, business processes, algorithms, hints, clues, roadmaps and best practices. But chances are, elements of these exist in different, often incompatible hardware and software systems. You cannot simply rip and replace entire systems, and when you do, the price is steep. Now and for the foreseeable future, you are going to need health information exchange technology to tie these pieces together.
2. Mergers and acquisitions: M&As will only accelerate your need for health information exchanges. Many of your organizations are already the product of the merger of two or more earlier systems. Such mergers, and any technology and business system purchases any system makes along the way, deal a particular deck of technology cards to your senior leadership, and winning the game means playing those cards as strategically as possible.
3. Interoperability: Playing your interoperability cards right gives you leverage with your vendor suppliers. Like any card game, you'll have to gamble at times. There may even be bluffing, especially as you negotiate with technology vendors. While you've been busy running your healthcare system, those vendors have been tirelessly working to develop and market technology to lock you in to those solutions. The more you know about how to move your data and business processes from one such system to another, the more leverage you will have in your vendor negotiations.
4. Standardization: You are balancing your need for industry standardization with your need to differentiate yourself among your local competitors. Market winners still manage to offer something special to customers. That means customizing technology to meet particular local needs. Sure, there will be standards—of care, of technology, and of quality reporting. But the best technology goes beyond all these things to delight those who use it.
Seek out innovative technology, but always be prepared to connect it to those systems that must communicate with each other. It is not easy. We have expectations that want these systems to be as simple to interoperate with each other as earlier technology paradigms: telephones, email, faxes. But with every wave of new technology, there is added complexity, so it becomes that much harder to make the interoperability of the newest technology as simple as earlier systems. We speak of "information dial tone"—if only it were that simple. But done right—think iPhone and iPad—it's a magical thing.
5. Portability: Patients and physicians will continue to have choices of where to go. The whole reason accountable care got as far as it did is that it preserves that choice. The challenge is to build the technology that makes that freedom work at a practical level – patients receive the care they desire, and physicians practice where and when they desire for job satisfaction. If your healthcare system makes it difficult for the information associated with patients or doctors to travel with them, you will become a less desirable destination.
To explore the very practical next steps you can take in healthcare information exchange, I'll be hosting a Webcast Monday, June 17. My guests will be HIE pioneers Linda A. Reed, RN, and David L. Miller. Reed is vice president of behavioral and integrative medicine and CIO of Atlantic Health System. She is also president of Jersey Health Connect, one of New Jersey's grant-funded health information exchange organizations. Miller is vice chancellor for information technology and CIO for the University of Arkansas for Medical Sciences.
I hope you can join us as we explore what's working, what isn't, and how you can make health information exchange a reality now. There's no time to waste.
The Robert Wood Johnson Foundation has launched a competition to develop applications and tools that will enhance and improve the way data comparing hospital prices is used.
How much hospitals charge for the same procedures (source: The New York Times)
The federal government's unprecedented release of hospital pricing data for inpatient and outpatient procedures with the last month comes with one overriding question: How will the information be used?
To find out, The Robert Wood Johnson Foundation has launched a competition among technology developers to improve consumer understanding and use of data that compare hospital prices. Winners of the RWJF Hospital Price Transparency Challenge will share $120,000 in prize money.
The challenge was announced at the Datapalooza IV, in Washington Monday.
Last month, the Centers for Medicare & Medicaid Services published prices charged by more than 3,000 hospitals for the 100 most common inpatient procedures. The information showed extreme variation in pricing among U.S. hospitals—even those operating in the same communities. Experts say it underscores the urgent need for transparency in the health care system.
The RWJF Hospital Price Transparency Challenge is designed to further disseminate the use of the CMS hospital data. The competition consists of two components—one for creating data visualizations and the other for developing consumer applications and tools.
The visualization challenge requires entrants to create graphic representations to help consumers and others better understand, explore, and interpret the information. RWJF encourages applicants to incorporate other data in combination with hospital pricing data to enhance its value.
The apps and tools developed should help improve understanding of the hospital pricing information and promote further transparency about prices.
Winners of the visualization component of the challenge will be announced at the Health 2.0 Fall Conference in October 2013. The deadline for submissions is August 25. The app and tools component of competition will take place in two phases. The first phase will select five semi-finalists, who will be announced at the Health 2.0 Fall Conference. The deadline for this first phase is August 4. The second phase will see judges select winning entries from among the semi-finalists. Winners will be announced on December 9 at the mHealth Summit.
Also at Datapalooza, the HHS Office of the National Coordinator released data from the Regional Extension Centersabout the different brands of EHR products used by 146,000 doctors by state, specialty, and each doctor's stage in meaningful use attestation.
A joint effort to provide interoperability among the electronic health records systems of competing vendors is proceeding without a great deal of transparency and openness outside of the participating members.
Three months ago this week, Cerner, McKesson, Allscripts, Greenway and athenahealth—rivals all—announced the CommonWell Health Alliance, a joint effort to provide interoperability among their electronic health records systems and others.
Technology companies are good at announcing such alliances, but customers often never see all the benefits promised. Making different technologies interoperate is difficult, and U.S. companies in particular are predisposed to compete with each other, making attempts at interoperability even tougher.
But since 90 days have passed, I thought it was time to check in with CommonWell to see how things are going, particularly since we haven't really gotten any general progress reports from the group.
As alliances go, it is my opinion that the work being done is being undertaken without a great deal of transparency and openness outside of the alliance members.
To its credit, CommonWell offered me time with two Cerner executives who addressed some of the recent issues brought forth by Epic founder/CEO and CommonWell skeptic Judy Faulkner. In recent comments at the Health IT Policy Committee, committee member Faulkner questioned whether CommonWell would be offering patient data for sale, or if it was trying to assemble a patent portfolio, both of which would definitely be unwelcome developments.
"We're very explicit that we will not use the data for any purpose other than to deliver the services of CommonWell," says David McCallie, senior vice president for medical informatics at Cerner. "There will be no data resale. We're not going to de-identify the data and do anything with it. We're not going to sell it in an identified form, and that's been clear from day one."
As to patents, McCallie says "if there is patentable innovation that comes out of the work, then the agreement would be to share that license with all of the members of CommonWell. But it would be sort of a side-effect, if necessary. We're not seeking a patent portfolio."
Faulkner has also recently been quoted as saying that Epic provides the most interoperability of any EHR vendor currently out there. I've heard tales that Epic will go to great lengths to connect its systems to a customer's other IT systems, but vendor and customers seem to be eager to keep such efforts on the QT.
CommonWell's top priority is to kick off a pilot later this year, McCallie says. A second big agenda item is to create a 501(c)6 not-for-profit trade association. Additionally, a "bunch of different committees" are defining the interface between service providers and EHR vendors.
In the pilot test, the service provider will be RelayHealth. CommonWell has to choose a metropolitan location for the pilot, a city where providers are using a variety of members' EHRs. If the city is dominated by Epic (some are) or by a CommonWell member's EHRs, that wouldn't be ideal.
This stage of CommonWell's work will culminate in an update and status report at HIMSS 2014, McCallie says.
After they launch, some technology industry initiatives spend a lot of time and energy announcing additional members as quickly as possible. Not CommonWell. In the first 90 days, industry reception to the alliance has been "enthusiastic," says Dan Schipfer, Cerner vice president for government and industry relations. And yet, CommonWell has yet to announce additional members.
"An invitation has gone out to the [EHR] industry broadly," Schipfer says. "We've had probably 45 to 50 different companies express interest." CommonWell has been asking these prospects what time and resources they can commit to the consortium this year. Some of those discussions are with non-EHR vendors. And around the industry, I've heard that those vendors talking to CommonWell have been asked to sign non-disclosure agreements. The truth is more nuanced, according to Schipfer.
"We've got these two goals," he says. "One of them is creating this technology, the services to go help facilitate the pilot demonstration, so there's work to do on that. And then there's this collective goal around formation and open and transparent supporting of interoperability.
Starting with the second goal, Schipfer is quick to say "there are no… NDAs and so forth, as it relates to how we're trying to go form that organization. We're trying to do this in a very open format. It's a new thing for all of us, but we're just methodically going through creating that, and expect to make this extremely very open."
Adds McCallie: "The process of creating the interfaces necessary to make this system work is complicated and cumbersome, and so we have limited the participation to those discussions [to] the vendors who have committed resources to deliver what we settle on. So these are all people with skin in the game, who if they agree on, this is what we're going to do, that means they're going to take it back to their companies and build that software.
"If somebody says, 'what are you going to do with standard such-and-such,' we'd be happy to tell them, and we'll give them the documentation to the degree that it's been settled and exists. So I think it's, at the moment, as open as it needs to be to move us forward. The APIs and all will obviously be completely open when we settle on them. There will be some open source developments done as we figure out what parts of the code are proprietary to the vendor itself, to the service provider, and then to CommonWell, and the CommonWell code could be opensourced, so we're just working all that out."
Recently, I talked about health information exchanges with a CIO who was confident that he could now wait for vendor-provided HIEs rather than rely upon regional, state or federal HIE efforts. I got the strong impression this CIO is expecting CommonWell to provide that HIE, and asked the Cerner executives if CommonWell was building a national HIE.
"A little bit of confusion stems from the fact that HIE has a lot of different meanings, and there are some functions that a traditional or typical HIE would deliver that CommonWell will overlap with," McCallie says.
"But there are other functions that some of the more successful HIEs are delivering that CommonWell will not try to deliver, so it's not a simple either/or question. The phrase that we've used, [is] we're focused on the plumbing, moving the data from where it lives to where the patient needs it with a current physician encounter."
To be specific, CommonWell is building the identity management and encounter locator services, as well as some consent management and "transparency services," says McCallie.
What does that leave HIEs to do? "HIEs are evolving in the direction of doing more in the realm of population health management, quality reporting, aggregation services, to abstract records, small provider access and the like, although they typically limit that to a region," McCallie says.
"CommonWell will obviously be able to pull data from anywhere in the network, which could be anywhere in the country. That's a long-winded answer, but it's not a simple answer, I'm afraid." And CommonWell members will be building out complete HIEs on top of the CommonWell platform, he adds.
"Each of the vendors has additional products like population health management or care coordination or continuity of care services that we will build on top of the data availability that CommonWell exposes."
So there you have it, an update on CommonWell at the three-month mark. Before CommonWell, there were already a lot of moving parts in healthcare IT, and we can hope that the additional activity of this new group will simplify the picture moving forward, and not complicate it further.
I wonder, however, if we can really afford to wait until 2014 for what amounts to a glorified demo, or if in the interim, we might see Epic suddenly reveal vast evidence of real interoperability happening now, tipping the market further in Epic's favor. The fate of dozens of competing EHR vendors probably hangs in the answer to that question.
For its work so far on building a model that predicts how many days a patient will spend in the hospital, one team has been awarded a half million dollar cash progress prize. Competition for the Heritage Health Prize continues.
Members of Team POWERDOT, receiving their $500,000 check.
(Photo: Blink Photography)
Continuing a trend of rewarding developers for building breakthrough technology solutions to unlock population health management from freely available, de-identified medical data, The Heritage Prize announced a $500,000 prize Monday at the Datapalooza IV conference.
Heritage Provider Network officials presented the cash award to the current leading team, POWERDOT, for its work on a predictive analytics challenge related to hospital admissions and length of stay.
HPN officials said they will continue the grand $3 million Heritage Health Prize competition until one of the leading teams reaches or exceeds the required benchmark.
"We are so encouraged by the results seen in the last two years, we will continue the competition and allow the top eligible leading teams access to an even broader data set to try to accelerate a successful benchmark performance by one of the teams," said Richard Merkin MD, president and CEO of Heritage Provider Network.
That broader data will include socio-economic status and additional pharmacy and lab data originally held back due to concerns that the data could be de-anonymized, Heritage officials said.
"There's a variety of additional claims and medical record data, still anonymized to that extent, so the patients will only be a number, but a broader set of clinical information that I think will make this much more usable," explained Mark Wagar, president of Heritage Medical Systems. "Those factors are important, as long as you can keep the personal aspect anonymous. They're not going to be able to download [such] data. They'll have to go to a HIPAA-secure Web site."
The prize challenges entrants to create an algorithm that predicts how many days a patient will spend in the hospital. Created, developed and sponsored by Merkin, President and CEO of HPN, the goal of the prize is to decrease the number of avoidable hospitalizations, saving the U.S. more than $40 billion in preventable hospitalization costs.
POWERDOT is comprised of data miners, researchers, information analysts, and a hedge fund manager in what Heritage describes as a global union of the world's best data scientists. The team members are former rivals and cash progress prize winners who completed independently at first, but then joined forces last October. They are:
David Vogel, chief scientist of Voloridge Investment Management;
Randy Axelrod, MD, executive vice president of the 32-hospital Providence Health & Services system;
Rie Johnson, a machine learning researcher;
Willem Mestrom, business intelligence specialist at Independer, based in the Netherlands;
Edward de Grijs, an engineer and software developer also from the Netherlands;
Tong Zhang, a machine learning researcher;
Phil Brierley, analytics consultant with Tiberius Data Mining, based in Australia
Vogel, Axelrod, Brierley and de Grijs accepted the $500,000 check on behalf of the group at the announcement.
Healthcare cost data released by the federal government Monday includes estimates for average hospital charges for 30 types of outpatient procedures.
The Obama administration made government transparency a campaign promise and on healthcare data it is delivering in a big way.
On Monday, Medicare data including estimates for average charges for 30 types of hospital outpatient procedures was released. This follows the release last month of pricing information data for the 100 most common Medicare inpatient DRGs or diagnostic related groups.
Health and Human Services Secretary Kathleen Sebelius Monday announced the availability of inpatient costs at the beginning of Health Datapalooza IV, the fourth annual national conference on health data transparency. The conference is "born from government efforts to liberate health data" and brings together government agencies, private companies and academics to improve healthcare.
The data released by the Centers for Medicare & Medicaid Services includes county-level data on Medicare spending and utilization for the first time, as well as selected data on hospital outpatient charges. In addition, the HHS Office of the National Coordinator for Health Information Technology released additional information on the adoption of specific electronic health record systems.
"A more data-driven and transparent health care marketplace can help consumers and their families make important decisions about their care," Sebelius says. "The administration is committed to making the health system more transparent and harnessing data to empower consumers."
The latest release of data was applauded by researchers and developers attending Datapalooza, but one hospital cost analyst notes that the newly-released data still represents but a sliver of the total amount of data CMS should release eventually, and for now leaves the bulk of that work to application developers.
"I'm deliriously happy to see all of the transparency going on at this conference," says Jeanne Pinder, a former New York Times editor and now founder and CEO of ClearHealthCosts.com, a healthcare cost search engine funded in part by the Tow-Knight Foundation. "It's only a fraction of what we need. It's a tiny fraction. It's not actionable, shoppable information that would help real-live consumers."
Pinder adds that every time a little bit more data is released, it begins another piece of a larger conversation. "Why does it look like this? Why is it so crazy? Why are the charges disconnected from the payments? Why can't we as real live human beings who are interested in making decisions about our health have real information? Ms. Sebelius is on the side of the angels, but we need more data."
Specifically, HHS built on the release last month of the average charges for the 100 most common inpatient procedures by releasing selected hospital outpatient data that includes estimates for average charges for 30 types of hospital outpatient procedures from hospitals across the country, such as clinic visits, echocardiograms, and endoscopies.
CMS also released new data sets for the first time at the county level: one on Medicare spending and utilization, and another on Medicare beneficiaries with chronic conditions. Both data sets will enable researchers, data innovators, and the public to better understand Medicare spending and service use, spurring innovation and increasing transparency, while protecting the privacy of beneficiaries. The data will also be available through an interactive state level dashboard based on the spending information, allowing users of any skill level to quickly access and use the data.
Patients today are empowered, engaged, equipped, and enabled. Healthcare providers should respond, and should help patients with another important "e": expectations.
By now, you've probably heard of e-patients. But it means much more than "electronic patients."
"Our culture assumes doctors know everything and patients can't possibly add anything useful," writes Dave deBronkart, better known as "e-Patient Dave," in his new e-book, Let Patients Help!, a quick but enlightening read that will inform you that the "e" also means empowered, engaged, equipped, and enabled. "Today some add educated, expert, and anything else 'e,'" deBronkart writes.
I've made a career out of documenting the empowering effects of technology. In the 1980s, among other things, personal computers were a way to engage students of all ages through the interactivity of educational software. In the 1990s, the Internet equipped us to get the most current data. In the 2000s, Web services enabled us to build "digital nervous systems" that automated the publication of that data, and our ability to subscribe to updates through the power of technologies such as RSS and search technologies such as Google.
But here in the 2010s, it's ironic that the most personal of data we generate – that about our health – remains locked in healthcare's vaults for a variety of reasons. Some of this is just technological inertia. Some electronic healthcare record software bears a strong resemblance to 1990s-style enterprise resource planning (ERP) software designed to manufacture widgets. (That's changing, too, but it's a topic for another column.)
Patients are not widgets, yet the healthcare system sometimes treats them like widgets. But no widgets ever stood up after a life-threatening illness to tell their story. E-Patient Dave tells his story, and the story of the e-patient movement, in a book that will take you little more than an hour to read, but it will be an hour well spent.
I was delighted to learn that the e-patient movement goes back as far as The Whole Earth Catalog, a 1960s tome that helped inspire personal computing itself. I learned that the founder of the e-patient movement was a Yale Medical School graduate, "Doc Tom" Ferguson, who went on to publish Medical Self-Care magazine, and appeared on 60 Minutes. Truly a man ahead of his time.
DeBronkart's own story has been told many times, including in HealthLeaders Media. But in 2013, his lessons bear repeating. Last September, I bravely made the first prediction in my first predictions column that there would be a national day of patients calling providers, demanding their medical records.
It hasn't happened yet, but it still should. Meanwhile, we have deBronkart's book, and a rollicking YouTube video inspired by the e-patient movement.
Here are a few more top takeaways from Let Patients Help!:
"In my view, treatment goals should arise in discussion between clinicians and patients." A laudable goal, but the devil is in the details. "Doctors only prescribe the standard of care about half the time," deBronkart says, and he punctuates this with a harrowing story of a patient who didn't receive the vaccines recommended after having a spleen removed, with dire consequences. "What if his family had Googled splenectomy, and said, 'Wasn't he supposed to get some vaccines?'"
"There's too much for anyone to know everything, even your doctor." Years ago, a white paper by Doc Tom quoted Donald Lindberg, Director of the National Library of Medicine: "If I read and memorized two medical journal articles every night, by the end of a year I'd be 400 years behind." Years later, Lindberg told deBronkart the situation today is "much worse."
"The Internet lets patients see information their doctors might not."
"Let patients check the entire medical record, then fix any mistakes the patients find."
"Clinicians should change shifts at the bedside."
"They can't control costs if we hide costs from them."
On this last point, the recent publication of hospital costs by CMS may lead to a patient-fueled Cambrian explosion of apps devoted to helping patients compare those costs. There's precedent for this, when Web programmers "mashed up" geographic data with crime data to vividly inform citizens about the distribution of crime. There is no reason not to expect CMS data to be similarly mashed up in the months ahead. Soon, such mashups will be available on mobile phones, ready to be used for everything from a standard doctor visit to comparing costs of ER visits to urgent care visits, perhaps at locations across the street from each other.
To e-Patient Dave's credit, he doesn't believe that giving information to patients, however necessary, will be sufficient to improve healthcare. "Information alone doesn't change behavior," he writes. "Even for smart people." We must also "make it easier to do the right thing," and make the messages that healthcare delivers to patients clear and concise. He recounts the great story from former Wired magazine executive editor Thomas Goetz, who asked the magazine's art directors to make his blood test results look like an investment report. "They came back with snazzy, easy-to-read graphics: a bar for each number, green at the good end, red at the bad end, and an arrow showing where he sits."
DeBronkart also notes that through the Internet, patients are sharing more information about the side effects of treatments and procedures than they typically receive at their traditional points of care. In fact, in his own recovery from kidney cancer,deBronkart's oncologist, David McDermott, MD, told him, "I'm not sure you could have tolerated enough medicine if you hadn't been so well prepared."
There's one more "e" that deBronkart tackles in the book's appendix, and in many ways, it's the biggest "e" of all: expectations. "Medicine can be dangerous, and clinicians work without a net," he writes. "Medicine is complicated and our systems are not fail-safe."
Sometimes, fallible systems can be made safer. DeBronkart reveals that "anesthesia errors were greatly reduced when the hoses for different gases' hoses were made to be different sizes, so you can no longer pump the wrong gas into the wrong hose … in medicine, such protections are often absent."
As you try to implement "patient engagement" in your health system, remember that it's all of a piece. Hear the patients. Let information flow. Manage expectations. And look for clarity in every process and technology, to avoid errors and speed workflow. That's true engagement.
iTriage CEO and co-founder Dr. Pete Hudson at the White House
Aetna will allow patients and providers to communicate directly via a mobile application that protects data privacy and indicates when care options are high cost, out of network, or present challenging payment arrangements.
If you have any doubt that leading mobile health apps are about to become a whole lot more important to providers, let Aetna's iTriage set you straight.
Aetna's application developers are preparing to allow patients and providers to directly communicate with each other in a new version of the iTriage app due to hit the streets in the next two months.
The new version, first revealed in a post-HIMSS video by Pat Salber, MD, uses the Direct protocol to solve a major usability problem with doctor/patient communications today.
That problem has to do with the fact that email is inherently not a secure medium. Due to the constraints of HIPAA, physicians cannot use ordinary email to communicate any protected health information to patients, nor to receive PHI from patients.
Instead, patients must log into secure Web portals to send and receive PHI to doctors. This personal data can be anything from test results, to changes in their treatment, to medical advice.
In the fee-for-service world, this mattered little, because email consultations were not billable events. In an accountable care world, the physician is incentivized to keep the patient healthy, while at the same time keeping costs low, including minimizing office visits, as well as enhancing patient satisfaction.
There's nothing very satisfying about a secure Web portal from a user experience standpoint. But apps such as iTriage are hot. In the iTunes app store alone, it has more than 70,000 reviews, an unheard-of number, even for game apps, according to iTriage co-founder and chief medical officer Wayne Guerra, MD. In all, more than 8 million people have downloaded iTriage to enter their symptoms and be directed to appropriate medical help.
So, the next release of the app, which was acquired by Aetna in 2011, will connect those questioning patients directly to their doctors, (if the doctors' health plans enter into agreements with iTriage). No more tedious logging into secure Web portals. Now, answers will be available with a couple of smartphone gestures.
It's not just a boon for patients. The app also helps providers meet a Meaningful Use Stage 2 requirement that a small but significant amount of data shared between patients and providers be secure. "Even five percent is a huge task, if no one's going to your portal," Guerra says.
Guerra tells me that iTriage has a letter of intent with Pennsylvania-based Geisinger Health System to manage a population of 100,000 Medicaid lives through this new app. Another Medicaid population in Delaware will see iTriage through the Delaware Physicians Network. More deals are in the works, he says.
Once iTriage identifies the patient, based on group number and member ID, recommended care starts to tackle the cost side of the equation as well. The app will continually reinforce when care options are higher cost, out of network, or face challenging payment arrangements, says Peter Hudson, MD, co-founder and CEO of iTriage.
"What we've found is when we offer lower-cost care, right on that screen, the utilization of higher-cost care, emergency department care, goes down 40 percent, because you have this great, contextual approach to your provider service," Hudson says.
iTriage's founders have been attracting a lot of attention in high places. First Lady Michelle Obama asked them to join her during February's State of the Union speech.
"The most disruptive thing in the history of medicine is for the consumer to be engaged in the knowledge of medicine, the knowledge of treatment, understanding the ecosystem, having a better dialogue with their doctor," Hudson says. "I think it has the ability to be a blockbuster drug."
As if that weren't enough, iTriage will soon be able to check multiple symptoms. When a patient enters a symptom, such as lower abdominal pain, and then their gender and age, the most common medical conditions for lower abdominal pain for that patient profile show up right on the patient's mobile device.
The change will be all the more dramatic because iTriage leverages the power of cloud computing to render a response quickly. Most of the computation is not happening on the smartphone or tablet. It's happening in the cloud, on a cluster of powerful servers.
Users can add other symptoms for a more refined—dare I call it this?—diagnosis. There's also an element of big data to this, because the new version relies upon the National Ambulatory Medical Care Survey, a surveillance survey from the Centers for Disease Control, to determine the probability of a symptom being related to a disease for a certain age group, using Baysian statistical methods.
This is an exercise in technological force multiplication and disruption. The cloud is a transformative technology. Big data is another one. Mobile technology is a third. And adding secure, private communications to healthcare—something that's been cumbersome at best, and more often impractical—makes for a fourth.
If you doubt that this sort of innovation is turning heads, this may help you see the light: I am writing from the first-ever industry-wide healthcare tech investor conference, HealthBeat 2013 in San Francisco. The halls are teeming not with patients, and not even with doctors or tech geeks, but with investors.
Some of their portfolios are already bulging with energy and "clean tech" investments, now they seem to finally understand the urgency of tackling the healthcare tech problem once and for all.
This week, they're busy learning about ACOs, bundled payments, and meaningful use. The conference has the feel of another inflection point for healthcare technology—the moment that Silicon Valley's deep pockets and brain trusts really get it.
It could have the makings of another bubble. There's already dire talk here of a coming implosion of physician practices, of hospitals closing due to the unsustainable waste, and of the slow reactions of many healthcare systems.
It may not be pretty at times, but we need this transformation to speed up.
The former Wall Street technology analyst turned key Silicon Valley investor believes city-wide ecosystems of health incentives and disincentives for unhealthy habits could have a significant positive effect on the nation's health.
Perhaps Esther Dyson has spent a bit too much time traveling, investing, and cosmonaut training in the former Soviet Union, becuase her latest pet project, for how healthcare and technology might start to fix America's health problems, can sound like a new spin on central planning, albeit with a twist.
Dyson, a former Wall Street technology analyst turned key Silicon Valley investor, helped jumpstart the current venture capital craze for healthcare technology startups. Her own investments include Medscape, PatientsLikeMe, HealthTap, PatientsKnowBest, and numerous others.
One can argue that even with Obamacare on the way, this country's response to lifestyle-generated epidemics of obesity and Type 2 adult diabetes are being addressed chiefly by the free market.
After all, fee-for-service care still accounts for 90 percent of healthcare in this country, and at Monday's Health:Refactored event, I heard the existing U.S. healthcare system described, not flatteringly, as "the mother of all adaptive systems." (The quote is attributed to Arnold Milstein MD, who directs Stanford's Clinical Excellence Research Center.)
That means big minds such as Dyson's are a bit stumped in 2013 about how free markets alone will solve some big healthcare problems. So they're taking a look at building city-wide ecosystems of health incentives and, equally, disincentives for unhealthy habits.
Imagine a city where people bent on unhealthy living encounter a series of interventions at their work, home, local eateries, and schools. Where healthful food is subsidized and a few extra-fatty meals are zapped from the local restaurant menu. Prize-laden contests would motivate citizens to be physically active. And technology would measure it all, from the activities and rewards to population's health indicators.
Dyson, the entrepreneur, plans to take a page from the Internet age, where user adoption typically starts at the price of free. Her initiative, launched at Health:Refactored, would approach the many makers of fitness devices and sensors with the following proposition. "If you give us your thing for free, we'll give you a population of 80,000 and we will promote it very heavily, and try and get everybody in town to use it," Dyson says.
Dyson's working title for this initiative, which she unsuccessfully tried to get funded by the XPrize Foundation, is HICCUP, for Health Intervention Coordinating Council, "and the UP is just because it needs something at the end," she told me in an interview Monday.
If Dyson is crazy, she's crazy like a fox. This is a country obsessed, after all, with the inter-city rivalries of its professional sports teams. She wants to tap into that frenzy, to seed five such communities to compete against each other, over 3 to 5 years, to demonstrate the huge difference she believes a coordinated, tech-powered community-wide healthy lifestyle push could make.
During our conversation, I was reminded that Dyson is not alone in her city-as-petri-dish subject focus. The CommonWell Health Alliance, announced at HIMSS, is targeting two cities, as yet unnamed, for its initial rollout of its health record exchange, says Arien Malec, co-founder of the Direct Project, and an executive at RelayHealth. Whether the topic is exercise, healthy eating, or health record exchanges, the city is shaping up to be the essential unit of measure.
Malec also spoke at last week's Health:Refactored conference in the heart of Silicon Valley, and revealed that the big launch of CommonWell's efforts is timed for HIMSS 2014. Details, and cities involved, remain unannounced. Yet when I told Dyson of CommonWell's city-scale plans, she seemed eager to explore possible synergies.
Elsewhere at this conference, I met a doctor who doubted that the current health gadget boom, and even coordinated care itself, could help those costing the system the most: older patients with multiple chronic diseases and co-morbidities, perhaps morbidly obese, who are unlike to strap on Fitbits and Nike FuelBand sensors and make dramatic strides.
Dyson concedes this. Her program is about prevention of these diseases, not cures. HICCUP itself is just one potential part of solving healthcare's problems. That doesn't mean it lacks value.
This experiment won't work in all towns, Dyson says. She's looking for communities where the inhabitants live, work, and go to school locally. Otherwise multiple communities will have to be involved. Towns with several large employers will be easier to test than communities with lots of smaller employers.
Her idea also needs money. Lots of it. A target community might spend a billion annually in healthcare costs. "Someone needs to be willing to spend, instead of $1 billion year after year, $1.2 billion the first year, in the belief that they're going to get that $200 million and more back in the fifth year, because it needs to be discounted," she says. "That's going to require either a very rich foundation, a benevolent billionaire, [or] some kind of social impact fund."
I started this column by gently presenting this notion as central planning reborn, but I really hope that HICCUP gets a chance to work, somewhere. The clinical trial system in this country is itself totally inadequate when it comes to establishing or proving the efficacy of the range of tech and social interventions Dyson describes.
The healthcare crisis is very real, and there's a danger that without showing dramatic, Biggest Loser-type results, the current craze of fitness and health-related gadgets will wilt like so many dot-coms did a dozen years ago. "Everybody's skeptical, with good reason," of these technologies, she says.
No single individual knows the ebb and flow of Silicon Valley technology waves, the investors who power those innovations, and the inner workings of healthcare like Dyson. If she says this is worth a try, I have to agree.
Dyson invites interested providers and other healthcare leaders to contact her. Perhaps her population health dreams are akin to your own. Maybe her interest in space travel is too.