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Open Source Software and the Path to EHR Heaven (Part 2 of 2)

Posted on September 20, 2018 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

The previous segment of this article explained the challenges faced by health care organizations and suggested two ways they could be solved through free and open source software. We’ll finish the exploration in this segment of the article.

Situational awareness would reduce alert fatigue and catch errors

Difficult EHR interfaces are probably the second most frustrating aspect of being a doctor today: the first prize goes to the EHR’s inability to understand and adapt to the clinician’s workflow and environment. This is why the workplace redounds with beeps and belches from EHRs all day, causing alert fatigue and drowning out truly serious notifications. Stupid EHRs have an even subtler and often overlooked effect: when regulators or administrators require data for quality or public health purposes, the EHR is often “upgraded” with an extra field that the doctor has to fill in manually, instead of doing what computers do best and automatically replicating data that is already in the record. When doctors complain about the time they waste in the EHR, they often blame the regulators or the interface instead of placing their finger on the true culprit, which is the lack of awareness in the EHR.

Open source can ease these problems in several ways. First, the customizability outlined in the first section of this article allows savvy users to adapt it to their situations. Second, the interoperability from the previous section makes it easier to feed in information from other parts of the hospital or patient environment, and to hook in analytics that make sense of that information.

Enhancements from outside sources could be plugged in

The modularity of open source makes it easier to offer open platforms. This could lead to marketplaces for EHR enhancements, a long-time goal of the open SMART standard. Certainly, there would have to be controls for the sake of safety: an administrator, for instance, could limit downloads to carefully vetted software packages.

At best, storage and interface in an EHR would be decoupled in separate modules. Experts at storage could optimize it to improve access time and develop new options, such as new types of filtering. At the same time, developers could suggest new interfaces so that users can have any type of dashboard, alerting system, data entry forms, or other access they want.

Bugs could be fixed expeditiously

Customers of proprietary software remain at the mercy of the vendors. I worked in one computer company that depended on a very subtle feature from our supplier that turned out not to work as advertised. Our niche market, real-time computing, needed that feature to achieve the performance we promised customers, but it turned out that no other company needed it. The supplier admitted the feature was broken but told us point-blank that they had no plans to fix it. Our product failed in the marketplace, for that reason along with others.

Other software users suffer because proprietary vendors shift their market focus or for other reasons–even going out of business.

Free and open source software never ossifies, so long as users want it. Anyone can hire a developer to fix a bug. Furthermore, the company fixing it usually feeds the fix back into the core project because they want it to be propagated to future versions of the software. Thus, the fixes are tested, hardened, and offered to all users.

What free and open source tools are available?

Numerous free and open source EHRs have been developed, and some are in widespread use. Most famously is VistA, the software created at the Department of Veterans Affairs, and used also by the Indian Health Service and other government agencies, has a community chaperone and has been adopted by the country of Jordan. VistA was considered by the Department of Defense as well, but ultimately rejected because the department didn’t want to invest in adding some missing features.

Another free software EHR, OpenMRS, supports health care in Kenya, Haiti, and elsewhere. OpenEMR is also deployed internationally.

What free and open source software has accomplished in these settings is just a hint of what it can do for health care across the board. The problem holding back open source is simple neglect: as VistA’s experience with the DoD showed, institutions are unwilling to support open source, even through they will pay 10 or 100 times as much on substandard proprietary software. Open Health Tools, covered in the article I just linked to, is one of several organizations that shriveled up and disappeared for lack of support. Some organizations gladly hop on for a free ride, using the software without contributing either funds or code. Others just ignore open source software, even though that means their own death: three hospitals have recently declared bankruptcy after installing proprietary EHRs. Although the article focuses on the up-front costs of installing the EHRs, I believe the real fatal blow was the inability of the EHRs to support efficient, streamlined health care services.

We need open source EHRs not just to reduce health care costs, but to transform health. But first, we need a vision of EHR heaven. I hope this article has taken us at least into the clouds.

Open Source Software and the Path to EHR Heaven (Part 1 of 2)

Posted on September 19, 2018 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

Do you feel your electronic health record (EHR) is heaven or hell? The vast majority of clinicians–and many patients, too, who interact with the EHR through a web portal–see it as the latter. In this article, I’ll describe an EHR heaven and how free and open source software can contribute to it. But first an old joke (which I have adapted slightly).

A salesman for an EHR vendor dies and goes before the Pearly Gates. Saint Peter asks him, “Would you like to go to heaven or hell?”

Surprised, the salesman says, “I didn’t know I had a choice.”

Saint Peter suggests, “How about this. We’ll show you heaven and hell, and then you can decide.”

“Sounds fair,” says the EHR salesman.

First they take him to heaven. People wearing white robes are strumming harps and singing hymns, and it goes on for a long time, till they take him away.

Next they take him to hell. And it’s really cool! People are clinking wine glasses together and chatting about amusing topics around the pool.

When the EHR salesman gets back to the Pearly Gates, he says to Saint Peter, “You know, this sounds really strange, but I choose hell.”

Immediately comes a clap of thunder. The salesman is in a fiery pit being prodded with pitchforks by dreadful demons.

“Wait!” he cries out. “This is not the hell I saw!”

One of the demons answers, “They must have shown you the demo.”

Most hospitals and clinicians are currently in EHR hell–one they have freely chosen, and one paid for partly by government Meaningful Use reimbursements. So we all know what EHR hell look like. What would EHR heaven be? And how does free and open source software enable it? The following sections of this article list the traits I think clinicians would like to see.

Interfaces could be easily replaced and customized

The greatest achievement of the open source movement, in my opinion, has been to strike an ideal balance between “let a hundred flowers bloom” experimentation and choosing the best option to advance the field. A healthy open source project encourages branching, which lets any individual or team with the required expertise change a product to their heart’s content. Users can then try out different versions, and a central committee vets the changes to decide which version is most robust.

Furthermore, modularization on various levels (programming modules, hooks, compile-time options, configuration tools) allows multiple versions to co-exist, each user choosing the options right for their environment. Open source software tends to be modular for several reasons, notably because it is developed by many different individuals and teams who want control over their small parts of the system.

With easy customization, a hospital or clinic can mandate that certain items be highlighted and that safe workflow rules be followed when entering or retrieving data. But the institution can also offer leeway for individual clinicians and patients to arrange a dashboard, color scheme, or other aspect of the environment to their liking.

Many of the enablers for this kind of agile, user-friendly programming are technical. Modularity is built into programming languages, while branching is standard in version control systems. So why can’t proprietary vendors do what open source communities routinely do? A few actually do, but most are constrained in ways that prevent such flexibility, especially in electronic health records:

  • Most vendors are dragging out the lifetime of nearly 40-year old technology, with brittle languages and tools that put insurmountable barriers in the way of agile work styles. They are also stuck with monolithic systems instead of modular ones.
  • The vendors’ business model depends on this monolithic control. To unbundle components, allow mix-and-match installations, and allow third parties to plug in new features would challenge the prices they charge.
  • The vendors are fundamentally unprepared for empowered users. They may vet features with clinically trained consultants and do market research, but handling power over the system to users is not in their DNA.

Data could be exchanged in a standard format without complex transformations

Data sharing is the lifeblood of modern computing; you can’t get much done on a single computer anymore. Data sharing lies behind new technologies ranging from the Internet of Things to real-time ad generation (the reason you’ll see a link to an article about “Fourteen celebrities who passed out drunk in public” when you’re trying to read a serious article about health IT). But it’s so rare in health care–where it’s uniquely known as “interoperability”–that every year, reformers call it the most critical goal for health IT, and the Office of the National Coordinator has repeatedly narrowed its Meaningful Use and related criteria to emphasize interoperability.

Open source software can share data with other systems as a matter of course. Data formats are simple, often text-based, and defined in the code in easy-to-find ways. Open source programmers, freed from the pressures on proprietary developers to reinvent wheels and set themselves apart from competitors, like to copy existing data formats. As a stark example of open source’s advantages, consider the most recent version of the Open Document Format, used by LibreOffice and other office suites. It defines an entire office suite in 104 pages. How big is the standards document for the Microsoft OOXML format, offering roughly equivalent functionality? Currently, 6,755 pages–and many observers say even that is incomplete. In short, open source is consistently the right choice for data exchange.

What would the adoption of open source do to improve health care, given that it would solve the interoperability problem? Records could be stored in the cloud–hopefully under patient control–and released to any facility treating the patient. Research would blossom, and researchers could share data as allowed by patients. Analytical services could be plugged in to produce new insights about disease and treatment from the records of millions of people. Perhaps interoperability could also contribute to solving the notorious patient matching problem–but that’s a complicated issue that I have discussed elsewhere, touching on privacy issues and user control outside the scope of this article.

The next segment of this article will list three more benefits of free and open source software, along with an assessment of its current and future prospects.

Nursing and Healthcare Reform Cartoons – Fun Friday

Posted on June 30, 2017 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

It’s time again for some Fun Friday cartoons. This week’s comics are more general healthcare cartoons, but they were both too funny to not share. I hope you enjoy them.

If you don’t love nurses, then we can’t be friends. They are some of the most amazing people in the world and undervalued and underappreciated in healthcare.

This one might be a little too close to home for many in the current healthcare reform environment. Humor that borders on reality are my favorite.

What Would New Care Delivery Models Look Like If Created Today?

Posted on November 24, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.


This tweet has been on my mind the last month. I’m sure that many in the trenches probably think that this type of thinking is a pipe dream and not worthy of discussion. While it’s true that we can’t go back and change the past, this type of thinking may predict where we need to go in the future.

I and many others have long talked about the way EHR software was built to maximize billing and then meaningful use. The focus of the EHR was not on how to improve patient care, but was really built around how the organization could manage it’s billing and make more money. So, we shouldn’t be too surprised that the EHR systems we have today aren’t these amazing systems that dramatically improve the care we provide.

With that said, there’s a sea change happening in health care when it comes to how organizations are being reimbursed based on value. Might I suggest that an organization that wants to be ready for this change in reimbursement might want to take the time to think about what care models would look like if they were created from scratch today without the overhead of the past.

I’m not the only one thinking about this. Check out this tweet from Linda Stotsky that quotes Rasu Shrestha, MD, MBA.


In the article that’s linked to in that tweet Rasu describes the real challenge of rethinking our care models:

What does it truly mean to have a patient-centered approach to care? As a clinician, I can tell you confidently that most of my colleagues tend to get defensive amid talk of the need to adopt a patient-centric approach to care. “Of course, we’re focused on the patient!” seems to be the most common reaction. Many simply assume that because care is essentially imparted onto a patient, everything we do, naturally, is patient-centric

Then he offers this frank comment:

But where is the patient in all of this? Is a system designed to help document our attempts to cure the patient, and help bill for the associated services, really the best we can do? Perhaps the problem is bigger than just the EMR. Perhaps our frequently paternalistic, and often heroic, approaches to care have been cherished, celebrated and incentivized for far too long. Perhaps we need to rethink care in a big way.

I agree with Rasu. He also quotes Ellen Stoval, survivor or three bouts of cancer who says, “We have been chasing the cure, rather than the care.” I’m actually optimistic that these changes are happening. We’re going to see a drastically improved health care system. It’s going to take time, but most changes do. What’s most exciting is that if we navigate these shifts properly, then doctors will finally get to practice medicine the way they imagined medicine. Instead of churning patients to meet revenue, they could actually spend more time caring for patients. That’s something worth aspiring towards.

Does Healthcare IT Need Stability?

Posted on February 12, 2013 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Last night during one of my favorite TV shows, Charlie Rose, he interviewed a guy about the economy. One of the discussion points that came out of this interview and that I’ve heard a lot in all the discussions about the economy is having some stability to the economy. Many argue that one of the biggest things holding our economy back is all the unknowns. When there are unknowns companies get paralyzed and hold back doing things they’d do if the economy felt stable.

I wonder if we’re experiencing the same thing in healthcare IT? Could we use some stability in healthcare IT?

Think about all the various unknowns that exist in healthcare IT. Let’s start with ICD-10. The pending ICD-10 implementation date is looming, but that date has been pushed back so many times it’s still unknown if it’s really going to happen this time. That’s the opposite of stability.

I’m sure that many also wonder if the same will be the case with EHR penalties. Will the EHR penalties go into effect? What exceptions will be made for the EHR penalties? I could easily see the EHR penalties being delayed, but then again what if they’re not?

Is it hard for anyone else to keep up with what’s happening with meaningful use? I do this every day and so I have a pretty good idea, but even I’m getting confused as it gets more complex. Imagine being a doctor who rarely looks at meaningful use. So, we’re in meaningful use stage 1, but meaningful use stage 2 is coming, unless you didn’t start meaningful use stage 1 and then meaningful use stage 2 won’t come until later. Oh, and they’re making changes to meaningful use stage 2. That’s right and they’re also coming out with meaningful use stage 3. However, don’t worry too much about meaningful use stage 3 because a lot of people are calling for it to be slowed down. So, does that mean that meaningful use will be delayed? Now how does the meaningful use stages match with the EHR certifications? Which version of my EHR software does which stage of meaningful use?

I think you get the picture.

Of course, I haven’t even mentioned things like ACO’s, HIE’s, 5010, HIPAA, RAC Audits, Medicare/Medicaid cuts, or healthcare reform (ACA) to name a few others.

It’s a messy healthcare IT environment right now. We could definitely use some stability in healthcare.

Keeping the “Health” in “Heathcare”

Posted on December 11, 2012 I Written By

Mandi Bishop is a hardcore health data geek with a Master's in English and a passion for big data analytics, which she brings to her role as Dell Health’s Analytics Solutions Lead. She fell in love with her PCjr at 9 when she learned to program in BASIC. Individual accountability zealot, patient engagement advocate, innovation lover and ceaseless dreamer. Relentless in pursuit of answers to the question: "How do we GET there from here?" More byte-sized commentary on Twitter: @MandiBPro.

‘Tis the season for family gatherings, holiday parties, and a plethora of professional networking events – all of which give me ample opportunity to perfect my “elevator speech”, introducing my business. It seems like each time I discuss what I do for a living, the question that follows is, “So, how do you feel about Obamacare?”

I understand that the Affordable Care Act, AKA Obamacare, is a significant slice of the polarizing pie our nation is currently attempting to consume and digest. And I appreciate that now, for the first time in my career, more people than not take an interest in what I have to say about being “a healthcare data consultant.” In years past, eyes would glaze over as I explained the enormous potential of predictive analytics in wellness and disease management programs, or the power of unstructured data mining for clinical notes data. Mentioning the health insurance plans I worked with brought inquiries into individual versus group rates, and complaints about the latest round of premium increases. It’s been refreshing to experience keen interest and pointed questions as I talk, rather than have each person gulp the last sip of wine and excuse themselves to run for more as soon as they figured out I have nothing to do with how much out-of-pocket expense they’re incurring after each doctor visit.

But as much as I enjoy the sudden interest in healthcare policy and data management, there isn’t enough wine in the world to make me debate the politics of healthcare reform with my 6’5″ uncles, my friends, or my social media connections. I am not a lawyer or political pundit. I am not qualified to comment on the merits of the ACA legislation. I am not an economist. I am not qualified to comment on the fiscal impact of Obamacare. I am a technologist. I am qualified to comment on the translation of ACA’s many provisions into the infrastructure and applications supporting our healthcare system. I am also a healthcare system consumer. I AM qualified to comment on what I believe this historic legislation means to my health, the health of my family, and the health of future generations.

This is what ACA healthcare reform and its many facets – Health Information Exchange (HIE), Electronic Health Records (EHR), Electronic Medical Records (EMR), Meaningful Use (MU) – mean to me: more, better, faster healthcare data capture and communication between all the stakeholders involved in my health and wellness:

– More health data: Meaningful Use-certified EMR applications require that particular medical service activities and clinical data elements are captured and stored discretely, electronically, and made available for retrieval upon patient demand.

– Better health data: The majority of medical procedures, products, services, events, and outcomes are codified in order to meet regulatory standards. It may take longer for your provider to enter the information about a patient encounter into an EMR system than it did to scribble notes on a chart; however, because those detailed discrete data elements are now tied to compensation and incentives, there is a higher likelihood that more specific details will be captured individually per encounter, generating a more complete picture of a patient’s medical history than a manual review of their paper charts. No handwriting recognition required.

– Faster access to critical health data: With EHR applications and HIEs, providers can instantly access patient medical records from provider/facility sources and multiple insurance carriers. The difference between electronic transmission speeds and manual chart retrieval could be the difference between life and death.

How could a higher volume of increasingly accurate, integrated, and immediately available healthcare data result in adverse health outcomes?

To me, healthcare isn’t about politics. It is health care. It’s about me, caring for my health, and the health of my loved ones. I believe that technological advances can and will empower healthcare stakeholders of all ilks – provider, health insurance plan, pharmaceutical industry, patients – to increase the speed of condition diagnosis and treatment, and to assist in establishing and maintaining healthy habits for improved health over a lifetime.

This season, put the “health” back in “healthcare”.

Government Shutdown and Other Governmental Impacts on EMR and Healthcare IT

Posted on October 6, 2011 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Yep, the government shutdown talks were in the air again. We heard all about this back in April, we just heard about it again and now they’ve pushed the discussion out until November. I have a feeling that we’re going to continue to hear about it for a while to come. I’m just a passive political sideline observer, but I’d say the chance of a government shutdown is still very little. For all the drama of the media, I have a feeling that the drama won’t actually lead to a shutdown. A last minute deal will be reached…again and again like it did this time and the last.

However, it’s interesting to consider how a government shutdown could affect healthcare IT. In similar situations I’ve seen budgets have usually seen healthcare as an essential function and so they’ve been fine. Although, that’s really talking about the short term possibility of a government shutdown. Who knows what the long term budgets could hold for the government related entities.

Medicare and Medicaid are constantly in the cross hairs of cuts. Most doctors I know talk about how those two government programs pay them the least amount of money. Plus, they talk how many of the cuts to Medicare and Medicaid basically get passed on to them as doctors. I wonder what the super committee that’s required to cut $1.5 trillion of the federal deficit over the next decade will do with Medicare and Medicaid.

We’ve discussed many times the potential impact of the workings in Washington on meaningful use and the EHR incentive money (most think it’s safe).

For those that think what happens in Washington DC won’t really have much impact on healthcare IT, you might want to consider the email I got today announcing the keynote speakers for HIMSS 12 in Las Vegas. Donna Brazile (Democrat) and Dana Perino (Republican) will be on stage for what will no doubt be a spirited debate about the 2012 presidential elections, the political landscape and healthcare reform.

It’s going to be an interesting next couple years to see how changes in government affect healthcare IT and EMR.

Random Thoughts: EMR Projects Decentralized; Problems Persist Despite ‘Solutions’

Posted on August 4, 2011 I Written By

Once in a while, I run out of Big Ideas to share and resort to a rundown of short items. This is one of those times. Often, though, that approach turns out to be more interesting than a well-thought-out commentary. (Thus, the popularity of Twitter, right?)

Speaking of Big Ideas, I’m thinking that the age of the massive EMR project may be coming to an end. You may have seen my piece in InformationWeek today about the reported end of the national EMR in England. London’s The Independent reported earlier this week that the Cameron government will announce next month that it will scrap the national strategy in favor of allowing local hospitals and trusts to make independent EMR purchasing and implementation decisions.

This news comes on the heels of a decision by the government of Ontario to give up on hopes for a single EMR for all of Canada’s most populous province.

On the other hand, here in the States, we’ve seen a lot of consolidation among healthcare providers, but I’m guessing that has more to do with administrative Accountable Care Organizations and the prospect of bundled payments than any desire to build a more unified EMR. Though, consolidation does make health information exchange somewhat easier, and that’s going to be key to earning “meaningful use” dollars beyond 2013.

On a somewhat similar note, doesn’t a headline like, “Positive Outlook for Small Practice EHR Adoption” sound like a no-brainer? I mean, isn’t that the segment of healthcare providers that historically has had the slowest adoption rates? More than anyone else, small practices—particularly small, primary care practices—are the intended target of the federal EHR incentive program. And most of the news from health IT vendors of late has been about how they are going after this long-neglected market, right? The innovation seems to be happening in ambulatory EMRs, as evidenced by DrChrono’s newly certified iPad EHR app, aimed squarely at independent physicians.

That said, vendors and publicists, please do not start inundating me with news about other EHRs getting certified. There are hundreds of certified products out there now, and I cannot and will not write about, oh, about 95 percent of them.

While you’re at it, please stop using the word “solution” as a synonym for “product” or “service.” Tech journalists hate this trite, lazy and, frankly, inaccurate term so much that I’ve been instructed by the editors of InformationWeek not to use it, except in direct quotes. In fact, I get reminded not to use it pretty much every time I’m forwarded a press release laden with news about someone’s “solution.” Solution to what? I’ve been seeing that term since I started covering health IT more than a decade ago, and I still don’t see much getting solved in healthcare. With all the “solutions” out there, you’d think that healthcare had been fixed by now.

I could get a whole lot more curmudgeonly on you, but I think I’ll stop now and await your comments.

 

HIE, ACOs Are the ‘Fast-Moving Train’ of Health Reform

Posted on May 12, 2011 I Written By

Healthcare and health IT are plagued by conundrums. Providers long have been the ones asked to make hefty investments in EMRs and other IT systems to help remove costs from the healthcare system, but payers and plan sponsors tend to enjoy most of the financial benefits. Clinicians wish their organizations would share data with others, but those in the executive suite have been reluctant to cooperate with competitors for fear of losing revenue. And, let’s face it, medical errors can be profitable if a routine procedure turns into an expensive inpatient admission.

Portions of the American Recovery and Reinvestment Act and the Patient Protection and Affordable Care Act are intended to address these problems by providing financial incentives for “meaningful use” of EMRs (including health information exchange) and by encouraging the creation of Accountable Care Organizations

I’m just back from the Institute for Health Technology Transformation health IT summit in Fort Lauderdale, Fla., where I moderated panels on how health IT underpins ACOs and how business intelligence can create a framework for health information exchange.

The panelists did great job of articulating some of these conundrums and strategies to overcome them, but none better than Kevin Maher, director of clinical innovations for Horizon Healthcare Innovations, a new affiliate of Horizon Blue Cross Blue Shield of New Jersey tasked with testing new care models, and Victor Freeman, M.D., quality director in the Health Resources and Services Administration‘s Office of Health IT and Quality.

The patient-centered medical home is a great idea for managing care, promoting prevention and, ultimately reducing costs. “We view the base of the ACO as the patient-centered medical home,” Maher said. But what exactly does an ACO look like? “An ACO is like a unicorn,” Maher said. “We can all describe it, but we’ve never seen one.”

He noted that Horizon has started paying some physicians a care coordination fee to manage populations that potentially could add $60,000 or more to a doctor’s annual income. But there are plenty of factors outside a physicians’ control.

“Potentially the No. 1 focal point of a patient-centered medical home or an ACO is patient behavior,” Maher said. A doctor can’t force a patient to exercise more, quit smoking or get a mammogram or PSA test. There’s pay-for-performance for doctors, but what about paying for patient performance?

In January 2012, Horizon will launch a pilot to offer incentives to members who get recommended tests and choose providers that meet the health plan’s quality standards. That’s right, the Blues plan in New Jersey will pay people to go to the doctor and to make informed choices about which doctors they see. (“Everyone says she’s a great doctor” won’t cut it as an informed choice anymore.)

Freeman called the Horizon experiment “P4P that makes sense.”

Let’s just hope the technology can support making the right choices. “People in government get more involved in quality measurement, not necessarily quality,” Freeman said. Incentive programs these days still tend to be more pay-for-reporting than pay-for-quality, and the technology hasn’t fully matured in that area.

“EMRs were designed for billing, not quality reporting,” noted Freeman, who has a background in public and population health. Information often isn’t stored in discrete form, such as with images generated by specialists flagged as being abnormal, so even with HIE, it’s hard for primary care physicians to identify patients who might be candidates for early interventions before they actually exhibit symptoms of a disease.

“My biggest interest in HIE is how clinicians communicate with each other,” Freeman said.

But is the technology ready to help them do so? “HIE now reminds me of what EMRs were five years ago,” said another panelist, Bruce Metz, Ph.D., newly hired senior VP and CIO at the Lahey Clinic in Massachusetts. It’s viewed as an IT project that’s not necessarily linked to a business or clinical strategy. “You can’t force the technology to mature that fast,” he added.

And so the ride continues on what Metz called “a fast-moving train.” Have we even had time to see if the right people are on board?

“Tell Me Something I Don’t Know” with Jonathan Bush from AthenaHealth

Posted on April 26, 2011 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

When I got the request at HIMSS 11 to be able to sit down and talk with Jonathan Bush, CEO of AthenaHealth, I knew that I had to take it. Him and I had a very interesting conversation and he’s a fascinating individual since you never know what he might say next.

On that note, I decided that I better get Jonathan Bush on video at HIMSS. In fact, I think it might have been the only video I did at HIMSS. Although, once I saw how easy it was to upload this video from my phone, I might have to do more EMR related videos on the future. Although, I’ll probably need to hold it the other way.

Now to the video. The basic idea of “Tell Me Something I Don’t Know” comes from the Sunday show that Chris Matthew’s does. In the segment, the people try and tell you something you probably don’t know. I decided to do the same with Jonathan Bush using the various buzzwords at HIMSS: meaningful use, ACOs, incentive money, and healthcare reform.


Video of Jonathan Bush at HIMSS 11
Sorry the video quality and ambient noise isn’t the best. It was on a cell phone in a crowded exhibit hall.

Side Note: If you like videos, let me know. I’m thinking about doing more of them. Possibly some Q and A style videos. If you are interested, drop a question in the comments and I can use them for a future video.