What Will Health Care Look Like in 2015?

Guest post by Allen R. Wenner, M.D.


"I am sitting here quietly listening to Pandora Radio while I work. I am thinking how it will totally change how people listen to music. I am listening to a music channel that is totally customized and specific for my listening tastes. This transformation is more dramatic than other changes. I think that is what is happens - each change is bigger than the last. Pandora Radio will send Satellite Radio the way of the Satellite Phone. It will downsize the Clear Channel listeners to people who do not have internet or drive an older car without an input jack. Radio stations will become essentially worthless.

Amazon transformed how people bought books bankrupting Books a Million and finally Borders. Now the Kindle, Nook, iPad are transforming reading again. Verizon announced it will no longer publish a phone book in many markets as search engines have replaced them. The same thing is happening to how people watch television as networks become less valuable and streaming via NetFlix becomes the video standard.

Transformations all come to medicine last. Medicine is the last industry to computerize information, but the transformation is likely to be the most dramatic, Although the digitalization has started, the workflow transformation has not occurred. Many providers still act like the computer is paper under glass. As more and more medical systems become digital, then the evolution of medicine itself will occur. With 49,000,000 million US citizens getting health care insurance at the same time growing millions of Baby Boomers are seeking care while patient satisfaction with care is already at generational lows, 2015 could be the time for real health care change. The Meaningful Use incentives will be over and the medical system will be divided into two tiers - those that are still paper-based and those that are totally paperless. The former will fade like mom and pop grocery stores as these doctors grow old with their patients.

The question becomes what will happen to health care delivery. The web enabled handheld device will play a critical role in changing health care. It will become the front door to the medical practice. 3G Doctor is an example of how patients will interact with the health care system. No longer will patients call up and get an appointment. The patient will complete an expert interview, Instant Medical History™, as described by Bachman in his study of e-visits.(1) The clinician will review the information before deciding on the plan: 1) come to the office; 2) go to ancillary service; 3) have a test; 4) conservative management; 5) go to specialist; 6) get treatment and schedule appointment later. The clinician will be at least twice as productive. Perhaps 50% of current office visits will be virtual, as safe,(2) and preferred by patients.

Care will be home centered with many point-of-service lab devices in the patient's bathroom. The current outdated reimbursement schemes that prevent this today will fail as population based payment renders quantity based payment obsolete. Home prothrombin devices will render Coagulation Clinics unneeded. These skilled coagulation nurses will manage ten times the number of patients using web devices like smart phones. Home blood pressure readings will be the standard. Diabetes will be a home health disorder. In-home video and clinical measurement devices connected to smart phones will allow new management of chronic medical issues. Face-to-face visits will be far more complex with two or more clinicians and others video conferencing about patients. Specialists will no longer have brick and mortar offices. They will have procedure suites and offices in hospitals where they can carry out virtual discussions. The primary care physician will manage the details of the treatment plan."

(1) Bachman, John, http://www.mayoclinicproceedings.com/content/85/8/704.full
(2) Munger, Mark http://www.mayoclinicproceedings.com/content/83/8/890.full

Will Electronic Records Cure Healthcare?

Guest post from Joe Weber:

"Implementing an electronic health record (EHR) costs tens of thousands of dollars for each physician. Soon, taxpayers will be footing the bill. That would be fine if we’re certain it will make our healthcare costs go down. But how can we be certain of that? There is no question that there will be some benefits resulting from the operational efficiencies and clinical alerts of EHRs. But do we really believe these systems will make healthcare all that it can be?

Until we are totally confident we know how to design and deploy EHRs in a manner that will dramatically improve healthcare, why would we want to proliferate these systems? The thinking is that EHR interoperability will solve healthcare's crisis. But ask yourself: Whenever you've received inadequate care, what was the root cause? Was it (1) because your doctor couldn't access a medical record that was in some other doctor's office? Was it (2) because your doctor did not have access to the clinical knowledge that would have led to accurate diagnosis and/or effective treatment? Or was it (3) because medical science, itself, just does not know enough?

Of those 3 causes for suboptimal healthcare, I believe the first one (lack of EHR interoperability) is actually the least impacting. For most clinical episodes, the treating physician is not truly handicapped by not being able to see what’s in some other physician’s record of your prior care. The second one seems to be considerably more instrumental. No physician can learn all s/he needs to learn, remember all that was learned, and apply it effectively during a brief clinical encounter. So we should clearly enable access to whatever is currently known by medical science, by providing computer-retrievable knowledge at the point of care. Not to do so is just plain foolish…or professionally arrogant.

The third cause, in my opinion, is actually the most significant deficiency in healthcare. Medical science just does not know enough. The reason for this is that healthcare does not learn from its own experiences. No one is retrospectively analyzing all the clinical encounters every day, to determine the early signs of what eventually become definitive diagnoses. No one is evaluating what treatments actually work best for various conditions, and under what circumstances. Medical science only moves forward via controlled clinical studies, which are too targeted and expensive to be our only strategy for advancing the science. We need to mine the data on real-life clinical encounters – nationwide. If you doubt this assertion, think about hormone-replacement therapy. The message here is that data interoperability, attained through a standardized clinical vocabulary, is more critical than operational interoperability.

Once we have determined, through data analyses (while controlling for potentially confounding variables), how to diagnose and treat more effectively, we must convert that learning into a "clinical guidance system", operational at the point of care. We would monitor outcomes, assuming we can figure out how to measure them, so that the system can be empirically enhanced – thereby establishing continuous quality improvement (CQI) for healthcare. That, along with systematization of healthcare delivery, via processes like triage and rational incentives, is the only way that we can prevent the current crisis from turning into an apocalypse.

We need to conduct pilots of alternative EHR approaches, rigorously analyzing both the financial and clinical outcomes – so that we can learn what truly works best. The point-and-click documentation requirement of most existing EHRs has ironically been demonstrated to decrease the productivity of physicians. That is the last thing we need…particularly if there are no offsetting benefits derived from improved quality and value. Let’s figure out how to do it right: How to make data entry physician-friendly and highly efficient. Let’s bring the best minds together to design and evaluate these systems, which will determine the future of our nation’s healthcare. Let's not throw money at this devastating problem until we know for sure it will buy the cure."

Joe Weber, CEO
Valadoc, The Medical Coordinator Company

HIMSS 2011 Report

The Health Information Management Systems Society, or HIMSS, conference this week in Orlando was a most interesting, and often delightful, experience. For me, it was almost continuous networking/meetings with entities that are seeking the best methodologies for delivering patient centered, value-based care. This movement is still a sideshow to the heavily capitalized power elites chasing the traditional volume-based health care delivery products. However, there is a definite shift taking place. I first detected this shift at last year’s show, and it is quickly gaining steam as both the government and several major players in the industry have more openly advocated the necessity of moving from industry-centric to patient-centric information management. There are relatively few at this gathering of over 31,000 that understand what this really means and even fewer that have any real experience. Because the SOAPware team has had this focus for almost 2 decades, we had the ear of many industry and government leaders during a dozen or more side meetings during the week. There is a recognition and movement toward the true interoperability and open standards (focusing on the Internet) that will be necessary to disrupt what is currently so dysfunctional.

At times, during the conference, when on the exhibit floor between many monstrous booths, I could not help but wonder if what most around me were experiencing would subsequently prove to be very similar to what the passengers of the Titanic experienced... the day before...

This next year, as healthcare policy rolls out promoting Accountable Care Organizations and Patient Centered Medical Homes, there is going to be a great acceleration away from the traditionally monolithic, siloed information systems that currently dominate the healthcare world. This is also going to finally open the industry to innovation and more efficient/appropriate uses of clinicians other than turning them into harried, distracted, data entry clerks. The interest in SOAPware’s approach to using medical coordinators and patients to perform almost all of the data entry is clearly the future. I predict the recent past, and current times, will soon prove to have been the darkest of eras for patients and the doctors deserving of their trust.

Time permitting… I will make some comments in the near future as to some more of the specifics.

We May Finally Be Moving Beyond Faxing to Exchange Clinical Information

I had a very rewarding week in Washington D.C. last week dealing primarily with issues and projects related to being able to exchange clinical information. The highlight was the Press Announcement - American Academy of Family Physicians Unveils New Secure Electronic Messaging Service for Physicians Based on Surescripts Network for Clinical Interoperability


Here is my quote regarding this initiative:

“Medical record information exchange in the United States has not been able to expand beyond the fax machine for more than 90 percent of medical practices and their patients. This initiative by AAFP and Surescripts could prove transformational by finally overcoming most of the pervasive obstacles that have prevented progress up until now. Finally, here is an initiative that promises practical transfers of patient information at a fraction of the cost and hassle of most current efforts. AAFP Physicians Direct also can deliver working solutions in an almost immediate time frame, rather than having to wait for years. We simply do not have years to wait for positive change in our health care system.”

We, at SOAPware, Inc. have been facilitating and encouraging this more simple approach to information sharing for years, and publically demonstrated its feasibility years ago -
AAFP/SureScripts/MinuteClinic/SOAPware Provider-to-Provider Clinical Messaging Demo'd at TEPR

Here is a summary of what this initiative intends to deliver:
AAFP Physicians Direct is an affordable and easy-to-use electronic messaging service for physicians that:
• Enables physicians to share patient health data through a secure network.
• Breaks down communication barriers between health care providers.
• Accelerates the digital transformation of the nation’s health care system.
The Benefits
• Improve communication among providers
• Enhance continuity of care
• Support achievement of Meaningful Use
• Advance the Patient-Centered Medical Home
The Technology
AAFP Physicians Direct is built on the Surescripts Network for Clinical Interoperability, making the new service available to family physicians and other health care providers nationwide. The AAFP, Surescripts, and many other organizations have collaborated with the federal government to create the standard protocols to make this type of electronic clinical communication possible.
The Cost
Unlimited messaging per physician: $15 monthly


Even though this is being announced/sponsored by the AAFP, it will be available to any physician of any specialty. The only requirement is that the prescribing clinician be connected to the Surescripts network. Many physicians are already connected and using it now to prescribe electronically. Surescripts is opening the network to now share more than just prescriptions. It is anticipated that just about any document type can be shared, and this includes CCR, CCD, .pdf, Word documents, images, etc.
The protocols for sharing are being based on the NHIN Direct Project which is national in scope and part of the federal initiatives for information sharing. Most regional health information exchanges, such as state HIE projects are going to be required, to some extent, to also support message transfers using the Direct protocols. Undoubtedly, there is going to be confusion amongst physicians as to why they would be interested in the Physicians Direct initiative when they have been approached to participate in one or more regional HIE projects. This blog post - Direct Model or HIE Model – http://www.emrandhipaa.com/emr-and-hipaa/2011/02/15/direct-model-or-hie-model/ - IMHO, does a pretty good job of explaining the Direct vs the HIE approach. Realistically, in the short term, it is going to likely be a both/and for most. The PHR that is projected to be at the center of the Direct model in this blog post is not yet tied into the Physicians Direct project, but may well be an option at a later phase. The Physicians Direct project provides a secure means to directly transfer electronic information from one physician to another. So, for now, this project could soon deliver a practical, more immediate, lower cost means to accomplish transfers of information beyond the limited faxing of today. Tomorrow, it may very well provide the tools to meet the interoperability requirements of Stage 2 and 3 of meaningful use with far greater practicality and lower cost (with less risk of being victimized by connectivity extortion) than some other options.
I predict, in time, the more national, Direct approach will subsume the regional HIE models when the latter run out of government fundings. I don't anticipate medical practices will be eager to pay for more expensive, regional information sharing networks when simpler, lower cost, national options are going to be available.

Another good read regarding the Direct approach to information sharing can be found here -
Getting DIRECTly to the Point: The Role of the Direct Project in Fast-Tracking Health IT Interoperability - http://e-caremanagement.com/getting-directly-to-the-point-the-role-of-the-direct-project-in-fast-tracking-health-it-interoperability/

IMHO, Surescripts and the AAFP are to be commended on their efforts toward encouraging more patient-centric and physician-friendly approaches to information sharing.

The other major meeting I attended this week in D.C. was the hearings related to the PCAST report. A good summary is found here - Comments to ONC: PCAST HIT Report Becomes a Political Piñata
http://thehealthcareblog.com/blog/2011/01/23/pcast-hit-report-becomes-a-political-pinata/

The Basics As to How to Receive Medicare "Meaning Use" Bonus Payments

In order to obtain the Medicare “Meaningful Use” bonus, you must:

1. Register for the Meaningful Use Incentive Program (plan for 20-60 minutes).

2. Use an ONC certified EHR such as SOAPware 2011 (use for 90 days in 2011).

3. Subsequently attest to meaningfully-using SOAPware (plan for 20-60 minutes).

1. Register for the Meaningful Use Incentive Program (plan for 20-60 minutes).

The first step is to get the EHR Certification number:

-Go to http://onc-chpl.force.com/ehrcert/

-Select “Ambulatory Practice Type.”

-In the middle grey box, ensure Product Name is selected from the drop-down, and type soapware in the “Search for” field.

-Click the Search button.

-Click on the Add to Cart link.

-Click the Get CMS EHR Certification ID button on the right-side. This gives you the number you will need when you subsequently attest for “meaningful use.”

The second step is to register for the Meaningful Use Incentive Program:

Preview the information at the https://ehrincentives.cms.gov/hitech/ prior to registering for Meaningful Use. At that location is a very good video explaining the process. The information from the video is also available in document form from: http://www.cms.gov/EHRIncentivePrograms/Downloads/EHRMedicareEP_RegistrationUserGuide.pdf

2. Use an ONC certified EHR such as SOAPware 2011 (use for 90 days in 2011).

Again, SOAPware 2011 is certified on ALL certification criteria, and on ALL NQF Quality Reporting Measures. Any eligible professional can use SOAPware 2011 to meet Meaningful Use requirements, including primary care and specialists. SOAPware 2011 expected to be available late February. Start now by reviewing the SOAPware 2011 Meaningful Use Guides online at http://soapware.screenstepslive.com/spaces/documentation/manuals/mu_overview

Much more information and several videos explaining and demonstrating the "meaningful use" of SOAPware are in the works for release within the next few weeks and the process will be fine-tuned over the next few months. (Warning!! Avoid any EMR/EHR implementation that does not demonstrate the step-by-step processes in advance.)

3. Attest to meaningfully-using SOAPware (plan for 20-60 minutes).

For Stage One, which is 2011-2012, providers only have to attest that they have used a ONC-certified product for at least 90 days in calendar year 2011. It will have to be used for all 12 months in 2012. Attestation will occur online, but the website to self-attest is not yet available. It is expected sometime in April, 2011. More information can be found at https://www.cms.gov/EHRIncentivePrograms/01_Overview.asp

In this Industry… 1. Anything Is Possible… 2. Given Enough Time and Money

I have recently been amazed at how often #1 is put forward and #2 is ignored. 2011 will prove to be an interesting year, and I am going to make a prediction that with the products that currently exist in the marketplace, no more than 50% of medical practices planning to capture meaningful use payments will actually do so. I am also going to predict that over 80% of EMR/EHR purchased in 2010 and 2011 will fail to receive meaningful use bonuses. Practices simply will not have enough time and/or money to carry through. It is my perception the bulk of recent purchases have been (and are currently) to acquire golden spoons for situations where backhoes are needed.

The sad realities are that, increasingly, purchasing and implementation decisions are being made by entities that really do not adequately understand the monsters associated with comprehensive EMR use. The persisting naiveté regarding what is needed at the point of care is nothing less than astonishing.

There simply is not enough time or labor available to dig foundations with spoons, no matter how expensive and “golden” the spoons might prove to be. As a result, I predict that there will be a lot of chaos and inconvenience for the majority of physicians that have recently taken, or are in the process of making, the EMR/EHR plunge. There will even be more chaos and transition at the CIO/CMO level, and in the EMR/EHR vendor world, when expected deliverables are not forthcoming.

It is also a sad reality that sources of information often used to assist in EMR/EHR selection and implementation are often misguided. For example, one of the most prominent vendor ranking/survey entities recently gave an acropolitic, 100% positive ranking to a vendor who has practically no significant, successful EMR/EHR implementations within busy practices. Look for this particular EMR/EHR vendor to sell out to an acquirer in late 2011 or early 2012 which will likely deliver immunities to their principles who have been unconditionally promising meaningful use reward payments to their customers. Also, look for this ranking company to continue, unabated, in their tradition of ranking many products at the top that will continue to have a greater than 50% failure rate. This has been the pattern for the past decade, and some things predictably don't change.

Another recent EMR/EHR survey included, as their top, recommended vendor, one who has only met 40% of the requirements for meaningful use, so it is only a “modular” rather than complete EHR system. Users of this “free” system currently have little probability of actually receiving meaningful use payments. Will this vendor be able to get enough, additional venture capital money (or ad sales?) in time to force cold fusion? Realistically, even if they do successfully add the necessary functionalities, the cumbersomeness of using this system to actually capture and report the data from the point of care is most likely to be more daunting than practical.

It is anyone's guess what will happen to some of the REC entities who are so prominently promoting golden spoons? Will they be allowed to fail, or will the taxpayers be pleased to come to their rescue?

So, for the next year, I predict somewhere north of 50% of medical practices will not have either the time, energy, or the money to persist in their currently misguided EMR/EHR purchases and implementations. We hope to be an exception to the norm. It is our goal for no less than 90% of SOAPware users who intend to receive meaningful use payments be successful in doing so. Rather than being focused on making promises, out of context, to potential purchasers, we are mostly focusing on assisting our users properly implement our software and see that they properly submit their attestations to the ONC. More to come on both of these key issues. It is our sincere intent to accomplish this in fashions that actually improve the well-being of patients and the doctors deserving of their trust.