Jonathan Bush from Athena Health on Government Reforms

Great interview on CNN Fast Money program with Jonathan Bush commenting on the investment and reforms and how this might impact his company.

He makes some salient points and in particular the focus on delivering data and focusing on data rather than paying to implement a bunch of "legacy systems" is the way to effect real change. Not using the money to "buy toys with it".

Athena Health helps clinicians get paid more money faster. They deal with the payment back end of health care. As opposed to building your own claim activity or use someone else who specializes like Visa does for retailers. So I guess Athena is the Visa of Health care. They offer Software Enabled Services rather than "shrink wrapped toys". In his word the key process starts with:

Step 1: Crap Removal

They claim to have one of the most sophisticated back ends in the business and they deal with 23,000lbs of paper for their customers each week! How they extract data from this is beyond me if this is coming in in paper form....

Follow this with a program not so much focused on the amount of investment but rather the execution that:

Pay for data and pay for results

Then stop using these legacy devices and start working towards capturing this as data as part of the process. Here he is singing my song and the need to capture the information in computer interpretable form (I have to believe that some portion of the 23,000 lbs of paper is being processed by an army of folks to digitize and extract data from it) and make this a requirement.

Once again Healthstory help satisfy this need allowing for the generation of the fine clinical narrative detail but complementing this with structured tagged data that can be used to process and show the health improvements and facilitate the flow of reimbursement for better results at higher rates.

David Brailer Weighs in on Health Information Technology

David Brailer writes on the Healthaffairs site with guidance to the incoming President on key reforms to our health care systems. The pledge he refers to of $50 Billion does not appear to jive with the released "American Recovery Reinvestment Act of 2009" (pdf file) draft report that features $20 overall for healthcare + $4.1 billion for preventative health care but relative to the previous investments this is a significant program.

He highlights 4 key areas:

The chasm between the have and have not's - not of health care but of EMR's but rightly he says

We should not incent physicians and hospitals simply to purchase electronic records. We get no benefit when a physician or hospital buys an electronic record. What we should do is reward the use of these tools as part of a patient’s care. “Pay for use” can fund the conversion of the health care system to digital records and ensure that we get the life-saving and money saving benefits they promise

I agree - just buying these expensive systems and funding them seems a flawed strategy and we will just end up with a bunch of unused EMR systems.

Second - the need to build a workforce to enable the digitization of health care - 50,000 people by his reckoning, of people who understand both clinical medicine and information technology. Already in short supply and years in the making. This is right on the money (and I say that with a certain sense of pride since I fall very clearly into this category having made this transition long before this was even a career path or specialization). It is bridging this divide with clear understanding of the issue and challenges faced in practicing day to day clinical medicine that will facilitate acceptance and success.

Third - Information sharing, which is a core fundamental but remains a significant challenge by virtue of the proprietary and protectionist nature to the health care vendors to date. This challenge has thawed and there are many initiatives that will move the industry towards real sharing of data. I certainly want to take my complete "Healthstory" with me wherever I go having just completed the valueless paper based forms for the umpteenth time in my daughters physicians office. There are others but Healthstory represents the complete picture with flexibility to allow participation at a wide range of levels and different detail that makes the adoption more likely. Not forcing or mandating specific data or fields may seem like we loose the data but pragmatic approaches that drive adoption quickly will succeed where highly regimented and overly demanding standards tend to fail in complex environments. So here's my pitch to the incoming Obama administration - mandate the Healthstory standard for capture, exchange and sharing of clinical data. The resistance will be minimal and the standard will allow all stake holders to participate quickly and effectively. Granularity of information will increase over time as the value of this increasingly detailed data is demonstrated with real world use cases - market forces at work.

Fourth - freeing up the clinicians to use the technology and to get paid for digital consultation remotely and facilitating telemedicine. While you are at it I suggest resolving the challenges faced over the practice of medicine in different states as detailed here in the sad case of a Colorado Doctor being prosecuted by California.

Health care reform will happen...it has to happen and there is an explosion of suggestions and ideas, but the above four make a great start and I concur with David Brailer on their importance and value in making these reforms a resounding success but lets make sure that the interoperability is a fundamental part of the equation.

Plans to Computerize the US Healthcare Records

CNN Money features an article today on the President-elect Obama's Digitizing the US Health Records System featuring the proposal to modernize the health care system by "making all health records standardized and electronic."

The plan calls for computerizing all records withing 5 years and is subject to much discussion in the various communities I participate in that is both positive (great investment and resources allocated to help fix a broken US healthcare system) to negative (are we just spending money on technology rather than spending money on
improving the outcomes and quality)

One observer put it this way:

this is a bit like watching a train wreck that is too late to stop

and more worryingly:

I don’t think that even a free EMR is attractive enough for most docs right now

One source cited came from information published by the AAFP (now restricted to members) that showed substantial variation in satisfaction with current implementations

....substantial variance in physician satisfaction with EMRs by product from “if I could get out I for zero cost I would” to “I’m not happy but my practice couldn’t live without it” to some actual satisfaction.....in large practices seldom rose above the “not happy, but …” level.

Current penetration and usage cited is at 8% of hospitals and 17% of physicians so there is a long way to go. Estimations for the price tag to achieve this range from $75 - 100 Billion. A Large percentage of any "bail out" that may or may not be approved but a small drop in the ocean of "$2 Trillion a year the industry spends" today.

But it is the usability that is required and ubiquitous access:

Doctors cannot spend hours and hours learning a new system," said Castillo. "It needs to be a ubiquitous, 'anytime, anywhere' solution that has easily accessible data in a simple-to-use Web-based application."

I agree but what is missing from this discussion is how to get this information into these systems. If we had a 100% adoption of EMR's today this would be an enormous mouth to feed with clinical data. It is no use implementing these systems if we don't have the data and the idea that clinicians will interact with the current technology, no matter how good it is with screens, feedback, menus and intuitive interfaces, is just not going to happen.

Providing the tools to capture the data naturally is going to be critical tot he success of these systems and there seems no better method that using voice. All our interactions are based on voice and capturing this as clinical data that can feed the data hungry EMR's. Speech recognition has gone some way to helping and automating this process but these older engines only output text which does not satiate the EMR's needs for structured and encoded clinically actionable data.

Ensuring that technology does not take over the practice of medicine and replace bedside skills is a major concern as detailed in this a New England Journal of Medicine article covered here where Dr Abraham Verghese says:

In short, bedside skills have plummeted in inverse proportion to the available technology. I truly believe that good bedside skills make residents more efficient," Verghese said. Doctors who rely on hands-on skills tend to order tests more judiciously, reducing the number of unnecessary and expensive trips to the radiology department.

To that point allowing for ready voice capture that generates the date required to make these clinical systems useful is essential and is precisely what speech Understanding does. Free form narrative that is converted into structured meaningful clinical documents that contain the full fine detail from the clinicians but also contains encoded structured data that is tagged against relevant controlled medical vocabularies including Snomed, RxNorm, RadLex, LOINC, ICD9 to name a few. All this can be output in CDA format for Common Document Types that has been defined and approved through the HL7 balloting process through the tremendous work being done by the Healthstory Project that creates one document that delivers multiple outputs for different purposes and retains complete and detailed clinical information. Due to the open nature and flexibility of the standard this format allows for ready adoption by multiple stake holders quickly creating immediate value to the participants by generating a flexible rich clinical document that provides useful output.

The conversation on Digital Health Records is going in the right direction and i think it is exciting but must include the capture of information and while speech understanding is not a panacea it is an essential contributor to the equation of making digital records work

Secretary Daschle First Steps

Senator Tom Daschle formally launched into his new role (to be confirmed but seems likely) as the Secretary of Health and Human Services yesterday at the Committee on Health, Education, Labor and Pensions - presided over by Senator Edward Kennedy.

His passion was clear and he was articulate and knowledgeable talking of personal stories of bankruptcy and lack of insurance coverage that he had witnessed. You have to like his agility in dealing with his colleagues from both sides of the floor and certainly his rhetoric resonated with me.

The problems are large and the challenges great but facing up to the issue of uninsured, catastrophic health bankruptcy (covered here in the US vs UK nightmare experience) is a great place to start. He referred back to the health care reform from 1994 which I personally remember well as an observer from the other side of the pond when many thought the two systems from the UK and the US were moving towards each other but unlikely to meet in the middle. The prevailing view then was the US system was moving to a UK style model and the UK was moving towards a pay for service US style..... neither materialized.

On first blush there is much to commend and like about his style, understanding and intent. The system is broken - I think most would agree on that and needs fixing. The process must include all the stake holders involved but requires government involvement with great leadership.

As a note on a colleagues board says - "if you think you are leading and no one is following you then you are just taking a walk".... I'm following for now and watch this with renewed optimism

Integrating Knowledge bases into Training Environments

Changing training is as much a part of the process of improving health care as is the implementation of technology. In many respects it can have more of an effect since influencing the upcoming generation of workers early, before they become set in the ways of the existing methods, will ease and promote transitions to new and more efficient tools and work process. This is a longer term strategy but one that will have a more persistent effect.

So the news that "Career Step" is integrating the BenchMark KB (Knowledge Base) into their training package for clinical documentation specialists bodes well for increased standardization and the provision of technical support tools to help with the process of verification of facts, clinical terminology, names of drugs and other elements of clinical documents.

The resulting output of trained clinical documentation knowledge workers (some 10,000 expected to be enrolled this coming year) will be fully fluent in using these resources and many others and be catapulted into the workforce equipped and more importantly experienced in using the latest tools for improved efficiency and accuracy of clinical documentation.

There is no doubt that new tools and technologies are going to change the way we practice and deliver health care. Providing access and incorporating this into training programs is a big step to moving our health care system forward along the path of improved, more efficient delivery of safer more cost effective medicine.