A lot of people seem to think that health care reform legislation is going to pass today. For all the flaws of the bill, both from the left and right perspective, as someone who has worked on improving transparency and impact of medical information for many years, I'm hanging my hat on one hope: that the bill and one of its core elements, required coverage for preexisting conditions, will help to build a better national health information economy.

1. Lack of health care information flow increases the cost of care.
2. A major reason for a lack of health care information flow is our justified fear that they will lose health insurance coverage or be denied employment based on that information.
3. With universal coverage, we will improve the flow of health information and significantly reduce the cost of care in a variety of ways we can imagine, and even more ways we cannot imagine.

Twitter's all atwitter and the bloggers are all a-blogging about what the iPad might mean for this, that or the other. I'm trying to reserve any opinion until I get to play with one and see some apps designed specifically for it, but I'll write about the potential it may have and some questions I that linger.

Big things it does have: 

• Relatively large, multitouch display (no surprise here.)
• Speed.
• WiFi and 3G.

The big things it doesn't have:

• SD or USB docks.
• Flash support
• Ability to run 3rd party applications simultaneously (but is rumored to be enabled in the next iPhone OS release.)
• Camera

That's all well and good, but the iPhone doesn't have these (except camera, which is not necessarily what patient want in his/her doctor's office) and is being adopted widely in health care. The big questions for me are form factor and usability: 

#1. How will people carry it? Will men need a manbag?

2. The other big question that I have (and haven't yet seen discussed) is: What applications does such a big 9.7" multi-touch enable for medicine? A large multi-touch seems like the perfect fit for physicians that are used to working with paper. We simply have never dealt with a multi-touch screen this large and it will take some pretty creative developers to see what can really be done. Just the ability to move rapidly through high resolution images and forms on a mobile device using your fingers could be the thing physicians have needed in a mobile device. If it's combined with reference articles, it could be a godsend, and the increased screen size could really help manage more complex information (when, presumably this summer, the release of the next OS and the ability to run multiple applications.) Either way, I'll await to hear feedback from the test markets.

As I wrote before, I think the killer app could be an EHR that nearly resembles a patient's actual chart and record. The iPad is designed to be a replacement for paper media: newspapers, magazines, books. What industry is more stuck on paper than health care and is (supposedly) looking for an alternative? (FYI, I do know some of the best developers in this area who would love to take on such a project.)

I'll wait until I can play with one before I make any judgements, but the potential is there. In the meantime, who's ready to start building some apps and defining the future?

I've been using Twitter for almost a year now, and I'd say that my knowledge of my industry and related industries has acceleratand dramatically, probably 3-5x. There isn't much big news or industry chatter that slips by with the people I follow and the information they so graciously provide. In the coming decade, sharing info online will be a strong professional advantage not just because of the economy of information you will receive in return, but because of how we connect with the participants in the knowledge economy. Your audience matters. They always have but now they're more available.

So, too, has my social intelligence improved. I'm now connected to about half of the people that present at the major conferences, close to all of those that are using twitter. I get feedback from them daily that helps me refine and extend my knowledge base. It took a great deal of effort to get here, but it is priceless.

Which brings us to the question at hand. Reading the astonishingly cogent principles of the HIT standards committee this morning, I couldn't help but wonder how much social media has provided the platform and the feedback to lead to principles that make this much sense? I've seen a lot of discussion online about what the role of the HIT standards committee should be, and I have the distinct sense that they listened. Call me an optimist by nature, but I also wonder if we are becoming smarter as as a society, in terms of people, context and information? And further, what will this will mean for health care and the economy at large?

As far as health care is concerned, the social sphere must, and will, get pulled into health care and the work that providers do. Just as sharing info professionally has and will define a large chunk of professional success going forward, sharing medical information with the right audience will lead to improved outcomes. The simple fact is that collaboration saves lives both through better communication, better coordination and better knowledge transfer across the many boundaries between various health care providers and their patients, as I've written before.

Today, seeing that SalesForce just launched an enterprise social app, Chatter, that will bring in a social element to the over 13,000 Sales Force apps, I can't help but wonder what might happen if we had the same for health care. What if all applications, caregivers and patients were connected online. How fast would our understanding of medicine and the delivery of care improve? We can only hope that we'll soon find out.

Still, I'm left wondering, will these various ecosystems connect or will we also be stuck with various silos of software, just web-based silos?

Part of the reason we haven't seen social medicine take off yet (and part of the reason HIT hasn't taken off) is that we can't expect physicians  to do more work, manage more complexity or spend more money. These are significant barriers to adoption. Solutions must be simpler, more convenient and less expensive to be considered disruptive.

Sure, there are physician social networks (Sermo, et al), but relatively few are about getting actual work done. Those that are focused on getting work done ad extra steps.The ideal social/collaborative platform in medicine will be an extension of an EHR.

In order to to have collaboration and the social sphere as an extension of the EHR, we need to spend considerable time and energy working out the permissions and rights of medical information. Several articles and studies have recently documented that without sharing information beyond the traditional silos of health care, the benefits of EHRs are minimal if any. We need rights that act as a default for the society at large, and can be changed by patients.

We need a sort of creative commons for medical information. Patients must have the final say in how their information is shared, but there also needs to be a reasonable default to information sharing.

I have a hunch most people will not take the reigns on their health info unless they have clear benefits to doing so. For most people the benefits of managing health info are unclear, but the risks are readily apparent. The benefits of managing health info, possibly through tax incentives, must be clear, and the risks of sharing info must be minimized. Having a plan where people cannot be declined insurance for preexisting conditions will be a godsend to information sharing in medicine.

We need this so that doctors can collaborate more effectively. HIPAA has not helped collaboration. Collaboration is part of the fiber of the practice of medicine. Think Grand Rounds and Tumor Boards. Yet it has lacked a real patient focus using the power of the web in specific clinical cases. When physicians can collaborate about specific cases at the point of care (on some portable device) we will see incredible results.

Eventually, physicians will have EHRs at the point of care with subsets of the EHR shared withing a large community of physicians eager to share their knowledge. Why will be the incentives to sharing? As this brilliant set of presentations points out: People love to share when they have the right audience. Right now, EHRs have very little to do with sharing, they are more about process and correcting errors within a very local setting. When physicians know they have the right audience, they will be eager to share, and improve, their knowledge. Once it gets started, it's a self-propogating cycle.

As far as the economy at large goes, nobody says it better than Juan Enriquez in this brilliant presentation. We are saddled with a mountain of debt, but we live in an open society capable of innovating quickly and rapidly increasing our collective intelligence. The collaborative web may be our saving grace in profound ways that we are only now beginning to realize from healthcare to government to everywhere. And this can only happen in a free society where there is little fear of sharing information, health-related or not.

(Thanks to all those on twitter who made this post possible by sharing information that I would likely have never seen otherwise.)

I'm a believer that EHRs are going to move ever more onto mobile platforms and I'm curious what that might mean for the larger EHR market. In order to help answer that question, I spoke with Practice Fusion’s CEO, Ryan Howard.

Practice Fusion is launching mobile EHRs in Q1 of 2010, and although, Howard wasn't as convinced as I am that mobile EHRs were the killer app for health care, he does believe that web/SaaS-based EHRs were really the only sensible option to support mobile EHRs.

Here's the short version of the interview:
 
Q. How might SaaS EHR providers benefit from the shift to mobile?
 
"If you're going to build a mobile (EHR) application, you essentially have three options:
 
1. You can build a native application that allows you to interact with the on-site system, but these are problematic because they still follow the same silo-based instance, you can't share information among coworkers, if you're a doctor you can't hand off information to a nurse and you can't pull in the power of the internet. 
2. You can have a hosted model with online access to a system, but these still need to point to a server or farm of servers somewhere. They are not a true SaaS play. Allscripts is one example. They still have the fundamental problem of not being able to share information across institutional boundaries. 
3. Or, you can have a fully hosted model on the internet that's ideal for browser-enabled devices, that already runs web services and has the APIs developed and allows sharing of critical information in care. Building mobile applications for these systems is a natural fit.
 
What this comes down to is that a shift toward mobile will be a disaster for old-school proprietary client-server vendors that have their businesses built on ongoing fees because it will only bring more attention to their failures. Moving mobile means moving to web services and that just doesn't fit with their business model or the way their companies are structured. How can they go from selling big, expensive proprietary systems to free or low-priced options? How will they convince their sales forces to promote these options?"
 
Q. Do you see a shift toward mobile EHRs?
 
"We get a lot of requests for it. It is one of our most requested features and we'll be coming out with cross-platform (iPhone, Android, Blackberry) mobile solutions in the Spring of 2010, but I'm not 100% convinced this is the way physicians are going to want to interact with the EHR. I don't see the same ability to interact with the same depth of information on these screens. The iTablet might be interesting, but I'm that's not really mobile to me. It seems that will be browser-based access on a slightly larger screen, similar to netbooks."
 
Q. What about your competitors?
 
"iChart, eClinicalworks and Allscripts I know are providing some mobile apps, but the functionality is so far limited, they have many of the problems just described and it's unclear that people are buying."
 
Q. Have you heard about Epic's new trial with Stanford to deliver an iPhone app?
 
"I haven't followed that, but I'm not overly concerned about what Epic's doing. You look at Kaiser and what have they spent, $4 billion on Epic?
 
All industries have adopted SaaS in one form or another at this point. The economic imperatives are just too great to go in a different direction. Many of these legacy systems will not survive.  Unified authentication on a single platform of networks of networks with all data in real time and aggregated gives us the ability to do the things we did for our recent H1N1 reporting. There's a huge value in being able to provide updates to the entire system automatically and do reporting across the network. This is also going to be critical for ARRA/HITECH. Practice Fusion can roll out required functionality much faster than traditional vendors."
 
With these kinds of things in mind, there has been a lot of talk about secondary use of EHR data. Kaiser just received a grant to do some studies. Are you looking at secondary use of data?
 
"This is an area of huge interest that we are tracking, but don't have any specific plans at this point."

Next post will discuss the various options for implementing mobile medical applications.

This post was originally posted by me on the EHR Guy's blog on Oct. 7th, and I'm reposting here for the record.

Remember 1999? Folks were promoting the Human Genome Project as the generational equivalent of the lunar landing and Columbus discovering America. Over the long term, they will likely be right, but the event itself was largely symbolic. Now we're undergoing another major event, with little to no symbolism (certainly not enough), even though the very short-term benefits are potentially earth-shattering. I'm speaking to the potential for ARRA/HITECH in the improvement of medical care, which should be heralded as this generation's moon shot.

Sure, I know what you're thinking: there is perhaps no safer bet than shorting the success of HIT initiatives. Once again, it would be easy to predict failure at trying to fix a such a complex, non-adaptive  system. However, the simple difference here is that never before has anyone been able to answer the fundamental economic question of "who will pay for EHRs?" , and few have decided to pay, because it's never been exactly clear who would stand the most to gain.

Here is what I think has been the crux of the problem as far as who could gain: For the most part, when we talk about medical records, we're speaking to the continuity of care they can enable, which may work as a rather fuzzy, feel-good mantra, but what is too often overlooked is the science of care a national system of EHRs will enable. 

And so far, the results we are seeing indicate that even a partial success will produce stunning results. I imagine payers will be kicking themselves in years to comes asking, "Why didn't we do this sooner?"

Exhibit A: Kaiser Colorado.  Kaiser's Collaborative Cardiac Care Service (CCCS) "uses an electronic medical record and patient-tracking software to document all interactions with patients, track patient appointments, and collect data for evaluation of both short and long-term outcomes." Studying over 10,000 patients has demonstrated that their integrated CCCS system has reduced mortalities associated with Coronary Arterry Disease (CAD) by a whopping 76%! Newer data suggests EHRs systems that regularly communicate with patients are highly effective at maintaining target lipid levels. Studies such as these strongly suggests that, as part of a coordinated care program, a nationwide system of EHRs may will be as historic as the lunar landing (and certainly no less difficult), but with direct and immediate benefits of millions of lives and hundreds of billions of dollars saved. As noted by David Blumenthal, the national coordinator of HIT, said earlier this month, “One thing we haven’t done is apply the scientific method in the practice of healthcare and medicine.” We as a nation have gone too long researching the mechanism of disease with far too little time spent researching the best practices in the delivery of care.

Other collaboration technology studies are beginning to show equally impressive results. A third party survey of Syndicom's (a client) case-based physician collaboration communities have found that 90% of spine surgeons using these case collaboration tools feel they improve their ability to practice surgery and make recommendations. Within Syndicom's community alone (over 1,000 spine surgeons), we're talking about thousands, perhaps tens of thousands of patients with improved outcomes, reduced pain, and reduced costs on our health care system. Collaboration has been a cornerstone of medicine for centuries (think grand rounds and tumor boards), yet we are just beginning to see the benefits of web-based collaboration.

If HITECH succeeds only partially in increasing medical collaboration and communities, the $20 billion spent will be a bargain. In a nation where total medical and social costs attributed to CAD alone tops $475 Billion and affects 80 million Americans, the cost savings and life improvement potential is nothing short of spectacular for implementing a nationwide Kaiser-like CCCS system. When ten percent of patients account for 80% of all health care costs and 75% of those costs are related to chronic diseases such as CAD, the effective management of these diseases through effective health information is more beneficial than even the greatest blockbuster drug at reducing time in the hospital for high cost treatments and mortality. Savings of $50 Billion per year in CAD patients alone for a nationwide, connected EMRS is not unrealistic.

Studies such as those above suggest that we've been thinking about HIT the wrong way. If these technologies can improve patient outcomes so dramatically, shouldn't they be considered part of the standard of care? Networked communication tools can improve treatments and protocols across the disease spectrum. If your cardiologist found a treatment that increased survival by 76% in all CAD patients over a 2 year period, could he be found negligent for denying the use of it? Would Medicare reimburse it? Absolutely! When you think of HIT as a method for improving treatment outcomes, it really makes perfect sense that the majority of ARRA/HITECH is funded as a CMS remibursement. The HIT portion of ARRA is a one time (hopefully) Medicare reimbursement for a systemic treatment that's long overdue.

The iPhone is the fastest growing consumer electronic platform in history and not just your average consumers are adopting it. 65% of physicians now have smart phones and half of these are iPhones.

I read with great interest Phillip Longman's Code Red article in the Washington Monthly yesterday about open source and the horrific results in user experience that some EMR vendors have achieved, but I'm not sure open source EMRs and delaying stimulus money are the answer. Usability testing and open APIs are the answer.

I've got no problem with open source, but there are other alternatives to the problems that Longman raises. Overall, Longman cites 2 main problems: 1. Proprietary software sometimes doesn't work the way users do and 2. Proprietary softare often doesn't connect with other software so readily. True.

The benefit of open source is that the source can be modified as needed. But this doesn't mean that users will like it. It just means that, if they don't like it, and a health care organization has the means and the will, they can change it, but that doesn't mean it will be cheap.

One of the major drawbacks to open source is that there often isn't any overall design. Compare the Android to the iPhone and you get the idea. What is needed is real usability testing by the software vendors. Spending 10% of an IT budget on usability can increase performance (KPIs) by 83%, and hosptals should demand it in selecting any HIT system.

As to the second point, connecting software these days is about developing open APIs, and this is Apple's big strength with the iPhone, not open source. This is also something that should be demanded as part of the HIT stimulus, There aren't nearly enough HIT companies adopting open APIs, but on the bright side, it appears that the standards committee is taking a logical approach to defining HIT standards. The proof is in the HIT pudding, but so far, for identifying a standard, things are looking better.

Finally, none of this is going to work without cultural changes and the incentives that will enable them. Hospitals are going to need strong leaders committed more to quality care than to how much they can bill.