CODE RED (kōd rĕd) n.

1. A system of hospital codes used world wide to alert staff to emergency conditions
2. Codes intended to convey essential information quickly with minimal understanding
3. “Code Red” typically implies catastrophic, life threatening emergency

I had the privilege to meet with Phil Longman several years back at a cafe in Washington DC when he was researching out information for his landmark piece on the Vista EHR developed by the VA. The report was so successful that Phil ultimately turned it into a book. I was interviewed at length for the book and was able to provide some of the good source material on the history of Vista from some of its luminary developers.

Phil recently contacted me for his most recent bombshell, “CODE RED – How Software Companies can Screw Up Obama’s Reform Plan“. It will appear in this months Washington Monthly to be released later this week

Cover from the new Washington Monthly. Phil Longman follows up with a power punch to the bottom line of proprietary HIT vendors.

The full article is contained below for review. In essence, Longman makes the case that the open source community has been making for nearly a decade – we can accelerate the growth, interoperability, functionality, performance, and capabilities of HIT software in the proven collaborative open source fashion faster than we can in the current silo’ed, fragmented, and non-interoperable world. In every other industry, we have seen how standards and sharing of common platform issues has dramatically increased the ability of information to flow. There is no data lubrication layer within healthcare, and hence we remain so far behind other industries.The stimulus bill would codify, and cement into practice, the current system.

Conversely, the stimulus bill could be used to mandate the standards, the information sharing protocols, privacy laws, and other infrastructure components that could help us get to the data liquidity that we all seek and absolutely must have as we transition to a next generation health system. I believe it is called CODE RED because Alarm Bells should be sounding in everyone’s ears regarding the unprecedented opportunity to get there with the stimulus bill. It is provocative, insightful, and hard hitting piece – all typical for Longman piece. I look forward to its impact in the ongoing debate.

Washington Monthly
Code Red – How software companies could screw up Obama’s health care reform.

By Phillip Longman

The central contention of Barack Obama’s vision for health care reform is straightforward: that our health care system today is so wasteful and poorly organized that it is possible to lower costs, expand access, and raise quality all at the same time—and even have money left over at the end to help pay for other major programs, from bank bailouts to high-speed rail.

It might sound implausible, but the math adds up. America spends nearly twice as much per person as other developed countries for health outcomes that are no better. As White House budget director Peter Orszag has repeatedly pointed out, the cost of health care has become so gigantic that pushing down its growth rate by just 1.5 percentage points per year would free up more than $2 trillion over the next decade.

The White House also has a reasonably accurate fix on what drives these excessive costs: the American health care system is rife with overtreatment. Studies by Dartmouth’s Atlas of Health Care project show that as much as thirty cents of every dollar in health care spending goes to drugs and procedures whose efficacy is unproven, and the system contains few incentives for doctors to hew to treatments that have been proven to be effective. The system is also highly fragmented. Three-quarters of Medicare spending goes to patients with five or more chronic conditions who see an annual average of fourteen different physicians, most of whom seldom talk to each other. This fragmentation leads to uncoordinated care, and is one of the reasons why costly and often deadly medical errors occur so frequently.

Almost all experts agree that in order to begin to deal with these problems, the health care industry must step into the twenty-first century and become computerized. Astonishingly, twenty years after the digital revolution, only 1.5 percent of hospitals have integrated IT systems today—and half of those are government hospitals. Digitizing the nation’s medical system would not only improve patient safety through better-coordinated care, but would also allow health professionals to practice more scientifically driven medicine, as researchers acquire the ability to mine data from millions of computerized records about what actually works.

It would seem heartening, then, that the stimulus bill President Obama signed in February contains a whopping $20 billion to help hospitals buy and implement health IT systems. But the devil, as usual, is in the details. As anybody who’s lived through an IT upgrade at the office can attest, it’s difficult in the best of circumstances. If it’s done wrong, buggy and inadequate software can paralyze an institution.

Twenty years after the digital revolution, only an astonishing 1.5 percent of hospitals have integrated information technology systems. Almost all experts agree that in order to begin to deal with the problems of the health care system, this has to change.

Consider this tale of two hospitals that have made the digital transition. The first is Midland Memorial Hospital, a 371-bed, three-campus community hospital in southern Texas. Just a few years ago, Midland Memorial, like the overwhelming majority of American hospitals, was totally dependent on paper records. Nurses struggled to decipher doctors’ scribbled orders and hunt down patients’ charts, which were shuttled from floor to floor in pneumatic tubes and occasionally disappeared into the ether. The professionals involved in patient care had difficulty keeping up with new clinical guidelines and coordinating treatment. In the normal confusion of day-to-day practice, medical errors were a constant danger.

This all changed in 2007 when Midland completed the installation of a health IT system. For the first time, all the different doctors involved in a patient’s care could work from the same chart, using electronic medical records, which drew data together in one place, ensuring that the information was not lost or garbled. The new system had dramatic effects. For instance, it prompted doctors to follow guidelines for preventing infection when dressing wounds or inserting IVs, which in turn caused infection rates to fall by 88 percent. The number of medical errors and deaths also dropped. David Whiles, director of information services for Midland, reports that the new health IT system was so well designed and easy to use that it took less than two hours for most users to get the hang of it. “Today it’s just part of the culture,” he says. “It would be impossible to remove it.”

Things did not go so smoothly at Children’s Hospital of Pittsburgh, which installed a computerized health system in 2002. Rather than a godsend, the new system turned out to be a disaster, largely because it made it harder for the doctors and nurses to do their jobs in emergency situations. The computer interface, for example, forced doctors to click a mouse ten times to make a simple order.
Even when everything worked, a process that once took seconds now took minutes—an enormous difference in an emergency-room environment. The slowdown meant that two doctors were needed to attend to a child in extremis, one to deliver care and the other to work the computer. Nurses also spent less time with patients and more time staring at computer screens. In an emergency, they couldn’t just grab a medication from a nearby dispensary as before—now they had to follow the cumbersome protocols demanded by the computer system. According to a study conducted by the hospital and published in the journal Pediatrics, mortality rates for one vulnerable patient population—those brought by emergency transport from other facilities—more than doubled, from 2.8 percent before the installation to almost 6.6 percent afterward.

Why did similar attempts to bring health care into the twenty-first century lead to triumph at Midland but tragedy at Children’s? While many factors were no doubt at work, among the most crucial was a difference in the software installed by the two institutions. The system that Midland adopted is based on software originally written by doctors for doctors at the Veterans Health Administration, and it is what’s called “open source,” meaning the code can be read and modified by anyone and is freely available in the public domain rather than copyrighted by a corporation. For nearly thirty years, the VA software’s code has been continuously improved by a large and evergrowing community of collaborating, computer-minded health care professionals, at first within the VA and later at medical institutions around the world. Because the program is open source, many minds over the years have had the chance to spot bugs and make improvements. By the time Midland installed it, the core software had been road-tested at hundred of different hospitals, clinics, and nursing homes by hundreds of thousands of health care professionals.

The software Children’s Hospital installed, by contrast, was the product of a private company called Cerner Corporation. It was designed by software engineers using locked, proprietary code that medical professionals were barred from seeing, let alone modifying. Unless they could persuade the vendor to do the work, they could no more adjust it than a Microsoft Office user can fine-tune Microsoft Word. While a few large institutions have managed to make meaningful use of proprietary programs, these systems have just as often led to gigantic cost overruns and sometimes life-threatening failures. Among the most notorious examples is Cedars-Sinai Medical Center, in Los Angeles, which in 2003 tore out a “state-of-the-art” $34 million proprietary system after doctors rebelled and refused to use it. And because proprietary systems aren’t necessarily able to work with similar systems designed by other companies, the software has also slowed what should be one of the great benefits of digitized medicine: the development of a truly integrated digital infrastructure allowing doctors to coordinate patient care across institutions and supply researchers with vast pools of data, which they could use to study outcomes and develop better protocols.

Unfortunately, the way things are headed, our nation’s health care system will look a lot more like Children’s and Cedars-Sinai than Midland. In the haste of Obama’s first 100 days, the administration and Congress crafted the stimulus bill in a way that disadvantages opensource vendors, who are upstarts in the commercial market. At the same time, it favors the larger, more established proprietary vendors, who lobbied to get the $20 billion in the bill. As a result, the government’s investment in health IT is unlikely to deliver the quality and cost benefits the Obama administration hopes for, and is quite likely to infuriate the medical community. Frustrated doctors will give their patients an earful about how the crashing taxpayer-financed software they are forced to use wastes money, causes two-hour waits for eight-minute appointments, and constrains treatment options.

Done right, digitized health care could help save the nation from insolvency while improving and extending millions of lives at the same time. Done wrong, it could reconfirm Americans’ deepest suspicions of government and set back the cause of health care reform for yet another generation.

Open-source software has no universally recognized definition. But in general, the term means that the code is not secret, can be utilized or modified by anyone, and is usually developed collaboratively by the software’s users, not unlike the way Wikipedia entries are written and continuously edited by readers. Once the province of geeky software aficionados, open-source software is quickly becoming mainstream. Windows has an increasingly popular open-source competitor in the Linux operating system. A free program called Apache now dominates the market for Internet servers. The trend is so powerful that IBM has abandoned its propriety software business model entirely, and now gives its programs away for free while offering support, maintenance, and customization of open-source programs, increasingly including many with health care applications. Apple now shares enough of its code that we see an explosion of homemade “applets” for the iPhone—each of which makes the iPhone more useful to more people, increasing Apple’s base of potential customers.

If this is the future of computing as a whole, why should U.S. health IT be an exception? Indeed, given the scientific and ethical complexities of medicine, it is hard to think of any other realm where a commitment to transparency and collaboration in information technology is more appropriate. And, in fact, the largest and most successful example of digital medicine is an open-source program called VistA, the one Midland chose.

VistA was born in the 1970s out of an underground movement within the Veterans Health Administration known as the “Hard Hats.” The group was made up of VA doctors, nurses, and administrators around the country who had become frustrated with the combination of heavy caseloads and poor record keeping at the institution. Some of them figured that then-new personal and mini computers could be the solution. The VA doctors pioneered the nation’s first functioning electronic medical record system, and began collaborating with computer programmers to develop other health IT applications, such as systems that gave doctors online advice in making diagnoses and settling on treatments.

The key advantages of this collaborative approach were both technical and personal. For one, it allowed medical professionals to innovate and learn from each other in tailoring programs to meet their own needs. And by involving medical professionals in the development and application of information technology, it achieved widespread buy-in of digitized medicine at the VA, which has often proven to be a big problem when propriety systems are imposed on doctors elsewhere.

This open approach allowed almost anyone with a good idea at the VA to innovate. In 1992, Sue Kinnick, a nurse at the Topeka, Kansas, VA hospital, was returning a rental car and saw the use of a bar-code scanner for the first time. An agent used a wand to scan her car and her rental agreement, and then quickly sent her on her way. A light went off in Kinnick’s head. “If they can do this with cars, we can do this with medicine,” she later told an interviewer. With the help of other tech-savvy VA employees, Kinnick wrote software, using the Hard Hat’s public domain code, that put the new scanner technology to a new and vital use: preventing errors in dispensing medicine. Under Kinnick’s direction, patients and nurses were each given bar-coded wristbands, and all medications were bar-coded as well. Then nurses were given wands, which they used to scan themselves, the patient, and the medication bottle before dispensing drugs. This helped prevent four of the most common dispensing errors: wrong med, wrong dose, wrong time, and wrong patient. The system, which has been adopted by all veterans hospitals and clinics and continuously improved by users, has cut the number of dispensing errors in half at some facilities and saved thousands of lives.

At first, the efforts of enterprising open-source innovators like Kinnick brought specific benefits to the VA system, such as fewer medical errors and reduced patient wait times through better scheduling. It also allowed doctors to see more patients, since they were spending less time chasing down paper records. But eventually, the open-source technology changed the way VA doctors practiced medicine in bigger ways. By mining the VA’s huge resource of digitized medical records, researchers could look back at which drugs, devices, and procedures were working and which were not. This was a huge leap forward in a profession where there is still a stunning lack of research data about the effectiveness of even the most common medical procedures. Using VistA to examine 12,000 medical records, VA researchers were able to see how diabetics were treated by different VA doctors, and by different VA hospitals and clinics, and how they fared under the different circumstances. Those findings could in turn be communicated back to doctors in clinical guidelines delivered by the VistA system. In the 1990s, the VA began using the same information technology to see which surgical teams or hospital managers were underperforming, and which deserved rewards for exceeding benchmarks of quality and safety.

Thanks to the stimulus bill, $20 billion is about to be poured into buggy, expensive, proprietary software that will not bring the benefits the Obama administration hopes for. Rather, it will amount to a giant bailout of a health IT industry whose business model has never really worked.

Thanks to all this effective use of information technology, the VA emerged in this decade as the bright star of the American health system in the eyes of most healthquality experts. True, one still reads stories in the papers about breakdowns in care at some VA hospitals. That is evidence that the VA is far from perfect—but also that its information system is good at spotting problems. Whatever its weaknesses, the VA has been shown in study after study to be providing the highest-quality medical care in America by such metrics as patient safety, patient satisfaction, and the observance of proven clinical protocols, even while reducing the cost per patient.

Following the organization’s success, a growing number of other government-run hospitals and clinics have started adapting VistA to their own uses. This includes public hospitals in Hawaii and West Virginia, as well as all the hospitals run by the Indian Health Service. The VA’s evolving code also has been adapted by providers in many other countries, including Germany, Finland, Malaysia,
Brazil, India, and, most recently, Jordan. To date, more than eighty-five countries have sent delegations to study how the VA uses the program, with four to five more coming every week.

Proprietary systems, by contrast, have gotten a cool reception. Although health IT companies have been trying to convince hospitals and clinics to buy their integrated patient-record software for more than fifteen years, only a tiny fraction have installed such systems. Part of the problem is our screwed-up insurance reimbursement system, which essentially rewards health care providers for performing more and more expensive procedures rather than improving patients’ welfare. This leaves few institutions that are not government run with much of a business case for investing in health IT; using digitized records to keep patients healthier over the long term doesn’t help the bottom line.

But another big part of the problem is that proprietary systems have earned a bad reputation in the medical community for the simple reason that they often don’t work very well. The programs are written by software developers who are far removed from the realities of practicing medicine. The result is systems which tend to create, rather than prevent, medical errors once they’re in the hands of harried health care professionals. The Joint Commission, which accredits hospitals for safety, recently issued an unprecedented warning that computer technology is now implicated in an incredible 25 percent of all reported medication errors. Perversely, license agreements usually bar users of proprietary health IT systems from reporting dangerous bugs to other health care facilities. In open-source systems, users learn from each other’s mistakes; in proprietary ones, they’re not even allowed to mention them.

If proprietary health IT systems are widely adopted, even more drawbacks will come sharply into focus. The greatest benefits of health IT—and ones the Obama administration is counting on—come from the opportunities that are created when different hospitals and clinics are able to share records and stores of data with each other. Hospitals within the digitized VA system are able to deliver more services for less mostly because their digital records allow doctors and clinics to better coordinate complex treatment regimens. Electronic medical records also produce a large collection of digitized data that can be easily mined by managers and researchers (without their having access to the patients’ identities, which are privacy protected) to discover what drugs, procedures, and devices work and which are ineffective or even dangerous. For example, the first red flags about Vioxx, an arthritis medication that is now known to cause heart attacks, were raised by the VA and large private HMOs, which unearthed the link by mining their electronic records. Similarly, the IT system at the Mayo Clinic (an open-source one, incidentally) allows doctors to personalize care by mining records of specific patient populations. A doctor treating a patient for cancer, for instance, can query the treatment outcomes of hundreds of other patients who had tumors in the same area and were of similar age and family backgrounds, increasing odds that they choose the most effective therapy.

But in order for data mining to work, the data has to offer a complete picture of the care patients have gotten from all the various specialists involved in their treatment over a period of time. Otherwise it’s difficult to identify meaningful patterns or sort out confounding factors. With proprietary systems, the data is locked away in what programmers call “black boxes,” and cannot be shared across hospitals and clinics. (This is partly by design; it’s difficult for doctors to switch IT providers if they can’t extract patient data.) Unless patients get all their care in one facility or system, the result is a patchwork of digital records that are of little or no use to researchers. Significantly, since proprietary systems can’t speak to each other, they also offer few advantages over paper records when it comes to coordinating care across facilities. Patients might as well be schlepping around file folders full of handwritten charts.

Of course, not all proprietary systems are equally bad. A program offered by Epic Systems Corporation of Wisconsin rivals VistA in terms of features and functionality. When it comes to cost, however, open source wins hands down, thanks to no or low licensing costs. According to Dr. Scott Shreeve, who is involved in the VistA installations in West Virginia and elsewhere, installing a proprietary system like Epic costs ten times as much as VistA and takes at least three times as long—and that’s if everything goes smoothly, which is often not the case. In 2004, Sutter Health committed $154 million to implementing electronic medical records in all the twenty-seven hospitals it operated in Northern California using Epic software. The project was supposed to be finished by 2006, but things didn’t work out as planned. Sutter pulled the plug on the project in May of this year, having completed only one installation and facing remaining cost estimates of $1 billion for finishing the project. In a letter to employees, Sutter executives explained that they could no long afford to fund employee pensions and also continue with the Epic buildout.

The VA’s open-source software allowed a nurse in Topeka, Kansas, to adapt for her own work a bar-code scanner she saw used at a rental-car agency. Her innovation cut the number of medication-dispensing errors in half at some facilities, and saved thousands of lives.

Unfortunately, billions of taxpayers’ dollars are about to be poured into expensive, inadequate proprietary software, thanks to a provision in the stimulus package. The bill offers medical facilities as much as $64,000 per physician if they make “meaningful use” of “certified” health IT in the next year and a half, and punishes them with cuts to their Medicare reimbursements if they don’t do so by 2015. Obviously, doctors and health administrators are under pressure to act soon. But what is the meaning of “meaningful use”? And who determines which products qualify? These questions are currently the subject of bitter political wrangling. Vendors of proprietary health IT have a powerful lobby, headed by the Healthcare Information and Management Systems Society, a group with deep ties to the Obama administration. (The chairman of HIMSS, Blackford Middleton, is an adviser to Obama’s health care team and was instrumental in getting money for health IT into the stimulus bill.) The group is not openly against open source, but last year when Rep. Pete Stark of California introduced a bill to create a low-cost, open-source health IT system for all medical providers through the Department of Health and Human Services, HIMSS used its influence to smash the legislation. The group is now deploying its lobbying clout to persuade regulators to define “meaningful use” so that only software approved by an allied group, the Certification Commission for Healthcare Information Technology, qualifies. Not only are CCHIT’s standards notoriously lax, the group is also largely funded and staffed by the very industry whose products it is supposed to certify. Giving it the authority over the field of health IT is like letting a group controlled by Big Pharma determine which drugs are safe for the market.

Even if the proprietary health IT lobby loses the battle to make CCHIT the official standard, the promise of open-source health IT is still in jeopardy. One big reason is the far greater marketing power that the big, established proprietary venders can bring to bear compared to their open-source counterparts, who are smaller and newer on the scene. A group of proprietary industry heavyweights, including Microsoft, Intel, Cisco, and Allscripts, is sponsoring the Electronic Health Record Stimulus Tour, which sends teams of traveling sales representatives to tell local doctors how they can receive tens of thousands of dollars in stimulus money by buying their products— provided that they “act now.” For those medical professionals who can’t make the show personally, helpful webcasts are available. The tour is a variation on a tried-andtrue strategy: when physicians are presented with samples of pricey new name-brand substitutes for equally good generic drugs, time and again they start prescribing the more expensive medicine. And they are likely to be even more suggestible when it comes to software because most don’t know enough about computing to evaluate vendors’ claims skeptically.

What can be done to counter this marketing offensive and keep proprietary companies from locking up the health care IT market? The best and simplest answer is to take the stimulus money off the table, at least for the time being. Rather than shoveling $20 billion into software that doesn’t deliver on the promise of digital medicine, the government should put a hold on that money pending the results of a federal interagency study that will be looking into the potential of opensource health IT and will deliver its findings by October 2010.

While a few large institutions have managed to make meaningful use of proprietary health IT, these systems have just as often been expensive failures. In 2003, Cedars-Sinai Medical Center in Los Angeles tore out a “state-of-the-art” $34 million proprietary system after doctors rebelled and refused to use it.

As it happens, that study is also part of the stimulus bill. The language for it was inserted by West Virginia Senator Jay Rockefeller, who has also introduced legislation that would help put open-source health IT on equal footing with the likes of Allscripts and Microsoft. Building on the systems developed by the VA and Indian Health Services, Rockefeller’s bill would create an opensource government-sponsored “public utility” that would distribute VistA-like software, along with grants to pay for installation and maintenance. The agency would also be charged with developing quality standards for opensource health IT and guidelines for interoperability. This would give us the low-cost, high-quality, fully integrated and proven health IT infrastructure we need in order to have any hope of getting truly better health care.

Delaying the spending of that $20 billion would undoubtedly infuriate makers of proprietary health software. But it would be welcomed by health care providers who have long resisted—partly for good reason—buying that industry’s product. Pushing them to do so quickly via the stimulus bill amounts to a giant taxpayer bailout of health IT companies whose business model has never really worked. That wouldn’t just be a horrendous waste of public funds; it would also lock the health care industry into software that doesn’t do the job and would be even more expensive to get rid of later.

As the administration and Congress struggle to pass a health care reform bill, questions about which software is best may seem relatively unimportant—the kind of thing you let the “tech guys” figure out. But the truth is that this bit of fine print will determine the success or failure of the whole health care reform enterprise. So it’s worth taking the time to get the details right.

Phillip Longman is a senior fellow at the New America Foundation and the author of Best Care Anywhere: Why VA Health Care Is Better Than Yours as well as The Next Progressive Era: A Blueprint for Broad Prosperity.

Spelling (spĕl’ĭng) n.

1. The forming of words with letters in an accepted order; orthography.
2. The art or study of orthography or the way in which a word is spelled.

Whoa . . . just ahead of a 21% cut in physician salaries we have an epic battle shaping up within the physician community. The AMA, long the Godfather and voice of physicians around the country, apparently is feeling the heat from a younger, more svelt upstart from across (cyber)town. I have just received back to back emails from Sermo CEO Daniel Palestrant essentially declaring his succession from the physician union. This comes at a critical time when further fracturing of physician leadership and political strength put in jeopardy the opportunity for the physicians to have a unified voice (or is it because the stakes are so high that this group is compelled to speak up?):

The leading missive from 7/1/09 (might require log in):

Dear Dr. Shreeve,

As physicians, our first step in the healthcare debate needs to be clearing the air about who speaks for us on what topics. Today, I am joining the increasing waves of physicians who believe that the AMA no longer speaks for us. As the founder and CEO of Sermo, this is a considerable change of heart, given the high hopes that I had when we first partnered with the AMA over two years ago. The sad fact is that the AMA membership has now shrunk to the point where the organization should no longer claim that it represents physicians in this country.

The AMA has drawn its power from the support of the physician community. The waning membership reflects our objection as the AMA has failed us consistently for over 50 years. Make no mistake, the debate within the AMA about how to stop their membership decline is not new.  What is new is the lengths to which the AMA appears willing to go to deceive the public on this topic.  The AMA routinely claims that their membership is 250,000 practicing physicians.  At best, this is 25-40% of practicing US physicians and even that claim is based on some stretching of the truth.  The 250,000 total includes a number of non-practicing constituencies, including medical students, residents, and subscribers of the AMA’s journals.  Paying membership is generally accepted to be far lower.  How much lower?  Actual numbers are remarkably difficult to come by.

At this critical moment in history, we cannot watch the AMA fail physicians so completely yet again.  Nor can we stand by and let false perceptions about who speaks for physicians persist. At the very least, all parties should understand the intrinsic conflicts of interest that are in play, and the AMA should be held accountable to these truths.  Better yet, physicians should call for sweeping changes within the AMA.   In the best-case scenario, the AMA will shed its relationships with insurers and abandon tactics that take advantage of physicans to generate millions of dollars in revenue.  It is an inherent conflict of interest to claim advocacy for physicians while profiting from a reimbursement system that makes it increasingly difficult for physicians to practice medicine.

The flight from the AMA signals that physicians don’t believe the AMA is willing to make these changes. The longer that the public and our lawmakers cling to the perception that the AMA represents the voice of US physicians (and the AMA succeeds in perpetuating this), the more imperiled the medical profession will be and with it the broader US healthcare system.  It’s time to turn to entities like Sermo where physicians are establishing a new voice to collectively discuss the future of our profession.

There can be no healthcare reforms that have any chance of succeeding without buy-in from physicians.  As a country, we cannot risk another failed reform effort.  As physicians, we cannot risk letting the AMA represent our interests.  This is our time to educate the public about which voices truly represent us and our commitment to our patients.

Daniel Palestrant, MD
Founder & CEO
Sermo, Inc.

The follow on upper cut (From 7/2/9):

Dear Dr. Shreeve,

Yesterday I posted on Sermo about the need for a new voice to represent physicians. The Sermo community’s response was clear. 2,400+ physicians voting in less than 24 hours. 90% say that the AMA does not represent them. That is a bold statement and the general public will take note.

The need for physicians in this country to have a strong voice has never been greater. And Sermo, a community of well over 100,000 US Physicians, needs to make its voice heard. Yesterday’s posting was the beginning of a regular series that will make your voice heard on issues critical to our profession. Results from these postings will be publicized to the media.

Believe it or not, we are already making dramatic progress. I have been contacted by major media outlets who are interested in what physicians on Sermo have to say. Beginning next week our voice will be heard.

Add your voice to the first topic:

The Biggest Risk to US Physicians Today: The AMA

Sincerely,

Daniel Palestrant, MD
CEO & Founder
Sermo Inc.

I have commented about Sermo before (here and here). I think it can be a useful tool – the virtual lounge if you will – which I totally get. Some of the hallway conversations were useful, but I had other settings in which to engage to my clinical and personal satisfaction. And just like the real thing, I never felt comfortable hanging out in the posh lounge with slightly better food when all my patients, colleagues, and fellow health care workers were sent somewhere else. It is the same discomfort I feel on the rare occasions I have flown first class and sat uncomfortably watching all the “regular” people pass pass on the way to the back of the plane.

Obviously a Sermo style virtual lounge has alot of potential and possibilities. While some of my previous comments can be taken as somewhat down on the platform, I am generally very much in favor and supportive of what Sermo is doing. In fact, I believe the collective intelligence within the network is a wonderful place to harness the cognitive surplus of physicians. Moreover, online communities of experts who can share real medical knowledge in real time, discuss and comment in warp speed peer review, and allow a business commodity to be created from voyeurism certainly has earned my respect.

The breakthrough is not in the message nor even the messenger, it is the manner in which I am getting this message that is most impressive. 100,000 physicians strong (and growing), online and interactive, and now muscling up for the biggest fight of their life. Perhaps most useful of all, is the ability to aggregate the physician voice into a common unified message. My articles above highlight the role of aggregators, and this specific type of network effect grows in influence and power to the point of being a  political force to reckon with. Perhaps the 100,000 member barrier represents the political tipping point to take on the slothful big brother?

Should be interesting to follow – looking forward to seeing if the new kingpin has the staying power to dislodge the king. Looks like he has certainly swiped the scepter.

Prevention (prĭ-vĕn ’shən) n.

1. Preventing or slowing the course of an illness or disease
2. Intended or used to prevent or hinder; acting as an obstacle
3. Carried out to deter expected aggression by hostile forces.

I was just referred this article which I found to be thoughtfully crafted. Abraham Verghese is a Professor and Senior Associate Chair for the Theory and Practice of Medicine at Stanford University. I found the article interesting, by somewhat anachronistic in terms of his perception of prevention and electronic medical records.

First, he raises an important point about the many overstatements as they relate to prevention. When we talk about how effective screening programs could be in identifying people for early interventions we have to realize what we are saying and what tools we are using for identification. Some tools can be too blunt, and not find the people we are looking for (false negatives), while other tools can be too sensitive and capture too many who actually may not have the disease (false positives). This is brought home in the example Dr. Verghese uses around the pitfalls of new diagnostic imaging equipment (and the situation is much worse with genetic testing at this point in time!). With these newer, more sensitive imaging studies you can pick up calcium deposits in a health individual can lead you down a pretty wild (and expensive) goose chase for someone who is completely asymptomatic. He also demonstrates that the “value” of some prevention recommendations as somewhat questionable  – meaning – that while taking cholesterol lowering drugs has clearly shown to be efficacy reducing cholesterol levels and cardiac risk, is it really worth $150K/additional life year extended?

Well, that depends on if it is your life I assume. My point being, that you need additional information to be able to make these difficult, complex decisions. You need to not only know the relative efficacy of the regimen, but also the cost of the regimen to truly get at the “value” of the intervention. In addition, patients have modifiers to which they will place on the intervention in terms of cost in time, pain, and other inconveniences that are unique to their own values. This is where shared medical decision making can have such an impact – lay out the good, the bad, and the ugly and allow the patient to make a decision based on all the available evidence according to their own value system.

I don’t think these types of decisions can be made with the type of information we have today within the current clinical infrastructure. First, the physician gets paid to order the test and not talk to you about whether or not pros and cons of whether you should get it. Furthermore, the doctor has very little to no data upon which to inform that conversations anyway. In the relatively rare areas in which we have evidence, we might not have other components required for decision making in terms of cost and experience of patients undergoing regimen. In the case of prevention items mentioned above, we might choose not to go on statins at $150K per year but instead invest $10,000 in a personal trainer who is going to get rid of the root problem anyway. Without the underlying information, this would never even surface as part of the decision making process. We absolutely must be gathering, comparing, and sharing result outcomes in order to increase our capacity as healers who use the right treatments for the right patients at the right time and in the right way.

Which leads me to my final point – you absolutely need EMR’s to function as an 21st century physician knowledge worker. We are purveyros, translators, and mediators of medical information for our patients. They can get most of it on their own now, but we can still add significant value through our interpretation, personal experience, and ability to process the myriad data points with our clinical acumen (the sum total of our diagnostic prowess which comes from experience, practice, expertise, and intuition). The EMR can be a very effective tool to help us gather, process, and present this information in a way that is meaningful and useful to our patients (actually most EHR’s don’t do this natively today, but with little effort a physician can lift the required information and present it in a format that is highly useful [alling all designers - get into health care!]). Furthermore, I truly dislike the characterization that the EHR makes the relationship cold and sterile.  I believe the current  generation of physicians, who have all grown up with the internet, see the EHR as an indispensible tool that helps them be more effective, efficient, and caring for their patients.

My sense is that I am more optimistic that we will get there with prevention, and that EHR’s will play a vital role to give us the clinical feedback to know whether our treatments (or prevention) efforts are having the impact that we hoped. Furthermore, I am hopeful, that efforts like the X PRIZE and others will help drive us to associate those outcomes with the total costs required to help us acheive the results so we can begin to understand the true value of the intervention. It is in this setting of data liquidity and information transparency, that they myth dissipates into a new reality of next generation medicine.

Lame (lām) adj.

1. Disabled so that movement, especially walking, is difficult or impossible:
2. Weak and ineffectual; unsatisfactory:

I just saw some seriously lame legislation proposed out of New Jersey by some ill-informed congressional lackey MANDATING that all EHR’s be certified through CCHIT. This is absolutely ridiculous. Do you really want to outlaw Google Health and Microsoft HealthVault in the Garden State? I mean get real!

The unintended consequences of such legislation is highly problematic and well described by David Kibbe, Fred Trotter, Ignacious Valdez, Neil Versel, and others. I have seen CCHIT make great efforts to correct this and make the process more open but they have a fundamentally flawed and constrictive position – that they alone can bestow the quality seal of approval on software.

They don’t realize, of course, that any attempt to subvert innovation will be futile. “Life always finds a way” (or in this case innovation). The notion of a new type of communication platform that will emerge as a result is already underway. Designated “Clinical Groupware” by David Kibbe and others or a new “Communication” platform by Myca or American Well, new tools will continue to emerge that defy current descriptions. Are you sure you want to lock down into today’s technologies through an already arcane certification process?

I would strongly argue that standardizing features and functionality is not the problem. These should be allowed to freely evolve and grow per the needs of users and the skills of developers. What should be standardized is the interoperability requirements of data, the database requirements, and related infrastructure elements that will enable the data to be truly liberated. These standards will do more for the industry than any other single legislative or policy initiative. This is where we need government help to force agreement on specific principles where the choice is not as consequential as just making a decision (driving on left or right side of the road is irrelevant; but it is clear that we need to make the determination!).

Legislative mandates for features and functions = #FAIL!

Never (nĕv’ər) adv.

1. Not ever; on no occasion; at no time
2. Not at all; in no way; absolutely not

Recently president Barack Obama told his Organizing for America fanbase that is was “Now or Never” for healthcare reform, “If we don’t get it done this year we are not going to get it done.” While this is a little dramatic, I think the point is that the stars are truly aligned to actually get something done this year. We are beyond life support in healthcare, let alone worrying about the ~50 trillion of unfunded healthcare liabilities already obligated as part of Medicare system. We absolutely need to shift the paradigm within health care and I am hopeful my little efforts can be contributory.

A major part of any reform effort includes the implementation of Electronic Health Records to bring our physicians into the new millenia. Much has been made about “meaningful use” and standards, and much more will be made of certification and outcomes as the money starts flowing. I have to agree with many of my open source friends who are making loud and passionate pleas to congress to consider including provisions to ensure that these investments have the greatest opportunity to yield a return for the public. I don’t think their message has penetrated the lobbyist fortress that is Washington, DC.

I hope to help the cause by making another plea here. I have been fortunate to be a part of a small group of individuals to recognize that one of our greatest national treasures should be given another opportunity to prove its serviceability in providing the highest care and quality to the most deserving of patients. I speak, of course, of my old friend VistA.  Having see this dignified lady transform state veteran facilities, public health clinics, and modern hospitals into higher performing health organizations, I can only but wonder what would happen if she were given a little makeover what she could do.

VistA has been available for 25 years as part of the Freedom of Information Act. Only within the last five years have serious efforts begun to commercialize the system.While there have been tremendous early successes, the lack of “spread” gives me pause for concern.With all the billions being dedicated to HIT and EHR, I have to think that an excellent public investment would be to extend and build upon VistA as a platform for a specific subsegment of public, state, and federal related facilities. These efforts would be dovetailed into efforts already initiated within the DoD and the VA (who are finally trying to have a single system for their singular patients). It could save hundreds of millions of dollars if these efforts were done openly, collaboratively, and in a true open source fashion.

I believe the event horizon for this opportunity is rapidly narrowing. As the pace of technology and computing advances, the opportunity to retool and reskin VistA is closing. I am concerned that without some direction (clearly none coming from the VA), some leadership (none coming clearly from the community), and some momentum (need to have 25+ Midland size implementations), VistA will become an interesting footnote in the history of HIT. The flood of new money will lock in current proprietary solutions and the opportunity to fundamental disrupt with an open source solution will be lost. This season of opportunity will not be an Endless Summer – the coming stimulus wave may be VistA’s last ride.

Its now or never.

Twitterview (twĭt’ər vyū) n.

1. A twitterview is a combination of the terms Twitter and interview.
   
2. The Twitter medium of 140 characters forces a concise style of interviewing and response.
   
3. The public can join in on the conversation and become participants themselves by following along or tracking hashtags.

On March 26, 2009 the leading health care bloggers (see list below) throughout the blogosphere participate din a Blog Rally to raise awareness for public participation in the Healthcare X PRIZE design. Bertlan Mesko, leading Medicine 2.0 Advocate and author of the popular Science Roll blog, also conducted a “Twitterview” in support of the effort.

Berci: Can we start the twitterview now? I’d have 10 short questions, you may have 10 short answers. So everyone can enjoy it.

HealthXPRIZE: Thanks for taking the time. We appreciate your help in getting the word out. This Twitterview will complement the Blog Rally. Ready!

Berci: Great! First, what is the X PRIZE Foundation? What is the X PRIZE model?

HealthXPRIZE: The X PRIZE Foundation is a non profit organization that conceives and operates large incentivized prizes that lead to revolutionary breakthroughs. The X PRIZE model is based on leveraging a large purse, with a clear set of rules, that allows innovators to break through barriers.

Berci: Please tell us more about Healthcare X PRIZE!

HealthXPRIZE: The Healthcare X PRIZE is intended to be a competition to redefine health and demonstrate how new models of care can dramatically increase health value. We chose to focus on health value as opposed to a new wonder drug or device as our sponsor (WellPoint and WellPoint Foundation) & advisors were most interested in a systems prize. Systems prizes are much more difficult to conceive and operationalize than technical competitions like going to space or even replicating the genome rapidly. We are expecting that teams will need to innovate around health finance, care delivery, and individual incentives to increase health value. We are currently developing a clear set of rules, which provide the parameters of competition, as we believe that “creativity loves constraints”.

Berci: Reforming the US healthcare system is quite a brave mission, isn’t it? Why the focus on health value?

HealthXPRIZE: The US Health reform gets serious this summer and the HXP is well timed to actually demonstrate and prove in practice the principles of reform. Value is powerful organizing principle for reform efforts – we cannot just reduce costs, nor can we just attempt to improve quality without financial accountability. The focus on health value highlights the need to focus on both sides of the equation. Since Value =outcomes/cost, we are challenging teams to improve both simultaneously.

Berci: Why use an incentivized competition?

HealthXPRIZE: Incentivized competitions are very efficient, highly leveraged, and create an “X” factor within the competitive framework. Sponsors only pay the winner, a $10MM purse typical spurs >$100MM of investment, and the X factor creates global media attention to a key problem, inspire hero’s, encourage non-traditional thinking, and creates a powerful incentive for innovation.

Berci: And how can you properly measure health value? I guess you need pre-defined parameters. What are these?

HealthXPRIZE: Health Value has never really been measured within the US Health Care system. There are many efforts underway right now to properly define and measure health value. Many innovators are leading the way and we are attempt to build on their work or actively collaborate with new/ongoing initiatives (Dartmouth, IHI, AHRQ, etc) to solidify the health value measurement framework. In the context of competition, we are trying to make our measurement framework as concrete as possible by focusing on outcomes (mortality, specific morbidity, ED visits, hospitalizations, sick days etc.). Effectively communicating the notion of “health value” remains a challenge; we are considering focusing on aspects of health value (like decreased hospitalizations and sick days) as a more effective way to communicate to the public the hoped for prize breakthroughs.

Berci: How are the Teams and Test Communities Selected?

HealthXPRIZE: Teams will be selected by through a series of concept design and testing evaluations. They will be required to demonstrate or model the impact of their proposed interventions against test database provided by WellPoint. Independent judges will evaluate the merit/validity of the concept in order to advance. Communities will be selected based on specific criteria that are still being worked through. Intent is to have a defined population of 10K participants from which Teams will voluntarily enroll in the intervention. Test community will be matched against a geographically adjacent control group. Both the team and community selection requires further design, detailed analysis, and expert opinion which we are soliciting at this time through our network of national measurement experts.

Berci: When does this competition start and when will it end?

HealthXPRIZE: The “competition” has several phases: Design, Selection, Competition. We are currently in Design phase through our anticipated Launch later this fall. The Design phase includes soliciting public comment on how we can improve our initial concept/construct to create the most viable competition possible. After official “Launch”, we will begin recruiting teams to compete. Teams will then be narrowed as described above through late Spring 2011 when 5 finalist selected. After a brief integration period into test community, HXP competition is planned to officially begin in January 2012.

Berci: How does this shift the paradigm? What kind of outcome do you expect?

HealthXPRIZE: Great question – we believe the current paradigm is based on volume not value, on process not results, and incents the wrong behaviors while delivering bad outcomes. We want to shift the paradigm to rewarding the reduction of hospitalization / sick days and begin to pay for overall health improvement (this is the outcome we want!). We also want to not focus solely on disease care, and aren’t interested in just improving health care; but believe that we must move to an entirely new notion of engaged, activated health called “Vitality”. We want to demonstrate that this CAN be done at scale, with new entrants / new ideas, and want to set the HXP up as a framework from which these efforts can be tackled in the real world. By focusing on outcomes, instead of regimenting care processes or dictating care delivery, let providers/patients innovate and create rewards for those who obtain the best outcomes.

We believe incentivized competitions are a great vehicle from which we can accelerate change, shift the paradigm, and be a catalyst for the transformation that is required for the US healthcare system. We hope the outcome is a new way to think about health, measure health value, and demonstration of new models of care that demonstrate how to improve community health and individual vitality.

Berci: My last question, regarding X-PRIZE – first rockets, then genomics, now healthcare. What do you think? What’s next?

HealthXPRIZE: XPRIZE is a mission driven organization seeking to inspire the very best in human kind for the benefit of all – this isn’t just a nice quote. It is inherent in the DNA of the organization. We are attempting to be the catalyst in any “stuck” industry by creating incentivized competitions that can lead to radical breakthroughs to the grand challenges of humanity. HXP is now looking at education, energy (some really cool stuff), and developing world initiatives that can truly have major impacts. Fortunately for me, HXP is our focus for launch this year. It is quite challenging work, deals with multiple hard to think through issues, but includes the privilege to work with great people and teams including our sponsor WellPoint.

I have been thrilled with the level of commitment to this process and this prize development process has been tremendous experience. They have a very talented innovation team, led by Chad Pomeroy, who is fully supported by senior executives all the way up to Chief Executive Officer Angela Braly. They have been driving this initiative forward far beyond the $10MM prize purse; they are providing operational resources, sharing data, working to create appropriate test communities, altering business practices to accommodate the prize, and are committed to transparency as part of the HXP process. Their commitment to the project is the reason I became involved as I saw an unprecedented opportunity to really implement the innovation in an idealized but competitive test environment. We appreciate WellPoints leadership, foresight,and commitment to engage X PRIZE in developing the Healthcare X Prize for benefit of all. Very cool stuff.

Berci: Thank you very much for the interesting answers! I will publish the transcript on Scienceroll.com in a few minutes.

HealthXPRIZE: Berci, again, thank you for this twitterivew. We hope to have everyone visit our website, download the initial prize design, comment on our blog, and add their input to the Prize Design process.

Blog Rally (b’lôg răl’ē) adj.

1. A coordinated, simultaneous presentation of identical or similar material on numerous blogs for the purpose of engaging large numbers of readers and/or persuading them to adopt a certain position or take a certain action.
2. The simultaneous nature of a blog rally can create the result of joining the efforts of otherwise independent bloggers for an agreed-upon purpose.

We are entering an unprecedented season of change for the United States health care system. Americans are united by their desire to fundamentally reform our current system into one that delivers on the promise of freedom, equity, and best outcomes for best value. In this season of reform, we will see all kinds of ideas presented from all across the political spectrum. Many of these ideas will be prescriptive, and don’t harness the power of innovation to create the dramatic breakthroughs required to create a next generation health system.

We believe there is a better way.

This belief is founded in the idea that aligned incentives can be a powerful way to spur innovation and seek breakthrough ideas from the most unlikely sources. Many of the reform ideas being put forward may not include some of the best thinking, the collective experience, and the most meaningful ways to truly implement change. To address this issue, the X PRIZE Foundation, along with WellPoint Inc and WellPoint Foundation as sponsor, has introduced a $10MM prize for health care innovators to implement a new model of health. The focus of the prize is to increase health care value by 50% in a 10,000 person community over a three year period.

The Healthcare X PRIZE team has released an Initial Prize Design and is actively seeking public comment. We are hoping, and encouraging everyone at every opportunity, to engage in this effort to help design a system of care that can produce dramatic breakthroughs at both an individual vitality and community health level.

Here is your opportunity to contribute:

1. Download the Initial Prize Design
2. Share you comments regarding the prize concept, the measurement framework, and the likelihood of this prize to impact health and health care reform.
3. Share the Initial Prize Design document with as many of your health, innovation, design, technology, academic, business, political, and patient friends as you can to provide an opportunity for their participation

We hope this blog rally amplifies our efforts to solicit feedback from every source possible as we understand that innovation does not always have a corporate address. We hope your engagement starts a viral movement of interest driven by individual people who realize their voice can and must be included. Let’s ensure that all of us – and the people we love – can have a health system that aligns health finance, care delivery, and individual incentives in a way that optimizes individual vitality and community health. Together, we can ensure the best ideas are able to come forward in a transparent competition designed to accelerate health innovation. We look forward to your participation.

Special thanks to Paul Levy for both demonstrating the value of collaborative effort and suggesting we utilize a blog rally for this crowdsourcing effort.  Participating bloggers and media include include:

• Bob Coffield, Health Law Blog
• Richard Elmore, Avance Healthcare
• Vijay Goel, MD - Consumer Focused Healthcare
• Vince Kuraitis, eManagement Blog
• Paul Levy, Running a Hospital
• Bertalan Mesko, Science Roll
• Modern Healthcare
• Bill Pomerantz, The Launch Pad
• Amy Tenderich, Diabetes Mine
• Fred Trotter, Open Source Hacktavist
• Matthew Holt, The Healthcare Blog

Tragedy (trăj’ĭ-dē) n.

1. A disastrous event, especially one involving distressing loss or injury to life
2. A tragic aspect or element.
3. A drama or literary work in which the main character is brought to ruin or suffers extreme sorrow, especially as a consequence of a tragic flaw, moral weakness, or inability to cope with unfavorable circumstances.

The Advisory Board to the Health 2.0 Conference have been rehashing the recent conference in preparation for the fall program. We are continuing to try to push the boundaries of how to highlight bleeding edge innovations (dessert) and the new tools and technologies (eye-candy), but trying to be disciplined in challenging the community to put up their hard core case studies (nutritious tofo in the words of Esther Dyson) that demonstrate why this movement actually matters. This latter one requires thoughtful discipline, and hard data, from people trying to do very hard things (like obtain accurate personal health data from disparate sources, help consumers understand and optimize health value, and show how these new models of care actually lower cost). We look forward to producing a great program and I will keep you posted on these conversations.

The reason it is so hard to “do the right thing” in health care is that the current environment is a conspiracy of connundrums - no accountabilty, no transparency, rules/regulations, culture, binding contracts, third party payments, behavioral choices, lack of evidence, etc ad nauseaum. A real world example of how this plays out can be seen in the Vicious Cycle of Healthcare Innovation. This article highlights what happens when health care providers “do the right thing” but are rewarded with less money, which then kills off not only their desire but also their capability to do the right thing. Its a beautiful mechanism to ensure that the status quo never changes. This “Death to Innovators” concept has been highlighted by Intermountain Healthcare (pneumonia), Virginia Mason (back pain), and health innovators like Rushika Fernandopulle , MD at Reinnassance Health.

These tragedies have to be overcome. Given the grip of the medico-industrial complex, and their lobbying minions in DC, the only hope I have is that an entirely new system of health can begin to develop and emerge “off the grid” for the current non-consumers of healthcare. From this toehold, and from early and small efforts of the myriad groups seeking to change the financing of healthcare, I am hopeful that innovation can emerge that will align incentives, coordinate care delivery, improve outcomes, and be rewarded appropriately for these results.  That is why I am involved in the various efforts to not only bring innovation to light but also demonstrate that these models can flourish.

This is a cross post to some of my writing over at the Healthcare X PRIZE blog

The focus on health care value is a powerful organizing principle, but communicating this concept in an elevator pitch is challenging

The Healthcare X PRIZE continues to build momentum as we receive a steady stream of inquiries regarding this $10MM competition. While many of the inquiries are regarding timing, application, and registration process, we have also been receiving a number of high quality request for information from technology companies, academic organizations, and communities who are interested to understand how they can participate. In fact, the most passionate inquiries seem to come from community based organizations who have a clear vision of how the community can be architected to function as a single entity that maximizes health value.

It is great to see how the X PRIZE can inspire this type of thinking. However, we have received some feedback that the health value story is a little difficult to grasp. Admittedly, it feels like it takes two or three sentences to explain what we mean by health value, how community health is related to that, and how individuals are connected to and influence the community. This is in contrast to the single statements of other prizes that immediately evoke a powerful and clear notions of what is the prize is about. As an example of the single sentence statements that create a singular focus:

• Ansari X PRIZE: “100Km, twice in two weeks, with three person payload”
• Archon Genomics X PRIZE: “100 genomes in 10 days”
• Google Lunar X PRIZE: “Land a rover, motate 500km, send back high definition images”

These are all clear and compelling; single statements that can be pitched in an elevator and understood by a child. They also represent significant scientific and technical breakthroughs that are understood and can be systematically worked through. However, the Healthcare X PRIZE is a different animal. It is actually a prize designed to change a system (and a very complex one at that). With approximately 20% of the GDP involved in the industry we are trying to reform, it is worthy of an X PRIZE type effort although many believe we are pushing the boundaries of the X PRIZE framework in designing a systemic prize versus something more confined, constrained, and ultimately more conservative.

But it is a challenge we are willing to take on.

We believe that health value is the right organizing principle, but perhaps we communicate the same message in a different way that drives home the point in a more singular fashion. Perhaps we need to focus more on the “healthy community” aspect (using the health value measurement framework), ala the huge success we are seeing with initiatives like Shape Up Rhode Island. Perhaps we need to shift to focus on a leading indicator condition like the Heart of New Ulm (which to impact would still require the systemic changes we seek). Or, perhaps, we just need to keep preaching the Health Value story with direct outreach, clear examples, and compelling case studies.

We look forward to your feedback as we continue to evolve the messaging of the Healthcare X PRIZE. Given the potential impact of the prize to demonstrate that radical transformations within health care are possible, we look forward to developing the most compelling single sentence statement.

Would love to get your feedback.