GHIT Notebook

December 12, 2007

Health Care Providers Restless for Mandate

An Italian electronic heath care pilot funded by the European Union includes a “smart medicine cabinet” that electronically screens medications for adverse drug interactions as well as automates refill ordering, payment authorization and delivery.

Making it work requires a complex set of identity management and privacy agreements, prerequisites of a future health care Internet where health information can be easily shared and data sifted to hone the performance and results of health care procedures.

In the U.S. today, that vision is obscure at best, according to health care executives at a forum this week on health care innovation and technology sponsored by the World Congress organization.

“The industry as we know it today is broken,” said Mohan Nair, chairman of Regence Life and Health, a non-profit payer organization, in his welcome to attendees.

“Health care has been locked in iron since the end of World War II,” is how Jerry Grossman, director of the Health Care Delivery Project at Harvard’s Kennedy School of Government, summed up the state of the affairs.

As to the future, worry competed with hope. “I’m seeing things overseas that frighten me in health care,” confessed Bill Crounse, director of world-wide health for Microsoft Corp.

“I’m no longer thinking that we’re the best of the best.” Canada, he said, was “leap-frogging” the U.S. in health care due mainly to its “government’s deep investment in health care.”

Of the Bush administration’s 2004 pledge to build a national health information network in 10 years, Crounse said: “I don’t know how we’re going to do that.”

Discussion at the forum focused on two main ways to break-up the stalemate: an evolutionary approach, where health care systems will slowly map to transformations of the World Wide Web.

The coming health Internet will give consumers greater control over their health care choices and treatments will be customized more precisely to individual patient health histories, even genetic profiles.

But most executives believe a brute force approach is necessary to overcome the inertia they see in the current schemes for achieving health system interoperability.

In an electronic poll, about 70 percent of the forum audience agreed that the government should impose a national mandate for health information interoperability standards – the health equivalent of lowering interest rates – in order to lift the industry out its current doldrums.

“The most important step is the development of standards and it’s the government’s role to do that,” said Keith Batchelder, chief executive officer of Genomic Healthcare Strategies, a consulting firm focused on personalized medicine.

Without a mandate, EMR vendors have little incentive to interoperate, said Lynn Vogel, chief information officer of the University of Texas’s Anderson Cancer Center.

“If you rely on voluntary adoption it’s going to take a long, long time,” he said. “Progress would be made when government “applied those standards to their own payer mechanisms.”

The federal government has avoided a mandate, preferring instead to experiment with incentives such as Health and Human Services Secretary Mike Leavitt’s push to reward physicians who adopt health IT with Medicare bonuses.

But most provider executives seem to prefer sticks to carrots. “I think it has to be just like the speed limit,” said Marc Probst, chief information officer for Utah’s InterMountain Health system. “It’s going to be the quickest way to get there, but I’m not sure it’s going to happen in my CIO lifetime.”

James Hummer, chief executive officer of Whole Health Management, which provides on-site corporate heath care clinics, said Medicare, “could play a great role but it’s “frightening to think of them driving change.” That’s because he is doubtful Congress can muster the political will to overcome pressure from technology corporations who might conclude a mandate cuts against them.

Which standards are the ripest candidates for a mandate? Several standards operate most powerfully and smoothly. “The nice thing about standards is there are so many to choose from,” said UT’s Vogel.

Probst called HL7, a clinical messaging standard HL7 “terrific,” adding it “was very well positioned to become a standard if it’s mandated.”

Chris Ross, chief information officer of MinuteClinic, which operates 435 clinics in 24 states, said the CCR (Continuity of Care Record) standard also “works extremely well. … It doesn’t have to take over the entire planet,” he said, calling it a “practical grass roots approach.”

But a mandate is not a panacea, executives said. UT’s Vogel noted that after Katrina, the heath records of military veterans were the most readily available because of the integrity of the of the Veterans Administration’s health system. Yet the most essential information in such crisis might only be records on allergies and current prescriptions.

“Do we need a VA for every provider?” he asked. “Perhaps we should focus on what we think we need to have not what we think would be Nirvana.”

Cultural attitudes toward sharing health information will also trump any mandate. For a generation used to sharing personal information via open Internet communities like Facebook, the line is shifting between what information is worth keeping private and what is not.

“Younger folks have a very different sense about how the share their information,” said Ross.

Most executives agreed that HIPAA has been woefully inadequate in addressing changes in attitude toward openness.

“HIPAA set us back a couple of decades in terms of ability to provide better care at lower cost,” said John Abele, chairman of Boston Scientific, which specializes in non-invasive medicine. “Did we really protect people? I don’t think so. This is a problem that affects a small number of people and we’ve thrown the baby out with the bath-water.”

“HIPAA is used as an excuse for why our health information isn’t more interoperable,” added Ross. “But its’ really not an impediment when you talk to the Web 2.0 crowd.”

In fact, the generational tide is what most observers say will ultimately break up the inertia over health information sharing. “Baby boomers are an impatient society that is going to demand something else,” said Microsoft’s Crounse.

People who grew up in computers are demanding health IT in health care,” said Jonathan Perlin, chief medical officer of the Hospital Corporation of America. “ They will not tolerate the limitations of paper.”

“Health care has not decided if it’s an industry or a public good,” said Harvard’s Grossman. “Now it’s being pried open by consumers who understand that the current system is broken.”