Saturday, November 14, 2015

EMRs, Government, and Capitalism

I wrote in my last post how the government screwed the pooch on Electronic Medical Records by not requiring interoperability as it invested $30 billion in the enterprise. With that kind of money going to by EMRs and equipment, surely the proviso that they be interoperable could be included. Was it corruption or incompetence that omitted that proviso? I couldn't be sure. Maybe a mixture

So here's a follow up from JAMA, September 22/29, pages 1213-1215, a medical news article: “On the Road to Interoperability, Public and Private Organizations Work to Connect Health Care Data.” The reporter, Julie Jacob, interviews the Office of the National Coordinator for Health Information Technology (ONC) spokesperson, Erica Galvez MA. The article states:

Although the ONC road map presents the movement toward interoperability as a smooth, straight road, in reality it's more like fitting together the pieces of a giant jigsaw puzzle. Several public and private organizations are working on different pieces, including organizations creating technical standards, establishing health information exchange (HIE) networks, connecting those HIEs, and developing principles of governance and usage. The hope (emphasis added), according to health care information technology experts, is that all the pieces eventually will interlock.

Because the Feds have basically opted out of direct action and laws requiring interoperability, several organizations have formed to try to fill the breach, one from the AMA called Healtheway, another called CommonWell Health Alliance which was spawned by the EMR industry sans Epic, and which requires a fee from participating institutions. Another older one is the Indiana HIE. Epic has their own system called Care Everywhere, available for a fee when you buy Epic and which was charging for each chart searched when Epic was presented to me, which links together Epic systems and some others who choose to join (for a fee which has been waived for five years, I guess under some pressure.)

Why all the flailing around? The JAMA reporter:

The highest barriers are financial and policy ones, not technical ones, noted those with expertise in health care technology.

Technology is almost never the obstacle,“ noted Indiana HIE's (John) Kansky. “It is really the governance of the data and getting organizations with different agendas to agree on what you are going to do.”

In other words, it is precisely the role of government that is not being well filled here. Government has taken a hike. Amazingly, this is the ONC goal:

...electronic exchange of health information among clinicians, health facilities,and patients should be widely available within 10 years.

Holy moley – 10 YEARS!! Let's see: Kennedy's speech, 1961; moon landing, 1969. ONC is not what we would call, let's say, overambitious.

I was interested that the spokesperson from ONC JAMA interviewed had only an MA degree, so I googled her, and got a hit from four days ago. From Healthcare IT News:

Former ONC Interoperability Manager Erica Galvez joins Aledade.”

What is Aledade?

Aledade was founded in 2014 by Mostashari with a focus on supporting independent, primary care physicians creating and or running ACOs. They provide healthcare technology, business transformation services and upfront capital.

More from Forbes:

Farzad Mostashari, who was formerly national coordinator for health information technology, raised $30 million in series B funding for Aledade. ARCH Ventures Partners led the round, with participation from return investor Venrock, bringing total funding to $35 million.
Mostashari, an internist, oversaw the nationwide implementation of electronic health records in the initial stages between 2011 and 2013. Last June, he founded Aledade to help doctor practices, as small as one, band together in so-called accountable care organizations (ACOs).
...By the end of the year, Aledade expects to have more than 100 physician practices in its ACOs, managing 75,000 Medicare patients. Practices pay a membership fee of $500 per general practitioner per month. They keep 60% of savings, with 40% going to Aledade.
In other words, the former head of ONC left to raise money for a private venture and hired a former staffer for him at ONC to come to the private venture. Let me note, however, that Aledade actually is interesting in that it focuses on private practices and has software that is designed to keep them independent of large hospital networks. Still, as they used to say, is this any way to run a railroad? But I have to say that I myself was in government early in my career, and looking around at what took place there, I decided that it was not a good place for me in the long run, much as I learned and loved some of my years there. I can't criticize others for making the same decision.

So, here is the picture. There are so many loose ends in the current non-system, it's not at all clear that this puzzle can be put together. To my mind, the Federal government has never looked so bad. They fail to look forward to see where private enterprise – here, EMR development – needs some help, some regulation if you please, to pave a road ahead so that companies can innovate and compete, but still develop a system that works together for the public's benefit. Companies themselves put a low priority on working together, as would be expected; that's why government is needed, as a convenor. Even when the Feds have a $30 billion windfall from ARRA, which would ensure they had the clout to enforce standards, they fail to exercise it. ONC continues to be meek and silly, setting a 10 year horizon for something that has governance and political impediments rather than technical ones. Government continues to fail to see, or at least talk about, the implications for the system as a whole, where some large capitalistic systems will benefit from lack of interoperability to the detriment of true competition and progress. Government accepts the role of bystander and beggar. Private companies seek to fill the government void of data coordination and interoperability. The problem of rotation of personnel from government to private business continues in health care as with other fields. Given the toothlessness and fecklessness of government, one can hardly blame them, although I'm sure there is much connivance from the private world. In fact, perhaps I am blaming the victim as I blame government. Who knows?

What I do know is, this really sucks.

Budd Shenkin

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