2009’s HITECH legislation with its incentives to promote healthcare IT that meets Meaningful Use standards is just the means to the end. That being the case, where are we on the road to this bright future? It’s easy to pontificate using glittering generalities, but when it comes to specifics, it’s hard to gauge. One easy metric might be the number of hospitals and physicians that have qualified for the first stage of funding under Meaningful Use, but all that means is that the providers can check the box—“Yes, we meet the letter of the requirement.” It says little about the intent of the technology or the larger progress towards a change in the way healthcare is delivered.

We think an interesting possible metric might be the number and percentage of Health Information Exchanges that either have achieved or see the way to achieve financial stability. More than any other type of organization, Care Coordination is at the core of the reason for an HIE to exist. On the other hand, it is not clear what role Patient Engagement plays from the HIE perspective. So we’ve been asking questions, trying to learn more about sustainability for HIEs. We’re looking for patterns in the sustainability model to better understand the value chain around Care Coordination and Patient Engagement.

There are a number of good studies and reports in this area, all of which reach pretty much the same conclusions. One good study, “A Survey of Health Information Exchange Organizations in the United States: Implications for Meaningful Use” by Julia Adler-Milstein, BA; David W. Bates, MD, MSc; and Ashish K. Jha, MD, MPH, was published in the Annals of Internal Medicine, May, 2011. The survey considered 197 potential HIEs (also called “RHIOs” or “Regional Health Information Exchanges”) of whom 75 responded and were operational as of December 31, 2009. According to the report, “Overall, 50 of 75 RHIOs (67%) did not meet the criteria for financial viability.” The authors concluded, “These findings call into question whether RHIOs in their current form can be self-sustaining and effective in helping U.S. physicians and hospitals engage in robust HIE to improve the quality and efficiency of care.”

Yikes. If we are looking to sustainability of HIEs as a larger measure for progress towards Care Coordination and, possibly, Patient Engagement, this ain’t a very good sign.

On the other hand, although published in May, 2011, the study was conducted in the first quarter of 2010—before the passage of the Affordable Care Act with its express focus on Care Coordination and Patient Engagement, and it was before the still pending shared savings model was announced for Accountable Care Organizations. Perhaps even more important, it was before employers received their steep increases in health premium renewals that really began in late 2010 and continued in 2011.

So we’ve been wondering: What, if anything, has changed in the last year and a half? Today, how many HIEs are operational? Is it up from last year’s 75? (We expect so.) If only 25 HIEs met the criteria for financial viability in early 2010, today how many either meet those criteria or see a vision to do so? (We don’t know.) And, most important, what are the elements of sustainability in light of the Affordable Care Act and the rapidly rising costs of health insurance? (We think we know.)

With luck, (now) Dr. Adler-Milstein, one of the authors of the above-mentioned study, who was at Harvard when the study was conducted, is now an Associate Professor at the School of Information at the University of Michigan, a few blocks from our office. This past week, I stopped by Dr. Adler-Milstein’s office to chat about these questions. (This was an informal chat, not a formal interview. These comments are paraphrased from that discussion.)

Dr. Adler-Milstein reiterated her concern whether HIEs can achieve sustainability in their current form, but allowed that they have not updated the study to reflect the possible impact of events since the study period in early 2010. As we talked about the value propositions for HIEs, she noted that most HIEs are still in the early stages of connecting the providers in their communities and are not in a position to clearly express any business model that will result in sustainability. As we talked about the value propositions for HIEs, she noted that for the HIEs with which she spoke, the value proposition was focused on efficiencies to improve communication of personal health information (lab results, medications, problem lists, etc.) between providers. We agreed that it appeared to be difficult to achieve sustainability based solely on a model of improved communication between providers.

If not simply improved communication, then what value proposition will lead to sustainability for HIEs?

At the highest level, ROI calculations and value propositions always boil down to two things:

1) How much money will we save?
2) How much new revenue can we earn?

Ultimately, these are two sides of the same coin. For the proposed Accountable Care Organizations, this appears to be fairly easy. ACOs will be required to improve Care Coordination and Patient Engagement, therefore, to the extent that an HIE is a participant in an ACO, it will be compensated by receiving a part of the savings paid to the ACO. That constitutes cost savings for Medicare and new revenue for the HIE.

But what about HIEs that are not part of ACOs? What value propositions will lead to their sustainability model besides improved communication among providers?

As we’ve talked to HIE executives and to other industry executives, we see a new trend emerging, focused on giving value to employers and insurers through Care Coordination and Patient Engagement to improve health and lower cost.

One of our favorite sources in these matters is Earle Rugg, CEO of Rural Health IT, one of the premier consultancies in this area. Earle’s answer was firm: “You can only get so much from improving communication among providers—and today that’s pretty slim. How much can you save from the perspective of any individual hospital or physician under the present or proposed payment models? Not much. Sustainability has to come from someplace else. It’s not going to come from consumers. They simply aren’t going to pay. So, it has to come from employers and insurers. They are the ones who take the hit for unnecessary lab tests, avoidable hospitalizations, and lost days at work. They are the ones who are willing to give up a part of their savings thereby creating a new revenue stream for HIEs. Physicians, clinics & hospitals are willing to pay for HIE  provided value & applications, especially if they can pass that along to payers/employers and/or patients/consumers…ultimately consumer stickiness and connecting consumers in new ways to improve their health & wellness will add to HIE sustainability. ”

I raised this idea with Dr. Adler-Milstein who said she had not encountered any HIEs that included value to the employers and insurers in their sustainability plan. When I told Earle about her comment, he was quick to say that she is right—as far as where the market has been. “But there simply is no choice today—and payers are starting to understand that. Unless an HIE figures out how to give value to the employers and insurers, unless they convince the payers that it is in their interest to financially support the HIE, there is no sustainability model. It is as simple as that. Payers are key stakeholders, just as Medicare and Medicaid are driving forces for the ACO rule, in every HIE with which we work.”

I tested this idea by speaking with Executive Directors from a few of the HIEs with which we work. Since our business is Patient Engagement, this isn’t a representative sample. If we’re talking to them, they are already interested in Patient Engagement. However, every HIE that is considering our Patient Engagement systems is directly focused on the payer as a critical stakeholder. While the financial models vary, the concept is the same: The HIE is compensated for providing not only communication tools between providers but also for engaging consumers on behalf of all providers. This may include health and wellness tools that go far beyond the clinical Patient Portals and Personal Health Records. As one executive director said, “I have the insurance companies and employers at the table. Now I have to move quickly to offer a community-wide Patient Portal before each of my individual members offers its own tethered patient portal. Once they do that, it will be hell to get them to change to our portal, and without a single portal, we’ll never achieve the levels of Care Coordination and Patient Engagement that our stakeholders demand.”

Of course, these are just anecdotes from biased prospects. That doesn’t demonstrate much.

Fortunately, this fall our company has been selected as a featured company in Professor Brophy’s Entrepreneurship class at the Ross Business School of the University of Michigan. That means we have 5 students conducting market research for us this fall. You can guess what we’ve asked them to research. Where the number of declared HIEs in early 2010 was less than 200, today the eHealth Initiative lists about 250, and another 30 to 50 (with some overlap) might appear in the form of ACOs. We do not intend to conduct a survey of all HIEs, but we do intend to conduct fairly detailed interviews with at least 25 of the most successful HIEs. Our questions are simple:

1) Do you see a path to sustainability for your HIE? What is it?
2) What are the key value propositions that lead to sustainability? Who are the key stakeholders?
3) What role does the payer have in your sustainability model?
4) What role, if any, does patient engagement play in your value proposition?

This should be very enlightening work. We don’t expect a unanimous or final insight into this, but we should get a nice snap-shot of where we are today on this long and important road.

Stay tuned.

I’ve waited a few days to see what other commentators would say before weighing in.  Our trusted sources, including John Moore at Chilmark Research, have done an excellent job of summarizing most of the issues.  Still, there is a bit to add.

Our perspective.

We formed White Pine Systems in January, 2006 to address the clear market need for technology-based patient engagement.  The term “Personal Health Record” had yet to achieve its still limited recognition and patient portals were almost non-existent.  In 2006, we built prototypes of our system, which we call SPINN, the Secure Personal Information & Notification Network, but quickly learned the market was just wasn’t ready and we were therefore too early.  Although consumers and even providers loved it, we could not find a way to quickly achieve enough traction in any particular community to ensure sustainability—still a problem, although the environment is much more encouraging.   So we put it in the drawer and waited.

By the fall of 2007, Microsoft HealthVault, Google Health and Dossia had entered the market and shown some early traction, each with tremendous promise.  We knew the market was still too early, but we also feared that not entering then would mean missing the opportunity.  We approached all three about a partnership.  Our added value was clear—at least to us:  We would build personal health applications on these PHR platforms that would bridge the gap between EMR systems and the PHR platforms while giving new functions and features to all stakeholders.  And we would provide layers of live customer support—something not offered by either Google Health or Microsoft HealthVault.

Microsoft said “Great.  How can we help?”

Dossia said “Well, if one of our client members asks, we’ll support you.  (One has since asked and we are in the process of working with Dossia now.)

And Google said, effectively, “Whatever.”  A less than embracing response.

At a Robert Wood Johnson conference in the fall of 2008, a panel of executives from all three companies expressed their vision that one day companies like ours would build applications that could inter-operate with all three platforms.  There it was:  Our vision acknowledged by the three giants.  We continued to build our application suite focused on HealthVault but kept it open to add Google Health or Dossia when the time came.

But the Google approach never quite made sense to us.  Google’s almost singular focus on the consumer was not supported by adequate attention to engaging physicians and care coordinators.  We competed against and lost to Google Health on two occasions.  This week we learned that neither of these projects made it off the ground.

Like others, we’ve been expecting the end of Google Health for the better part of a year.  At the same time, there is a lingering feeling that they could come roaring back at some point when the market direction is clear—which we’d embrace.

So, what lessons do we take from the Google Health experiment?

Lesson One:  Personal Health Records aren’t for everyone—and that’s just fine.

In Google’s post announcing the end of Google Health it says:

“Now, with a few years of experience, we’ve observed that Google Health is not having the broad impact that we hoped it would. There has been adoption among certain groups of users like tech-savvy patients and their caregivers, and more recently fitness and wellness enthusiasts. But we haven’t found a way to translate that limited usage into widespread adoption in the daily health routines of millions of people.”

That idea was echoed by other commentators who cited the study from earlier this year that only about 7 percent of Americans have a PHR today.  The Google expectation appears to be that PHR adoption should become as ubiquitous as online banking.  To use a health-related metaphor, that’s like saying that Lipitor must be a complete failure solely because the number of patients who take it are only a tiny fraction of those who take aspirin, ibuprofen or acetaminophen—right evidence; wrong conclusion.

The conclusion should be that patient engagement, particularly PHRs, can give huge value to families dealing with chronic medical conditions but are just not as important to folks who do not have chronic health issues.

Very early in our research, back in 2006 and 2007, we tried to understand who would be most likely to adopt and regularly use a PHR.  We broke the population into four categories:

1. Healthy.  Individuals who were not focused on specific medical conditions either personally or as a care giver.
2. Recent onset chronic illness.  Individuals for whom their recent diagnosis, or that of someone close, is the most important thing in the world, and who are searching for tools and solutions to manage this new life state.
3. Long term chronic illness.  Individuals who have had a chronic condition so long that their behaviors are established, and for whom new solutions have relatively little perceived value.
4. People who are “disenfranchised.”  Individuals who, for a wide range of reasons not the least of which is a lack of insurance, operate mostly outside of the healthcare system.

Although I’m sure it exists, we couldn’t find statistical evidence that shows levels of interest based on both a person’s own personal health and that of others for whom he or she is a guardian or care giver.  After digesting the information we could find, we guesstimated this pie chart, which we think is still sufficient for this purpose.

We decided our initial product design and marketing would address the needs of people with the recent onset of a chronic illness.  These are the folks we think are most inclined to adopt a new health process, to sustain their use over time, and to benefit from it.  Other profiles would develop as the market evolved.  Noting also that people with chronic medical conditions typically suffer from multiple co-morbidities, see several different physicians and specialists, with lab results and interactions with a range of health providers, and, finally, account for a vastly disproportionate percentage of healthcare cost, it is clear that even modest levels of adoption by the right people will have a huge impact and create a thriving business.

The lesson should be clear:   The goal for PHR adoption should not be measured as a percentage of the entire population, but should be considered as a percentage of those people who directly or indirectly are affected by chronic medical conditions.  In that framework, an adoption rate by as few as 15 or 20 percent of the total population could still be a resounding success by all other measures.

Lesson Two:  When it comes to patient engagement, one size does not fit all.

In an age when market segmentation means that Coke comes in 18 different flavors, it didn’t make sense for Google to offer a its generic interface even when that UI gave users considerable range and flexibility in how to configure and use it.  That would be like offering a Coke flavor kit and allowing consumers to mix and match to create their own 18 (or more) flavors. (I know I’ll be challenged on this, so let me be clear: we like the range and flexibility of Google Health, we just don’t think it was easy for end users to derive value for their specific health interests.)

We believe that pre-defined dashboards designed around particular health interests that are closely connected to care coordinators through EMR and other health information systems are key to achieving regular, sustained use.  For example, a patient with diabetes will want to have the shortest possible path to information related to living with diabetes, while a person whose loved one is struggling with cancer will want a very different experience, as will someone who is pregnant, etc.  And they don’t want to have to figure it out on their own.  Configurability around specific health interests is key to successful adoption and sustained use.  Equally, close linkage to care coordinators reinforce behaviors and help identify problems at the earliest moment.  We call these personalized dashboards “Care Units.”

Studies of PHRs and Patient Portal usage and outcomes are still quite limited.  As described in the Program Announcement for a present AHRQ grant program titled “Understanding User Needs and Context to Inform Consumer Health Information Technology (IT) Design”, “there is still a lack of basic research around these end users’ PHIM [Personal Health Information Management] practices and needs and how these methods are influenced by a multitude of other contextual factors.” Still, success with similar telemedicine programs and Patient Portal/PHR applications at The Cleveland Clinic, the VA and a few others suggest that this kind of personalized experience is successful.

The lesson is simple:  Unlike an intuitive single purpose application like on-line banking, personal health applications need to be pre-configured for the specific health interests of divergent groups of users and closely linked to care coordinators.

Lesson Three:  Patient engagement must give value to all stakeholders.

As noted above, Google’s clear, almost exclusionary focus was on the consumer.  By contrast, Dossia focuses on employers and insurers as vested stakeholders along with the consumer, and Microsoft pursues a broad range of stakeholders with a heavy focus on provider engagement.  We believe that patient engagement must have the consumer at the center and in control, but must give significant value to all stakeholders.

So who are the stakeholders?

• Patients
• Families (and un-official caregivers)
• Providers (including physicians, hospitals, labs, pharmacies, home healthcare providers and nursing homes, to name the most obvious)
• Employers/insurers/third-party administrators (including Medicaid and Medicare)
• Patient advocacy groups

Some commentators reduce this to a battle between tethered patient portals and un-tethered PHR systems, concluding that the battle will be won by large integrated providers that offer an integrated patient portal, with the provider at the center of ownership, control and design.  Certainly patient portals will be the preferred choice for many users, particularly consumers not dealing with chronic medical conditions.  We expect that will be the case in some markets but it will not prevail in all markets.  Particularly in markets where there are multiple providers with no integrated patient portal, the PHR becomes the platform for a multi-provider patient portal, providing tremendous value to all stakeholders.  A likely example of this will be the proposed Accountable Care Organization rule, where wide-ranging providers, including physicians, hospitals, labs, home healthcare services and nursing homes are expected to collaborate closely but cannot be expected to operate off a single EMR system.  Another setting is in communities supported by Health Information Exchanges.  Relying on tethered patient portals at the provider level effectively precludes the patient/consumer from the benefit of health information exchange.  In these settings, a multi-patient provider portal at the HIE level that incorporates a PHR platform is an ideal solution.

At the same time, we see a host of new personal health applications coming to market including health and fitness, games, and personal disease management tools.  In the larger scheme, we don’t see providers or EMR vendors as the moderator of all these applications for all of these stakeholders.  We see the consumer as ultimately dictating the combination of functions and features, while recognizing that all stakeholders will expect value.

The lesson is simple:  While the patient must be at the center and in control, other stakeholders must be embraced.

Conclusion:

Google Health’s exit from the stage is a reflection of its own strategy and expectations.  It is not representative of the market for PHR systems or PHR platforms as a whole.  With the huge changes in healthcare delivery and payment models (not just the Affordable Care Act but also changes being driven by employers and insurers) now is the time to promote care coordination and patient engagement, not take a step away from it.

The inherent value of the remaining PHR platforms, Dossia and Microsoft HealthVault (along with a few other smaller players and possible new entrants) and patient engagement solutions like SPINN is the ability to create a community of services and participants that can be engaged by the patient/consumer that simply cannot be offered through a provider-controlled, tethered patient portal.  Ultimately there will be a convergence between tethered patient portals and PHR solutions that empowers consumers while giving value to all stakeholders.  PHRs will certainly evolve through this process, but, to borrow from Mark Twain, the reports of their death are premature.

Yesterday afternoon I had the fun of seeing HHS CTO Todd Park give a guest lecture at the University of Michigan School of Information.  (Apparently, it is part of a tour he’s giving to major universities and communities around the nation.)  While I’ve seen Todd before, this was the first time that I experienced him ‘up close and personal’.  His charisma is spellbinding and his vision is spot-on—it’s just what the doctor ordered.

It was a modest lecture room, almost full with 50 or so attendees. Not surprisingly, most were students.  The ubiquitous double projected screens on the wall behind seemed more crowded than necessary and everything paled once Todd started to roll.

I had planned just to absorb and maybe send a few tweets—after all I live and breathe this stuff every day.  [The arrogance!  The arrogance!]  That didn’t last 30 seconds.  I started scribbling notes on the back of a flier I’d picked up on the way in, filled that in the first minute and opened the binder I’d brought, thankfully.

I can’t say I captured enough to convey more than a small part of Todd’s gift and none of his energy, but I will throw out a few things and linger for a moment on the one question and answer that I hope will continue with Todd’s invitation to exchange email messages.  [Any inaccuracies are purely mine, with apology.]

The title of the presentation:

“A Historic Opportunity:  Unleashing the Power of Open Data and Innovation to Improve Health.”

The opening slide and consistent theme are simple:

“New Incentives + Information Liberation = Rocket Fuel for Innovation”

First, Todd reviewed the usual and timely suspects:  Meaningful Use and Accountable Care Organizations, with brief mention of bundled payments, Medical Homes and the related reform pilots.  There were updates to a few numbers and new facts including:

• Of the 68 EHR vendors who have received certification, 50 have fewer than 50 employees.  (Todd didn’t say it directly, but the implication is clear:  we are witnessing broad scale discontinuous innovation in healthcare IT.  We wonder what the effect of the inevitable consolidation will be on this core change.)
• Private payers have long wanted to shift broadly to capitated or bundled payments, but they can’t as long as Medicare pays on a purely fee-for-service basis.  Hospitals and physicians simply cannot support two such divergent payment models simultaneously.  (The implication, again unstated, is clear:  payers will indeed jump on the new ACO and bundled payment band wagon.)
• It’s all about data liquidity in HIT as the foundation to foster process change that improves health and lowers cost.  Todd featured the VA/CMS “Blue Button” as one example of easy data liquidity that is already having a big impact on patient empowerment and care coordination.
• The HHS role is to create an environment where innovation can thrive, in considerable part by making the vast stores of data available to the public in machine readable form (sanitized, of course).
• He described part of his role as CTO of HHS as “entrepreneur in residence, giving air cover to the people who have wanted to innovate all along.”
• Todd talked about how the NHIN Direct came into being—through the common sense request of a physician in a hearing who asked “Why can’t I send a patient’s records to another physician through some easy-to-use secure email-type system?  Why does it have to be so complex?”

And then Todd wrapped up this part of his presentation with a rhetorical question and a prediction:

“Can you imagine more fertile ground, a better opportunity for innovation?  I am certain that the next Mark Zuckerberg, the Mark Zuckerberg of healthcare, is sitting in this room.  My only fear is that I won’t know you.  I urge you to do this now.”

I admit, at this point, the question on my mind was where would Todd go next, towards the provider side, the consumer side, or some combination?  I should have seen it coming.

Todd’s primary focus was on the HHS’ role in creating an environment in which innovation can thrive.  He talked about the vast stores of health data that are now made available to the public at no charge and gave a machine gun introduction to some of the companies that are leveraging the data and the opportunity in new and exciting ways.  The remainder of Todd’s discussion focused primarily on consumers, where he believes the impact of the revolution will be greatest.

Todd lingered on the emerging market for health gaming and the potential to change behaviors through gaming rewards, and noted the limited success of traditional incentive and behavior modification models.  To make his point, he asked the audience about the FaceBook/iPhone game FarmVille that allows members to manage a virtual farm by plowing land, planting, growing and harvesting virtual crops, harvesting trees and bushes, and by raising livestock.  He asked “How many regular monthly users did FarmVille acquire in its first 18 months?”  The answer:  “78 million!  Imagine the impact of such a success in healthcare!!”

He went on, talking about Hospital Compare, which allows consumers to compare providers in a given community, Asthmapolis, which uses a smart phone to plot on a map the locations and frequency of inhaler usage by people with COPD and asthma, and how it helps identify both at the individual and the population levels places where intervention may have a huge impact.  And the machine gun kept firing with the possibilities and accomplishments.

Todd ended with this:

“The next 5 to 10 years will be the most productive in innovation in Healthcare, with a speed and ferocity that will stun people.  It is the chance of a life time.”

I, and everyone else in that room, truly believe.

During the Q&A, several people asked about consumers’ limited access to their own personal health information.  When it was my turn, the question was easy:

“You talk about incentives and liquidity of information, but today providers are neither required nor incented to give patients their personal health information in an electronic format, and EHR vendors resist enabling these easy technologies for competitive reasons.  Tethered patient portals that grant limited access to sub-sets of personal health information from isolated sources are not a sufficient alternative for the kind of innovation you envision.  How do you see this evolving in the near term to increase access for patients and their families?”  (Actually, my question wasn’t quite that well stated, but Todd understood the gist.)

His answer was that it should be easy.  “There’s no reason that providers can’t give patients their own personal health information in an electronic format.  Tell them to look at Blue Button.”

That was the only time I felt his comment was less than I’d hoped.  He followed with something to the effect that patient-consumer demand will drive providers and vendors to offer electronic access to personal health information.

And there we are.  Back where we started—expecting consumer expectations and demand will change the way medicine is practiced.  How long will it take for consumer demand to grow to the critical mass needed to achieve the point of inflection?  Ultimately consumers will be the force, but right now we need a catalyst, an incentive, to allow that consumer expectation to take root and grow quickly.

I agree with Todd that incentives + data liquidity = rocket fuel for innovation, but to the extent that providers are not required or incented to give easy electronic access to personal health information, and therefore patients are effectively denied true electronic access to their personal health information, that rocket ain’t goin’ very high—at least not as high as Todd’s vision would suggest.

I’ll take Todd, my new BFF, up on his kind offer to correspond on this important topic by email, and will post any further developments.

P.S.  In yesterday’s post, I said I’d post something dealing with the economics of the proposed ACO rules.  Well, this is more fun and a whole lot easier, so that will have to wait another day or two.  Check back please.

——————–

Last Thursday, March 31, HHS’s Center for Medicare and Medicaid Services (CMS) released proposed rules for Accountable Care Organizations.

Chilmark Research CEO and analyst John Moore referred to this as  “a Neutron Bomb” that “will leave buildings standing, but any healthcare organization (HCO) planning to become a successful ACO will need to decimate cherished internal processes to create new models of care delivery.”   Assuming the final rule is close to this proposed rule, the effect for patients and families is as profound—though from a patient perspective, perhaps there is a better metaphor.

Whereas 2009’s HITECH Act provides incentives to Medicare and Medicaid providers to adopt health information technology (HIT) but says little about how HIT should be used, this rule, issued under authority of the 2010 Affordable Care Act (ACA), speaks directly to the way in which healthcare is delivered.  This rule is about process with HIT at its core.

So, what is an Accountable Care Organization?  It is a group of healthcare providers, who have implemented electronic health records, health information exchange, and quality data warehouses to coordinate care and measure population health, to “improve quality and lower growth in expenditures.”

At the heart of the new ACO rule is a revenue sharing model called the Medicare Shared Savings Program (MSSP).  This is a simple yet sophisticated concept.  As described in the proposed rule, “Under these provisions, providers can continue to receive traditional Medicare fee-for-service payments under Parts A and B, and be eligible for additional payments based on meeting specified quality and savings requirements.”

The basic idea is this:  The Center for Medicare and Medicaid Services (CMS) will establish spending benchmarks by reviewing aggregate beneficiary-level payment data for the last three years, and will establish cost targets that are slightly less than past experience (generally 2 percent below the benchmark).  Actual spending will be compared to these cost targets and the savings will be shared.  The savings allocation starts at 50 or 60 percent for the ACO (depending on the degree of risk accepted by the ACO for cost overruns), but can be reduced depending on the ACO’s ability or inability to meet certain quality and performance measures.  (The proposed rule includes 65 measures across five measurement domains.)

For some ACOs this could result in a very large net income stream.  For others, the cost of HIT systems and compliance may make it difficult to come out ahead.

At 429 pages, we will not try to summarize the many regulations and guidance.  (There are good articles and blog posts that summarize the rules.  One good starting point is “50 Things to Know about ACO rules” by legal expert Scott Becker.)  Our interest is in patient empowerment and patient experience.

According to the proposed rule, “…to be eligible to participate in the Shared Savings Program, the ACO [must] provide documentation in its application describing its plans to:

(1)     Promote evidence-based medicine;

(2)     Promote beneficiary [patient]engagement;

(3)     Report internally on quality and cost metrics; and

(4)     Coordinate care.”

Here is part of what the rule says about care coordination and patient-centeredness:

Care Coordination

Coordination of care involves strategies to promote, improve, and assess integration and consistency of care across primary care physicians, specialists, and acute and post-acute providers and suppliers, including methods to manage care throughout an episode of care and during its transitions, such as discharge from a hospital or transfer of care from a primary care physician to a specialist. Compliance with this requirement may involve a range of strategies which may include the following examples:

• A capability to use predictive modeling to anticipate likely care needs.
• Utilization of case managers in primary care offices.
• Having a specific transition of care program that includes clear guidance and instructions for patients, their families, and their caregivers.
• Remote monitoring.
• Telehealth.
• The establishment and use of health information technology, including electronic health records and an electronic health information exchange to enable the provision of a beneficiary’s summary of care record during transitions of care both within and outside of the ACO.

Patient-centeredness

A patient-centered, or person-centered, orientation could be defined as care that incorporates the values (to the extent the informed, individual patient desires it) of transparency, individualization, recognition, respect, dignity, and choice in all matters, without exception, related to one’s person, circumstances, and relationships in health care. Patient-centered care should extend not only to the patient but to the family and caregivers of the patient.

As a consumer of health services, it just makes sense that care coordination and patient-centeredness should be at the heart of our healthcare system.  This proposed rule removes the barriers and provides incentives for healthcare providers to make this important change.

In our next post, we’ll take an early pass at the revenue sharing model itself to see if we can glean who the early adopters might be, with a view of which patients may be most affected.  Updates will be posted as this develops.

We know that the final rule will undergo significant revision.  Still, we can’t see how CMS can back away from the core principals.  For that reason, we are indeed very encouraged.

One of our favorite games was and is to track and predict the change in priorities through the legislative process.  The initial set of priorities by the vocal tax reformers of either party usually started about like this:

1. Tax simplification
2. Deficit reduction or tax reduction (depending on the party)
3. Income re-distribution (for one constituency or another)
4. Policy manipulation (thru incentives and penalties)
5. Earmarks (the cost of doing business)

During the public debate, the discourse was full of high morality sound bites—supply side economics, trickle down, deficit reduction, the balance of trade—you know the ones, but by the end, the change in priorities reflected the real deal making.  In the end, regardless of who won, the priorities usually were:

1. Earmarks (extortion)
2. Policy manipulation
3. Income re-distribution (based on who gained and who lost)
4. Some mishmash of deficit/tax adjustment

As anyone who’s filed a tax return recently knows, the original top priority, tax simplification, was a consistent casualty of the legislative process.  Clearly, its proponents didn’t have the power to prevail.

I’ve been thinking about that history as we prepare for President Obama’s big healthcare reform speech tomorrow evening.  While I’m not convinced, there is at least the appearance that we are at the point in the protracted haggle where a deal may in fact be within reach.  A middle ground may be taking shape.

So it’s time to reflect a bit on the evolving priorities in the healthcare reform debate and play our old game of priority prognostication.

Realizing that everything is fodder for hyperbole at this contentious moment, here’s a ridiculously high level view of what the original priorities were—although not necessarily in a consensus order:

1. Reduce the cost of healthcare (for the government and employers)
2. Increase access (for the 48 million people who do not have health insurance)
3. Increase the quality of healthcare (at least partly by improving information exchange among providers)
4. Improve the quality of life (implying a shift to prevention and consumer-centric wellness as well as improvements in living with chronic medical conditions)

The first thing worth noting is what’s not on the priority list.  Despite the absurd claims of some, “socialized medicine” is not on anyone’s priority list.

Nor do I believe that “a public option” per se is a priority at all, although it may be a means to achieve priorities.  We lose sight of this distinction when we look for the inclusion or exclusion of a public option as measure of the administration’s overall success or failure.  If the final legislation makes significant progress towards the priorities, then it is a success regardless of the means.

But what is most amazing about the present discourse is the near absence of improving quality of life and the reduction of cost other than through the manipulation of insurance programs.

This is personal.  As the child of two well educated, barely-employable disabled parents, our only access to healthcare came as a result of government insurance programs.  It is unconscionable that today one in six people in our country do not have access to healthcare because they do not have insurance.  Improving the quality of life is absolutely impossible if you don’t have access to adequate and timely healthcare because you do not have insurance.

It is not about free market versus socialism.  If the free market is what is now operating (and that is open to discussion) it has not provided insurance for 48 million people.  That is a fundamental failure.  It is as simple as that.

As for cost reduction versus quality, it is not an exclusionary choice.  There is no doubt that expanding coverage will increase total cost, which makes the focus on cost reduction even more important, but not an exclusionary alternative.

Therefore, as we look to President Obama’s important speech, here are a few items I’ll be listening for, at least between the lines if not addressed directly:

1. Reduce cost and improve quality of life by reducing avoidable hospitalizations.  Evidence suggests that we could cut cost by $10 billion per year net by improving our management of patient care post discharge.   While $10 billion isn’t much in the context of a $2 trillion industry, it is still a big step.  Furthermore, reducing avoidable hospitalizations will have consequential benefits such as lower sick time for employees and improved productivity for employers, not to mention improved satisfaction.  It is also just the start of other improvements in delivery that can be achieved. (I’ve written about this before, so won’t repeat it all here.)
2. Reduce unnecessary testing and improve diagnosis and treatment by improving information exchange among providers.  (Fortunately, it appears that the present funding for health information technology is not itself being challenged, although incentives for implementation and support are far from assured.)
3. Engage unofficial care givers through technology and process to promote healthy living and improve our ability to maintain active lives living with chronic medical conditions.  With our amazing advances in treatment, we see both an aging society and a higher percentage living with or close to someone living with a chronic medical condition.  This needs to be a clear and recognized priority.
4. Rethink and expand our investment in Emergency Medical Services.  A too easy casualty of the political process, EMS is critical to our healthcare system.  On the one hand, we see constant and increasing funding pressures on EMS—in my opinion, at least partly because their lobbying power is not as strong as others.  On the other, we see a huge increase in the use of EMS as a means of gaining access to healthcare for those who do not have access to insurance and who know they will be turned away if they enter through any other door.  The consequence is a waste of precious resources and an increasing percentage of the population that does not seek care until a costly crisis is at hand.  Whatever the result of the healthcare reform debate, we cannot allow the further deterioration of our excellent EMS system.

Last month, the Brookings Institute, with support from the Robert Wood Johnson Foundation, published a wonderful report called “Bending the Curve:  Effective Steps to Address Long-Term Health Care Spending Growth.”  The report suggests steps in five areas which can guide policy makers to substantially achieve the above priorities:

Build the necessary foundation for cost containment and value-based care;

1. Reform provider payment systems to create accountability for lower-cost, high-quality care;
2. Improve health insurance markets;
3. Support better individual choices.

This excellent report stands as the scale against which we can measure the success or failure of our leaders.  As we watch this important speech and then pay close attention to how our leaders react to it, I’ll be paying close attention to make sure that the original four worthy priorities are not thrown out with the wash, and I’ll be looking for an environment that allows us to make big progress on some of the specific areas that are outlined in this report.

And I hope we’ll do a better job of fulfilling our promise and meeting our priorities with healthcare reform than we have been able to do with our efforts at tax reform.

The contrast could not be more profound.  The picture is reminiscent of the bread lines from the Great Depression, just as the accusations of encroaching Socialism hark back to similar accusations hurled at President Franklin Roosevelt in response to his Works Progress Administration and the Civilian Conservation Core.

But between these extremes, there is a middle ground, an opportunity, to effect change that will lower cost and improve the quality of life—if only we can get out of our own way for the common and individual good.

In our last post, we set forth a case that reducing avoidable hospitalizations could result in net savings of $10 billion or more while improving the quality of life for patients and their families.  In this post, we’ll consider some of the issues around the effort to reduce avoidable hospitalizations.

The basic idea is to improve communication with patients and their families once they are discharged from the hospital to help them take better care of themselves outside the hospital setting.  It’s a simple enough idea, but there are a few challenges along the way.

A rose by any other name…

What exactly is it we’re talking about anyway?  What should we call this service or function?  The concept is simple:  Nurses or other care givers communicate with patients and their families to accomplish basic tasks such as:

• Make sure the patient understands the treatment regimen (medication, life style, testing, follow-up)
• Help the patient adhere to the treatment regimen
• Look for early warning signs that the condition is moving in a dangerous direction
• Engage family and others in the care network to support the patient.

But what do we call it?

I’ve asked this question of various healthcare providers almost all of whom give me a rather disgusted look at my incredible stupidity before giving me a firm, concrete, absolute, obvious and different answer.  So far, I’ve asked about a dozen professionals and received about a dozen different absolute, obvious, only-an-idiot-wouldn’t-know-the-answer anwers.

Nurse Navigator.  That’s what they call it in the cancer center, where the objective is to coordinate care very quickly across many entities towards both diagnosis and treatment.  A quick search of the Internet supports this usage.  The term is common in the cancer world, but we found very little use of “Nurse Navigator” outside of the oncology setting.

Out-patient Support. This came from the anti-coagulation therapy unit of a major cardiovascular center.  Their objective is to help patients adapt to life taking Coumadin (generic name Warfarin), a truly amazing drug that requires careful management of many things to be safe and effective.

Patient-Centered Medical Home. This comes from one of the major insurance companies (as well as a bunch of other sources) that views PCMH as a consumer-friendly term that will engage and empower patients and their families across a broad range of chronic medical conditions, for the purpose of reducing cost and improving quality of life.

Telemedicine. This comes from an independent physician’s group associated with a major hospital.  In this discussion, we were talking mostly about recent on-set diabetes, where the focus is on the proper use of glucometers, insulin therapy as well as life style adjustments.   (This term is a bit problematic for me because “telemedicine” means different things to different people.  For some, it is a means to provide access to primary care for people in remote locations.  For others, it is a means of engaging specialists from around the world in the management of complex cases.)

Interactive Health Communication Applications (IHCA) Needless to say, this came from an academic paper.  You get the idea.

We could go on, but whatever you call it, it is essentially the same thing:  It involves the use of procedures and technology in some combination to improve communication upon discharge to extend the care given to patients in the in-patient setting to the home.

But where’s the proof?

In the last post, I cited the case of Park Nicollet Health in Minnesota which estimates it saved Medicare about $5 million in avoidable hospitalizations with an investment of $750,000 per year.  Unfortunately, that program was scaled way back because it was a losing proposition for the hospital.

A search of the literature shows a mixed bag of results with some reports suggesting big improvements while others show a net increase in cost, implying that the savings from the programs did not even recover their own cost (this is regardless of who pays and who is the beneficiary of the savings).

I had this discussion with one of the leading telemedicine doctors who commented “All this doesn’t prove anything.  It is all just anecdotal.  None of these reflect statistically valid, peer reviewed research.”

Of course he’s right, although there may be better research that neither he nor I have found.  But in the absence of such proper research, from his perspective that means we cannot have confidence in the expected result from implementing such a program.  However, as a vendor, and as a peddler, this is the perfect time to conduct the necessary research to figure out exactly what the best combination is of policies, procedures and technologies to yield the greatest savings.  Indeed, this is the opportunity of a life time.

The time is perfect

We are starting to see various programs undertake this important piece of the healthcare puzzle without waiting for the federal government to re-invent itself.  In May, 2009, the Institute for Healthcare Improvement, with grant support from The Commonwealth Fund, announced a new initiative to reduce avoidable hospitalizations by working across organizational boundaries in three states:  Washington, Michigan and Massachusetts.  The initiative, called “State Action on Avoidable Rehospitalizations (STAAR)” seeks to reduce 30-day rehospitalization rates while increasing patient and family satisfaction with transitions and coordination of care.

It is too early to know how this will roll out, but we are very encouraged and we applaud their leadership.  Indeed, we hope to participate in some of these communities towards this important goal.

As for the federal government, funding for solutions that reduce avoidable hospitalizations appear to be within the scope of the present proposals.  Let’s hope that this is one piece of middle ground that is elevated, not suppressed by the political hyperbole.

In this blog, you can expect to see a blend of personal stories along with a discussion of policy and technology.  We hope you like the blend.

In the near future, we will add a forum to this site and invite you to tell your story and share your views.  Until then, please feel free to send me your story and ideas directly.  We’d love to share your thoughts with the community.  My email address is ddormer@SPINNPhr.com.

By the way, if you want to know what a “TAB” is, please visit the “About” page for the answer.

“You can’t get there from here.”

We heard that line more times than we could count as we peddled along pulling our aluminum-frame plywood trailer.  I don’t know if it was because we were on a bike, or because my mom was 50 years old and blind or because I was 12 and, well, 12.  I think the real reason is because they knew they couldn’t do it so we certainly couldn’t do it either.

We heard it when we hit the Seney Stretch, a 25 mile long flat straight section of highway M-28 through the Seney National Wildlife Refuge (a beautiful ride on a sunny day full of wildlife).

It was proclaimed authoritatively by a state cop who told us we couldn’t ride our bike on the highway even though we knew we could.  (Late one evening he also chased us out of a road-side picnic area where we’d pitched our tiny tent in a far corner.)

We read it on the sign that said “bicycles and motorcycles less than 250 ccs prohibited” as we rode past it to the International Bridge in Sault Ste. Marie that was our passage into Canada.  (Without a moment’s hesitation, the bridge authority folks loaded us into a pickup and drove us over with nothing but smiles.  Standing in the back of that open pickup holding the bike in place as we crested the bridge with the wind blowing through my hair—I felt like Leonardo DiCaprio in Titanic—“I’m King of the World.”)

And we heard it when we tried to load our gear onto the train for the last leg from the suburbs into the heart of Montreal, just before a wonderful stranger named Hazel Mulqueen said “Oh, don’t worry about them.  We’ll drive you i, and you can stay at our house.”

In a car, you get into your little glass and steel bubble, complete with your packet of air, and zoom from one place to another.  You can think about where you started and where you are going.  In between, you watch the world go by like you’re sitting on the couch watching a reality TV show.  Who has the remote?

On a bike, you live in the moment.  Where you have been or where you are going is only what you can see— as far as that bend in the road, to the top of that hill,.  You gauge your speed by the clicking sound of the seams in the pavement as first the front then the rear tire rolls over, and you mark your progress by the change in alignment of the trees as you look far off to the side of the road.  Incremental progress is all there is, and it is enough.

“You can’t get there from here.”  After a while, it made us laugh out loud before we answered softly “Watch us.”

Which brings us to healthcare reform.

President Obama has had to back away from his goal of passing healthcare reform by August and now talks of passing legislation by the end of the year.  He’s adjusting expectations too, shifting the language from the broader “healthcare reform” to narrower “health insurance reform.”  Now his opponents are raising doubt whether anything at all can be accomplished and threatening doom if anything does pass.  We all know what we’re in for.  It is the kind of political diatribe that shakes our confidence in our leaders, and leaves us discouraged, sometimes even ashamed.

Amidst the rancor of the larger fight, it is too easy to lose sight of the real opportunities that are in front of us.

The low hanging fruit in healthcare reform.

The idea is simple:  Say, for example, a loved one is newly diagnosed with and treated for a chronic medical condition, like diabetes or hypertension or congestive heart failure. You hope that by the time he or she is discharged from the hospital, he/she will be reasonably stable.  By reasonably stable, we mean we hope that the person won’t be admitted back into the hospital within, say, 30 days for the same condition.  That seems like a reasonable expectation, don’t you think?

To put this in perspective, according to an excellent report in the New England Journal of Medicine published in April, 2009 called “Rehospitalizations among Patients in the Medicare Fee-for-Service Program,” a study of Medicare claims data for 2003 and 2004 showed that “almost one fifth (19.6%) of the 11,855,702 Medicare beneficiaries who had been discharged from a hospital were rehospitalized within 30 days and 34% were rehospitalized within 90 days.”  The report went on to estimate that “the cost to Medicare of unplanned rehospitalizations in 2004 was $17.4 billion.

Another report from June 2008, published by the Medicare Payment Advisory Commission (MedPAC) estimated that “Medicare expenditures for preventable hospitalizations may be as high as $12 billion a year.”

Recognizing the number and potential for savings not to mention the improvement in the quality of life, President Obama’s healthcare proposals in 2009 have made the reduction of avoidable hospitalizations an important priority in healthcare reform.

It is beyond the scope of this discussion (thankfully) to consider the specific variables that lead to re-hospitalization.  They are complex.  Some rehospitalizations are planned and some are simply unavoidable.  Still others may on some level be avoidable but reflect people and situations that do not respond to proposed solutions.

Still, the evidence shows that systems can be developed to support patients in transition as well those receiving long-term outpatient care that can reduce avoidable hospitalizations and improve the quality of life.

According to a New York Times article from May 9, 2009, a program at Park Nicollet Health Services, a hospital and clinic system based in St. Louis Park, Minnesota, has shown considerable success.  Park Nicollet invested about $750,000 per year in nurses and software to track heart failure patients after they left the hospital.  “It reduced readmissions for such patients to only 1 in 25, down from nearly 1 in 6.”  It is estimated that the annual savings to Medicare through this program was about $5 million per year.

But the program was a big loser for Park Nicollet.  Not only did they incur $750,000 in unreimbursed cost, but their very success reduced their revenue for reimbursable services!  They simply could not afford to continue this successful program at the desired levels.

If Park Nicollet is representative of the cost/benefit relationship applied to the total potential savings from reducing avoidable hospitalizations, it would mean that an annual investment of less than $2 billion in outpatient follow-up could result in a net savings over $10 billion per year.  As Senator Everett Dirksen used to say, “A billion here and a billion there and pretty soon you’re talking real money.”  While we have suffered some degree of inflation since Senator Dirksen’s famous quote, I think he’d say it certainly applies in this instance.

So where’s the problem?  It is obvious.  Doctors and hospitals are paid for services rendered, not for services avoided.  As Dr. Barry M. Straube, the chief medical officer for Medicare is quoted in the NY Times article, “Ultimately, we have a reimbursement system for health care that is not aligned all the time with providing high-quality care.  Unequivocally, there has to be payment reform.”

So, as we consider the long term objectives of healthcare reform, let’s start with a modest little piece of payment reform that has the potential to yield savings in the $10s of billions of dollars per year.  Let’s make funds available for nurse navigator and outreach programs that help patients in transition and in long term outpatient settings, and let’s use the Stimulus funds to optimize the tools and techniques that improve health while reducing avoidable costs.  (We’ll discuss these systems in more detail in our next post.)

So, as President Obama and the entire Congress travel down the long road of healthcare reform, I hope they’ll focus on the narrow opportunity right in front of us, and as the naysayers proclaim “You can’t get there from here,” I hope President Obama smiles as he responds with a quiet “Watch me.”

On July 22, the eHealth Initiative published a report titled “Migrating Toward Meaningful Use:  The State of Health Information Exchange, A Report Based on the Results of the eHealth Initiative’s 2009 Sixth Annual Survey of Health Information Exchange.”  Among the report’s key findings:

“For the first time in six years, initiatives identified ‘addressing privacy and confidentiality issues’ as the most pressing challenge they face, surpassing ‘developing a sustainable business model’.”

In one sense, that is tremendous news.  If HIEs are beginning to see their way to a sustainable business model such that it is not their top concern, it means that they are seeing a quantifiable benefit from HIEs against which they can favorably compare the cost.  Indeed, the report goes on to say that health information exchange can help reduce costs for a number of different stakeholders and that “hospitals and physician practices could see the greatest return on investment (ROI).”  Among the benefits reported are:

• Reduced staff time spent on handling lab and radiology results
• Reduced staff time spent on clerical administration and filing
• Decreased dollars spent on redundant tests
• Decreased cost of care for chronic care patients
• Reduced medication errors

That’s pretty compelling stuff, but what is equally striking is the lack of benefit associated with patient participation in or through the HIE.  Of the 193 organizations (150 respondents plus 43 HIEs that reported in 2008 and are still active but did not report in 2009), only 14 have patient portals with 3 more in the planning stage.  No wonder that operating efficiencies, risk reduction, customer/patient satisfaction or improved health through improved communication with patients did not factor into the benefits.  We predict that consumer access to personal health information through or in collaboration with HIEs will see a significant advance in the next year—assuming privacy and confidentiality objections can be overcome.

Which brings us back to the question of security and privacy.

We completely agree with the position take by Dr. Deborah Peel and the Patient Privacy Rights Foundation that “the potential benefits of electronic health systems cannot be realized unless Americans have confidence that ironclad privacy protections are in place for online health records, databases, and networks.”

However, the concerns and the solutions are not the same when comparing provider-centric health information technology with consumer-centric personal health records—at least not today.

When it comes to provider-side health information technology, including internal electronic medical record (EMR) systems and community wide health information exchanges (HIEs) the consumer has very little—if any at all—control over his or her personal health information.  The consumer must rely upon the protections of HIPAA as well as various state and federal regulations for privacy protection.

Personal Health Records, on the other hand, give the ultimate control over personal health information to the consumer.  You decide not only what information should be in your record, but whether there should be a personal health record at all!!  If it don’t exist, it ain’t at risk, and that is the ultimate assurance of privacy.

Fundamentally, each of us must have the right to decide whether the risk of disclosing personal health information is greater than the benefit.  For a significant number, unauthorized disclosure of personal health information outweighs the benefit of having access to critical information at the time and place of need.  But for most of us, availability of information is the higher priority.  In an emergency, I want people to know my mother has Alzheimer’s disease.  I want them to know this is not some critical emergent condition that needs immediate testing and treatment.  Rather, it is just another day in our struggle with this terrible condition.  Frankly, my concern over the confidentiality of her personal health information is not a factor.

Even within a family, a father (like me for instance who is never ever going to get sick or die) can choose not to enter any medical information at all, while capturing as much information as possible about my mother.  It is my choice. I have control over security and privacy.

Ultimately, we would all like to have both availability of personal health information and absolute confidence in our privacy, and we’d like that dual assurance to apply to all of our personal health information wherever it resides.  With that objective, on July 21, a federal advisory panel, the Privacy and Security Workgroup, presented 37 technical standards to the Health Information Technology Standards Committee including a recommendation that consent management tools be implemented by 2015.  Consent management tools refer to software and legal policies that allow consumers to control access to their personal health information.

According to an article in Federal Computer Week, the recommendation to delay the effective date for consent management standards compared to other security and privacy standards reflects the levels of maturity of existing standards.  According to Steven Findlay, the work group’s co-chair, “The standards do not currently exist to do the complexity of consent management that we would like to see.”

We completely agree.  In the meantime, we expect to see big advances in consent management at least with respect to personal health records.  As for consent management applied to provider-side health information technology, that feels like its somewhere over the rainbow, while we’re still stuck back in Kansas.

The other day, John and I were talking about the impact that the recent proposed criteria for Meaningful Use will have on the market for PHRs. Looking at these requirements, particularly the requirement that all health care providers allow patients access to Personal Health Records by 2013, and even allowing for some evolution before finalization, it’s impossible to reach a conclusion other than that some form of interoperable Personal Health Records is coming in the near future.

So John asked: “How effectively do you think untethered PHR systems like yours will compete with tethered PHR systems offered by EMR/EHR vendors?”

Although I didn’t fess up at the time, I was knocked a bit off kilter by John’s question because I thought my opinion on this was lifted straight from John’s own excellent post earlier in the year. After stumbling through the call, I did a quick search and sure enough—WJS. Here’s a link to John’s post titled “Siloed Tethered PHRs are a dead end.” http://chilmarkresearch.com/2009/03/26/siloed-tethered-phrs-are-a-dead-end/

I don’t think I can improve on John’s comments, but perhaps I can extend them a bit.

From a vendor’s perspective, there is no doubt that acquiring a tethered PHR as either a free-bee or at a modest cost from an existing EMR / EHR vendor is an easy decision for many providers. Indeed, for many patients, who see only one provider and who have relatively little need for close monitoring between the patient and the provider, these are probably sufficient.

However, for people and families living with chronic and severe medical conditions such as congestive heart failure, diabetes, cancer and other conditions, siloed, tethered PHR solutions simply don’t work.

The other day, I visited a large cardiology practice in a community that has a fairly well developed health information exchange. Doctors at the cardiology practice can see information from the primary care physicians’ group, and both can see information from the regional hospital, and vice versa.

I asked if they offer a PHR. They said “Oh yes, it’s really starting to see some traction. Our patients like it.” So I asked if their patients had access through their PHR to information in the other provider EMR systems, visibility that the doctors themselves have on behalf of the patient. They answered “Oh no. The patients can only see what we have. They have to go to each separate provider’s web site to see each separate set of information.”

So, if a patient has more than one chronic condition, say diabetes and congestive heart failure, he or she needs to have at least two separate tethered PHR accounts, and probably three to include the hospital, in order to paint a comprehensive picture that is comparable to what any one of those providers can see.

That is a failed model.

There is an interesting precedent from the financial services industry. About 10 years ago, we saw the emergence of online bill payment services like Bluegill and CheckFree (Checkfree acquired Bluegill). In the earliest days, you could only pay your bill online by going to the web site of the specific vendor. Paying your electric bill, your insurance and perhaps your telephone, required visits with separate user names and passwords at three different web sites. Over time, banks and other independent vendors offered a consolidated bill payment service.

From a market perspective, most people today use a consolidated bill payment service, often provided by their bank, but a fair percent still prefer to pay directly at the specific vendor’s site. It is really a question of convenience with no inherent value beyond that.

We expect to see a similar progression in PHRs where tethered phrs are analogous to the direct vendor payment sites, and untethered PHRs are analogous to the consolidated bill paying services—but with one HUGE difference: Other than the bank accounts from which the banks are paid, there is no relationship between one vendor and another that warrants consolidation. Paying for your phone bill has nothing to do with paying for your water bill. It’s just a matter of convenience and personal preference. On the other hand, your personal health information is itself one single, consolidated set of information. Every transaction or record with every provider could have an impact on every other provider and on your health profile as a whole. That makes a compelling case for an untethered PHR.

So, there’s pretty good evidence for how this could roll out. Initially, as traction develops, we will see success for both tethered and untethered PHR systems. However, as we see sophisticated PHR solutions emerge that are targeted at specific chronic medical conditions, where their success dictates communication between the patient and multiple providers, the requirement for untethered PHRs will be inescapable—at least for that part of the population dealing with chronic medical conditions—which is the whole point of the exercise in the first place.

So, when it comes to the question “to tether or not to tether?”, my answer is clear: WJS and then some.