Category Archives: Change Agents

Crossover Health: Welcome to Next Generation Health Care!

Crossover Health Launches New Model of Primary Care in South Orange County
Innovative membership service delivers Urgent, Primary, and Online Care

Aliso Viejo, CA (PRWEB) October 1, 2010

Crossover Health Medical Group announced today the launch of their flagship membership-based, primary care practice in Aliso Viejo, California. The new clinic will offer urgent, primary, and online care services directly to individual members, families, and employer groups. Membership based health care is a new health care finance and delivery innovation that has gained widespread popularity as the cost of health insurance and ongoing service deficiencies have plagued the current health care delivery system. The Crossover membership model decouples health care from health insurance, and allows individuals and organizations to purchase primary care directly from health care providers who offer increased access, enhanced services, and an exceptional service experience.

“The membership-based practice model allows Crossover Health to fundamentally change the way health care is practiced, delivered, and experienced,” according to Chief Executive Officer Scott Shreeve, MD. “Crossover has been specifically designed to restore and enhance the patient-physician relationship, increase access and convenience, reduce the cost of health care, and deliver an unprecedented patient experience.” The membership fee pays for access to the technology enabled practice and wellness services, as well as affordable prices for office visits, specialty consultations, and ongoing health management followups. A health concierge is assigned to each member to assist in overseeing follow-ups, proactive health maintenance, and care coordination. Crossover also provides health advisory services to guide patients in financial decisions related to the management of their health.

Crossover Health introduces two key innovations to the membership model. First, Crossover members have direct access to their physician via Crossover’s unique online, anytime, from anywhere technology platform that includes options for email, text, and video chat consultations. Second, the technology also enables a direct financial, administrative, and clinical relationship between the patient and their personal physician and the extended Crossover care team of medical specialists, diagnostic testing centers, and other licensed professionals. This inherent connectivity enables the creation of the Crossover Health Network™, a network of specialist providers who commit to deliver to a specific service level, make their prices transparent to members, and communicate on a common platform. The result is a simple, efficient, and affordable care experience.

“Many people, including employers, are surprised to find out how affordable exceptional health care can be when purchased directly from the physician,” said Chief Medical Officer Richard Patragnoni, MD. “Members can typically save a significant amount of money while enjoying a broader range and higher quality of personalized service to meet individual, family, or corporate health needs.” Crossover offers a variety of individual and corporate memberships that provide essential primary and preventive care services as well as targeted wellness programs like medical weight loss, executive health programs, health portfolio management, and virtual clinics.

Crossover Health memberships appeal to individuals looking to establish a personal relationship with a physician, families whose care requires a higher service level, and busy professionals who need flexible access to their physician. Membership care is particularly attractive to employers facing annual double digit health care cost increases. Employers using this model have consistently shown significant reduction in inappropriate utilization, dramatic improvements in satisfaction, and cost savings of up to 50% when bundled with lower premium insurance plans. Crossover Health is currently accepting new members throughout the Orange County area.



Filed under Change Agents, Crossover, Design, Direct Practice, Entrepreneurship, Innovation, Launch, Medical Home, Membership, Primary Care, Quality, Value

Day 73 – Demolition Weekend

Demolition (dĕm’ə-lĭsh’ən) n.

  1. The act or process of wrecking or destroying, especially destruction by explosives.
  2. Explosives, especially when designed or used as weapons.

We are having a blast on our march toward revolutionizing the way that medicine is practiced, delivered, and experienced. In fact, we feel so strongly about it that we are literally busting down walls, bashing in doors, breaking windows, ripping up the carpet, smashing mirrors, and throwing away all the trash of our current health care system. And this is just the build out phase:

The above is a very cool timelapse video showing Large Construction leading a team of 35 volunteers, who donated more than 150 hours, over an intense two day period to completely demolish our current 4,000 square foot space. The video was shot by Benny Ek, of BennyEk Media fame, who happens to be a very talented close personal friend. He used a two Canon G11 cameras with a special wall mount shooting every two minutes. Even cooler – it sends the images wirelessly to a shared Flickr account. Cooler still is how Benny can splice these to produce a true timelapse experience.

The store is going to be epic! Can’t wait to share some renderings soon.

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Filed under Change Agents, Crossover, Launch, Uncategorized

Career Walkabout: Going On and Off the Grid

Walkabout (wôk’ə-bout’) n.

  1. A temporary return to traditional Aboriginal life, taken especially between periods of work or residence in modern society and usually involving a period of travel through the bush.
  2. A public stroll taken by an important person, such as a monarch, among a group of people for greeting and conversation.

I have been off the grid for the last several months heads down on a project which is the cumulative result of my last three year walkabout. Each of the experiences I had along the way provided a stepping stone and preparation for the path that I have recently embarked on.

After a couple of years of talking about health deliver reform (starting with Redefining Health Care), health care financing (Health Equity), health plan innovation (Lemhi Ventures), new practice models (Current Health), and health care reform (X PRIZE), I was left feeling like I was nibbling around the edges without having anything to sink my teeth into. The X Prize proved to be the catalyst, as I had to think about which side of a competition I wanted to be on (Administration vs. Competition). As a former collegiate athlete, there was never a question that I would choose to compete. As my contribution to that project wound down late in the fall, my decision was made – it was time to hang up the Blue Blazer and Khakis and put the stethoscope back on.

I used to think that I had moved on beyond being “just” a physician. I always respected and appreciated the work that went into becoming a doctor. But along my journey, I somehow lost the appreciation for what it means to be a physician – a trusted heath advisor, a healer, and someone who people turned to with confidence during some of the most difficult times in life. Perhaps the shift work in the ER, the patient population I dealt with on a daily basis, and certainly the shiny objects flashing on the always greener side of the fence were contributors to the reasons I chose to pursue other interests outside of the practice setting.

Ironically, those same interests have led me on a walkabout journey that has come full circle. When we founded Medsphere, the market was at a tipping point for implementing EHR’s. Those were the days we had to convince people that EHR’s were a good idea, that the VA was a benchmark for automation, and that open source was actually a viable development and business model. Our thought was always that the implementation of the EHR was the first step, that you absolutely needed to get an information gathering infrastructure in place in order to even consider improving health care delivery. We often talked about our second company, which would be a data analytics powerhouse that could create actionable work plans to turn the data into information and ultimately knowledge about health care performance. Health care delivery is where the action is, because that is where the monetary and resource allocation decisions are made. Its also where the rubber truly hits the road. I have since become convinced that no matter how fast your rev your RPM’s (health care hype), it is in the friction, heat, grime, and gristle of contact (physicians “touching” patients) that true progress can be made.

Its also where we need the most help with innovation.

Health care delivery is woefully behind most other professional service industries in nearly every measurable criteria. Our customer service is atrocious, our efficiency metrics don’t even register, and we certainly can’t provide very good guidance to our patients when we practice in a data free environment. Beyond just being a typically conservative industry, our cottage nature is confounding and for a profession that highly leverages the peer review process in sharing knowledge, we take a parochial perspective when sharing best practices. As a result of these and many other factors, the way our profession is compensated has morphed in negative ways to the exclusion of some, the short term gain of others, and ultimately to the demise of all.

I think we can do better; I know we can do better; and I look forward to being a contributor to the required change. Given my cumulative experiences, I believe the way that I can have the most impact is in the actual “rubber meets the road” delivery of care. As a physician, it is my privilege to touch patients through practice delivery innovation that incorporates the best thinking, technology, and talent that can achieve the best outcomes. All that I have learned, experienced, and seen during the last several years is going to be leveraged in the creation and implementation of Crossover Health.

I look forward to having you join me for the journey.

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Filed under Change Agents, Crossover, Entrepreneurship, Innovation

CODE RED – How Proprietary HIT Vendors May Screw Up Health Reform

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.

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.


Filed under Change Agents, Open Source, VistA

Whats the new spelling for the AMA? S-E-R-M-O

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


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.


Filed under Change Agents, Consumerism, EHR

Primary Care Possibilities – Kaiser Leads the Way (again)

Leadership (lē’dər-shĭp’) n.

  1. The position or office of a leader
  2. Capacity or ability to lead
  3. Guidance; direction

I have written extensively about Kaiser Permanente in the recent past (here, here, and here) – not only for their notable achievements but even more impressive to me is their genuine interest to share their results with others as model for global health improvement. The recent issue of Health Affairs has two impressive articles from Kaiser regarding their EHR implementation as well as their Online Portal efforts. Great material.

As part of the same issue, Health Affairs newest contibutor Carleen Hawn highlighted the work of Ted Eytan in an article discussing the new social media delivery model. The article was a campy, highly conversational piece introducing some Millennial Vibe into what has always been the hushed tones of the highly academic/policy focused Health Affairs. Ted continues to do alot of interesting work, and in his role at Kaiser travels the country looking at new models of care delivery, new technologies, and the beautiful symphony that occurs when patients/physicians are working together in partnership to optimize health. A recent blog post of his highlights some of what he is seeing within Kaiser in terms of delivering more valuable primary care to patients. I thought it was worthy of re-posting large sections:

Because the innovation in primary care they are helping create involves all members of the care team, they created an experience for me that included shadowing physicians as well as nurses and clinical pharmacists. We should understand how every member of the team contributes, and this was great.

So what did I see?

  • Data systems and the workflow to support it are maturing to the point that primary care teams can understand how to keep patients healthy whether or not they actually come in for appointments. Teams are alerted about patients with chronic illness proactively, not reactively, more quickly than ever before. Medical and Nursing staff are responding to this new ability by creating new workflows and partnership around supporting patients, families, and populations.
  • Physicians are comfortable with the comprehensive electronic health record in practice: quote from an Ohio Permanente physician, “I don’t want the computer to get in the way (of the visit) but at the same time it’s a wonderful opportunity to share with the patient.”
  • Participation of a wider array of team members including nurses and clinical pharmacists, to leverage their skills, whether it’s coaching/teaching, medication management, all connected electronically (now).
  • Rethinking of the primary care practice altogether – including the idea that primary care physicians may see higher acuity patients as population management is spread across more staff, that they will use non-traditional communication methods including secure e-mail and telephone as part of what they do, and that managing a panel is work integrated into the day.
  • My favorite After Visit Summary workflow – every member whose care I observed got one – physicians and nurses work together to create and go over information with patients, it is not just a task of one or the other. They use the electronic health record to signal each other consistently for the handoff, which happens reliably. This helps accuracy and efficiency for the member and the system.

I think this work is not only useful for Kaiser Permanente, but for all of health care, because Kaiser Permanente’s financing model allows for this type of innovation, and sharing of such.

At the same time, there are major challenges here. The primary care provider shortage has affected Kaiser Permanente as much as the rest of health care. The good news is that this shortage is driving many of the innovations above, which I actually think will be portable to all of health care.

Wow. High performing health systems do more with less, do less for each patient (because the patients do more themselves), and involve a team approach given their aligned incentives all focused around a patient centered experience. I also love that they are willing and wanting to share their experience, to help others see the possibilities, and working together to improve our health as a nation. Isn’t that the essence of leadership?

Bravo, KP!


Filed under Change Agents, Innovation, Leadership, Medical Home, Quality

Health Care Moonshot: The Health Care X PRIZE Development Project

Moonshot (mūn shŏt) n.

  1. Description of the audacious attempt and the subsequent race to place a man on the moon
  2. Used as an analogy to describe similarly gigantic challenges under competitive influence

The best health care book I have ever read, is ironically the first one I was fortunate to pick up. “Redefining Health: Creating Value Based Competition on Results” literally became a life altering experience for me as I read it at a time when I was seeking to redefine my career path. The notions of health care value (outcomes/price), the organizational principles engendered by this approach (focus on the medical condition across the full cycle of care), the competitive forces that this framework unleashes (virtuous cycles of innovation), and the overall promise for improving our deliver system (increased access, lower costs, and high quality) absolutely resonated with me and framed where I wanted to take my professional career.

After reading the book, I immediately set about to capture the key concepts and ideas visually, and to weave the story of value based health care. This effort launched me into the emerging Health 2.0 movement, and illuminated for me a clear path to move toward next generation health care (this is why I always argue for an expanded definition). As the tools and technologies of Health 2.0 began to be introduced into the health care conversation, I also observed that a more systematic approach was being taken to quality, cost containment, health care disparities, payment reform ideas, and the design of a high performance, connected health systems with built in pricing, incentive, and quality transparency.

Subsequent consulting projects in management of health/wealth, direct to consumer laboratory services, new payment models, and ultimately new models of health care delivery, led me to create a new concept of care called “personal health advisory services”. These concepts are now being introduced to a small group of private clients, but more importantly, the notion of new types of health care organizations (Accountable Care Organizations) being created within the construct of a new type of health system (based on value and focused on health vitality as the metric that matters) are infinitely more promising. As part of these developments, I have become convinced that we aren’t going to get there incrementally, with modest improvements, with limited vision, or paralyzed by the “inevitability” of our current staggering national and health sector problems.

I have always dreamed big, and sought impossible challenges, and for this reason I am excited to announce my association with the X PRIZE Foundation as a Senior Health Advisor. This very discrete project (through June 2009) is solely focused on defining a Health Care X PRIZE that can leverage a well described competition as the catalyst for transformative change. Over the coming months, I will be meeting with corporate executives, policy experts, government officials, thought leaders, patient advocates, and others interested in engaging in this work to to define the “health care moonshot”.  The X PRIZE framework has specific competition constraints, a unique investment multiplier effect, and holds the promise of organizing many of the best and brightest reform efforts currently underway in our country. I look forward to working with Dr. Peter Diamandis and Robert Weiss on this very exciting project.

I will also look forward to speaking with many of you, sharing our findings and research as we proceed, and engaging the broad health community and ultimately our entire country to join in the inspirational effort to transform our health care system.  Please feel free to contact me directly with your interest, your X PRIZE ideas, or to discuss how you can help be a part of the “Health Care Moonshot”.

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Filed under Advisory Services, Change Agents, Entrepreneurship, Innovation