Category Archives: Open Source

Crossover Piquant: Check this out!

Piquant (pē-känt’) adj.

  1. Appealingly provocative
  2. Charming, interesting, or attractive

One of the great promises of technology is to make things simpler, easier, and more affordable for end users. In the medical practice, we have so much complexity, difficulty, and cost in most of our processes that when we find something that actually works as advertised we fall in love.

I had one such “appealingly provocative” experience this weekend. While attending a high school football game in support of one of my member patients (leading passer in Orange County by the way!), the player was injured. I initially thought it was a concussive injury but the reason he remained down was the he knew he had severely rolled his ankle. His father called me from the field (I was in the stands) and I followed along by text messaging as he was treated initially by the trainer and later by the team orthopedic surgeon. He was unable to continue playing due to the injury and it was iced and wrapped overnight.

The next morning I met him at our clinic, fired up our new TRX GP-5 machine (all digital x-ray machine), and took some beautiful images. These were captured on our PC based OmniView rendering software (proprietary and expensive) and fed to our OsiriX viewing software (open source and free!). I was able to manipulate the image at will, contrast and enlarge as needed to highlight all the structures, and automatically send the image to a remote radiologist for reading. No films to carry, no chemicals to purchase, and no storage required – ever. Simple, Efficient, and Affordable.

But I was just warming up.

The process we are using at Crossover Health to acquire an x-ray image to the iPad

The piquant was my ability to wirelessly transmit the image from my MacBook (serving as a server) to the iPad. This process is made possible by the fact that I have can move the standards based DICOM image from a PC to a MAC (using OsiriX), and then push it out to my iPad. While I thoroughly enjoy technology, I often get frustrated because I lack the technical expertise and patients to work out all the kinks. I was pleased to see that I was able to point and direct all the connections where they needed to go and the images appeared neatly onto my iPad without any problems.

From the patient experience, all they knew was that the image was shot, its being read by a board certified radiologist, and they are seeing, touching, and experience the iPad as a new device in our patient-physician relationship.  The patient was intrigued, impressed, and engaged (entertained?) by the whole process. I dare say it was a “fun” visit (why does the typical health care experience have to be so lame anyway?) for them to participate in this process, see their physician pushing the technology barriers, and engaging in the diagnostic process in a way they never have before.

The piquant experience certainly piqued the interest of their family who had the family.


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Filed under Design, Health 2.0, Innovation, Open Source, Uncategorized, Value

Open Letter to Athena: Open Up the Afterburners!

Afterburner (af·tər′bər·nər) n.

  1. A device for augmenting the thrust of a jet engine by burning additional fuel in the uncombined oxygen in the gases from the turbine
  2. The augmentation of thrust obtained by afterburning may be well over 40% of the normal thrust and at supersonic flight can exceed 100% of normal thrust

athenahealth is one of my favorite companies anywhere. I believe they have a great vision, a highly capable team, an incredible business model, and an unprecedented business opportunity before them. However, for all the amor, I have been disappointed that even with all their blistering success (Bam, Bam, and Kabam!) they have captured less than 2% of the target market since the IPO. I am not just disappointed for them but for the entire ambulatory care space which doesn’t seem to readily get the value of the collective intelligence inherent in the network.

In November 2007, I attended a technology conference with Jonathon Bush in the LA area. Jonathon was in rare form that day (probably trying to get psyched for his WFC battle with Allscripts CEO Glen Tullman which never materialized – Glenn was a no show) and I challenged him to get serious about getting his software in the hands of as many physicians as possible. We had an animated 45 minute banter on how this could actually happen. He asked me to write up the proposal I drafted on the back of a napkins that were doubling as our ad hoc whiteboard.  I think he briefly considered it, but the business focus and the upcoming IPO made it just a passing interest. Now, nearly two years later, I still think what I wrote is highly relevant and could be highly very useful in helping athenahealth rapidly expand their current book of business.

My pitch to athenahealth, then as now, is to turn on the AFTERBURNERS by opening up the platform:

November 6, 2007

Provocative Quotes

Business Case

AthenaHealth is the hottest health care information technology on the planet as I write this. The recent oversubscribed IPO has been sequentially followed by exceptional national press coverage, impressive recent customer wins, and an ongoing run up in the stock price.

This unprecedented public launch is another confirmation of Athena’s compelling business model. Athena provides back office automation software that leverages a proprietary claims database and workflow engine that dramatically reduces the inefficiencies of medical practice finances. As a result of this technology, Athena has been able to provide medical practices with real-time information on claims, cash flow, and financial optimization. By focusing on the revenue cycle management service, Athena knows first hand how relevant clinical information is the creation and management of financial information. In order to more effectively capture that information, Athena recently launched AthenaClinicals, their web based EMR which complements their web-based AthenaCollector software.

Because Athena’s business model is based on revenue cycle management, and the clinical software is a means to acquire better financial data, Athena does not have to charge money for the software itself and choose to sell it as a service. In fact, since the revenue model at AthenaHealth makes money off the increased collections, Athena is willing to go at risk on implementations.

This representats one of the new school business models and an evolution of the Software Value Chain evolution. Furthermore, due to its architecture of participation, each new practice becomes a contributing member of the Athena Network. This Network effectively creates a natural “collective intelligence” and collective experience around best practices, insurance rules, and financial optimization. 

Because Athena was conceived as a “Software as a Service” company and because the revenue model does not involve software licenses, the value of AthenaClinicals does not reside in the features/functions, but in its ability to gather bits and bytes. The greater the ability to gather bits and bytes, the greater the ability or opportunity to generate revenue streams. It therefore stands to reason that the more broadly your bits and bytes gathering ability is distributed, the more opportunity you will have to generate revenue. Why not have as many doctors as possible using AthenaClinicals by making if freely available for their use?

This decision would allow you to reap the whirlwind of innovation, while still protecting all your proprietary knowledge and intellectual property within Athena Collector and Athena Enterprise applications. Access to the Network would continue to be on a subscription basis but you would open up development and collaboration opportunities which you have not previously contemplated. The Athenista’s will be celebrated as hero’s, an appreciative community would form and become a veritable “army of messengers”, and I believe you would continue to force disruptive change within the industry.  Based on your successful business and your successful brand, I believe that you could accelerate the creation of a public good that you have previously discussed by engaging a worldwide public of developers, users, and potential customers.

Specific and tangible additional benefits would include:

  • Get the benefit of solidify your message that “Software is Dead” and the “Network is Nirvana”
  • Get the benefit of a huge branding and buzz opportunity
  • Get the benefit of expanding the number of potential developers of the software
  • Get the benefit of expanding the number of potential users of the software (decrease adoption impedance)
  • Get the benefit of having a larger installed user base to upsell your professional version and access to AthenaNetwork
  • Get the benefit of collaboration from partners, players, and payers that you have currently not contemplated
  • Get the benefit of co-announcing and co-branding with Red Hat and/or Ubuntu to leverage up on the ongoing buzz associated with Linux
  • Get the benefit of creating a community, neigh an entire nation of Athenista’s, who plug into the network effect which you have amplified.

I have struggled to find a compelling reason not to do it. Most companies struggle with the decision due to their business model reliance on software licensing. Not your problem. Others struggle because they are so conservative or do not want to disrupt current partners. Not your problem. Still others don’t make this decision because they do not have the corporate resolve or insight to see where the market is going. Not your problem.

Again, I realize this will have the flavor of a religious conversation, but I believe in there is a valid business proposition in this proposal. I honestly believe you guys can accelerate your current trajectory – opening up the afterburners by opening up your software.


Filed under Innovation, Open Source, Value

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

Ten Fold (10X): Is There Really an Order of Magnitude Difference?

Magnitude  (măg’nĭ-tūd) n.

  1. Greatness in size and extent.
  2. Greatness in significance or influence.

Two recent news items caught my attention. They follow on the heels of some of my recent writings on VistA EHR, MUMPS based systems, and the idea of virtuous cycle investments as a true stimulus in helping to lay down the health care foundation from which a National Health Information Infrastructure can truly be built.The article highlights the approach of the Have’s and the Have Not’s in dealing with transportation on the health care information technology highway:

The Mercedes

The first article is a  Go Live Announcement from West Virginia University announcing the completion of their  $90M Epic Systems Implementation (Fact Sheet).

The 2009 S600 Sedan, price $150,000

The 2009 S600 Sedan, price $150,000

The Toyota

A second article highlights the successfully implementation of life saving Bar Code Medication Administration from the West Virginia Department of Health and its seven facilities (BCMA was final segment of a comprehensive, statewide implementation of the VistA EHR for approximately $9M).

2009 Toyota Corolla, price $15,000

2009 Toyota Corolla, price $15,000

If you are trying to arrive at the same location (Stage 6), which car should you drive to get there? Well, I guess it depends on who you are. But question for the Mercedes driver, or more appropriately the people paying for you to drive the Mercedes:  is your ride really worth the 10X order of magnitude difference? Are those bells and whistle really that valuable? To the four wheels, the transportationPerhaps, but only if you can “afford” it.

But these economic times demand a little more introspection. Certainly within the health care IT world you have to ask yourself can you “really afford” it?  What could you have done with the other $81M dollars? What if you would have spent the $9M to get to the same place, and then use the balance to whack out your Toyota (Supra Size me!) and have a whole lot left over to increase access, reduce costs, and improve quality. Would it be a better decision to divert additional funds to true health delivery – additional vaccines, additional prevention screening, etc?

The Famous "Fast And Furious" Supra

The Famous "Fast And Furious" Supra

Furthermore, what if I told you your spending to improve your Supra would directly benefit others who could learn directly from you. What if every dollar you spent improving your Supra was somehow magically matched (ie, via open source collaboration) to benefit others. What if your investment somehow made it possible for more and more people to actually have a car to go to the same place as you? (OK . . . so my analogy is getting stretch a little thin, but you get my point).

I would challenge anyone at WVU (love to hear from their board, their leadership, their clinicians, etc), particularly if that organization takes public money, to justify their spend when there is a viable alternative that could be selected particular when that selection could be made better and the enhancements made available to others in the future. An “investment” in VistA is an example of the catalytic Virtuous Cycle Investment that I discussed previously.

You can make the argument to justify the extra spend, but you can’t and won’t win it, particularly when the differential fare of 10X gets you to exactly the same place.

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Filed under EHR, Open Source, Quality, Rational Choice, Uncategorized, Value, VistA

$50M Men Win 2008 Linux Medical News Freedom Award

Revolution (rĕvə-lū’shən) n.

  1. The overthrow of one government and its replacement with another.
  2. A sudden or momentous change in a situation

I am deeply honored and profoundly grateful to be recognized, along with my brother Steve Shreeve, as the 2008 winner of the Linux Medical News Freedom Award. While this is a niche award in a niche space, it is highly symbolic in recognizing individuals who are “crying in the wilderness” regarding the promise and potential of open source within health care.

The award comes with the bitter irony of course, in the history and historicity of the events which have led to it being awarded. On the positive side, Medsphere was born as a revolutionary force within the Health Care information technology world. The company was founded on the premise that open source could have a similar impact within health care as it has had in other major industries of lower costs, improving quality, and delivering more value. The open source approach has a particular kinship with health care, as the notions of price sensitivity, peer review, open collaboration, and transparency are desirable attributes. I have discussed this at length before in many forums, and I see that Medsphere is still using our same slides to describe this connection.

The timing of the company being created in 2002 could not have been better in terms of bringing VistA to the forefront.  Vista had been implemented for 3-4 years within the VA by this time and the resulting impact was just beginning to get published in reputable journals, peer reviewed articles, and in the popular press. The Best Care Anywhere, and similar articles became commonplace and national calls were made to implement VistA as the foundation and backbone of a national IT infrastructure. I see that this still causes groups like HIMSS to have severe indigestion, calling foul on leveraging an investment that we have already made.

We were fortunate to be able to close our first few watershed deals in 2004 with the Oklahoma Department of Veterans Affairs and then our first commercial break in 2005 with Midland Memorial Hospital. I will be forever grateful to the wonderful team that we were able to recruit to the cause, who believed in what we were doing as much as we did, and worked as hard as we did to make it reality. These were people who had worked at the VA for decades, knew the system inside and out, and were beyond thrilled to see their skills be able to be plied in new settings for the benefit of the patients. I wouldn’t begin to try to name names, but we forged some deep friendships in the backwaters of Oklahoma in places like Talahina, Norman, Lawton, Sulphur, Ardmore, and Claremore. We also witnessed true collaboration, tireless effort, and a incredible flexibility by this team to go against all odds to get it done. We ended up putting first time systems in place in less than 70 days, complete with training, pharmacy setups, registration of entire facility, and order sets as well. It was an amazing time.

Midland was an entirely different experience. We were going up against Cerner, Mckesson, Meditech, and the other big boys. David Whiles was absolutely amazing, an early convert and believer in the possibilities to save more than $13M dollars leveraging a proven system. Being the first commercial adopter of VistA was not lost on him, both from a risk and reward perspective. We spent nearly a year visiting the hospital, given demos (17 major ones in a single trip), and then casting (prostrating?) ourselves before the selection committee time and time again. I give credit to their team, particular their lab manager, who sacrificed some functionality for the overall benefit to the entire organization. Ultimately, CEO Russell Meyers made the call and put his faith and trust in our little outfit to pull this off.

By now, we were growing fast, having to add team members and increased capacity to deliver multiple implementations simultaneously. We were also bumping up against the natural constraints of growth, striving to maintain culture, and rushing to build the systems that could support the rapid growth and nuances of how we worked. During this time, our annual conferences began to really become a meaningful and symbolic gathering time for the organization. We had some pretty cool concepts that we rolled out in these meetings – new programs, new software, surfboard awards, great luau parties on the beach, and general excitement of everyone who was participating in something big.

One memorable year, I spoke about the stages of revolution. We had always talked about Medsphere in revolutionary tones, and the phrase “Viva La Revolucion!” was emboldened in not only the t-shirts we passed out but in our entire approach to business. We believed wholeheartedly that how we were going to impact the entire industry was manifest destiny. Revolutions pass in stages, and I took our group through these stages in detail and merged them with our little corporate reality. We cast the big boys (Cerner, Mckession, Allscripts, etc) as the big, blundering ruling class who were not providing for the needs of people. We helped prepare the team for the 5 stages of death by this ruling class (first denial, second anger, third bargaining, etc) and the turmoil that we would cause.

We did not realize at the time that we were also foreshadowing some of the internal conflict we would experience as our growth catapulted us into the crisis (stage III). While actual deployments were humming along successfully, the revolution turned internal with secret policing, foreign threats, suppression of pleasure, and class struggle. Ultimately, as is common with many revolutions, the revolutionary forces were “extinguished” to pave way for a new regime.

Unfortunately, the extinguishing did not happen in the prescribed way, but rather in an otherworldly fashion. We were publicly accused of releasing source code that was always intended to be released, harboring secret organizations that were written in board approved business plans, and seeking to destroy the company we founded by our alleged actions in a $50M in terrorem lawsuit. The irony of course is that the company subsequently released the source code in question, publicly launched the “secret organization” in grand fashion, and followed the original strategy to much community fanfare. All I can say is that I am grateful to see our vision being made reality by others and wish them the very best to bring open source health care to the masses.

Revolutions are ultimately about redemption and change, so perhaps these recent positives can begin to remove the tragedies of the past. More personally, perhaps this award and the attendant recognition for these efforts, provides some meaningful closure to a difficult transition. Regardless, I still believe (and live on to innovate another day).

Viva La Revolucion!


Filed under Irony, Leadership, Open Source, Transparency

Speaking Circuit: Coming to a Conference Near You

Circuit (sûr’kĭt) n.

  1. A path or route the complete traversal of which without local change of direction requires returning to the starting point.
  2. An association of theaters in which plays, acts, or films move from theater to theater for presentation.
  3. A group of nightclubs, show halls, or resorts at which entertainers appear in turn.

We are now entering into the fall conference season. I have been fortunate to have been invited to speak at several upcoming conferences which can be found in the Whats Up? section of my blog as well. A couple of highlights . . .

    Health 2.0 – User Generated Content

    • Will be moderating Business Model Panel
    • Will be moderating the Health and Wealth Panel

    Open Source Health Care Track (simultaneously with World Healthcare Innovation & Technology Congress (WHIT v.4.0)

    • Will be moderating Convergence of Open Source and Health ( Health/OS ) Panel
    • Will also be speaking about how innovations in the patient physician relationship are driving health care delivery changes.

    I look forward to the two panels I will be moderating at Health 2.0. The first one will be an important discussion regarding the Business Models of Health 2.0. This remains the number one legitimate ongoing concern and criticism for the fledgling movement. Can we take these technologies and create disruptive, yet sustainable, companies that will catalyze meaningful change within the health care industry. The intent of the session will be to review real business models, get real investors who placed bets on health 2.0 companies, and other industry pundits with deep start up experience to hash through the legitimate and the ill conceived.

    My other session will deal with the companies and new technologies out there to help people manage their health care finances. We will have some companies who were previously featured and a few new ones who are really innovating at the convergence of health and wealth. Transparency is the name of this game, and these companies are helping people play at an entirely new level (who is going to be the of health care?). Looking forward to seeing how far the envelop is going to be pushed.

    I will also be attending the World Healthcare Innovation & Technology Congress (WHIT v.4.0) to both moderate a panel on the convergence of Health Care and Open Source (Health/OS). This should be very interesting as immediately following my presentation Medsphere CEO Mike Doyle will speak on the Health/OS ecosystem (or the unfortunate lack thereof in my opinion). I have already spoken about the assigned topic at both the Scale 5 and Scale 6, but now I will be moderating a panel of individuals who are actually innovating across the continuum of care (clinic, hospital, IDN, and RHIO) and geographies (local, regional, and national). I note there is quite a lineup shaping around this Health/OS track and it should be pretty interesting.

    Finally, at this same conference, I will be sharing some updates on the well received concept of how the Millennial Patient is driving innovation in the health care delivery space. This is actually a very timely presentation, in that I hope to be able to introduce a surprise or two, as well as showcase some real case studies of how the patient physician partnership can drive incredible value for everybody in the health care value chain.

    Ping me if you are able to attend either of these events or have some thoughts/ideas that could be incorporated.

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    Filed under Conferences, Health 2.0, Healthcare, Innovation, Open Source, Transparency, Value

    Perot on the Prowl: Observations on Press Release Arithmetic

    Prowl (proul) v.

    1. To roam stealthily, with predatory intent, as in search of prey or plunder
    2. Actively looking for somethin

    HISTalk just recorded its 1.5 millionth hit. Besides the snarky commentary, HISTalk (and the lovely new addition of HERTalk) has continued to gain readership with its dead pan commentary that is always dead-on. As the readership has grown, the quality of the tips and the accuracy of the insight has also increased. I believe nearly everyone with a need to know turns to HISTalk when they need to know.

    I use HISTalk to confirm suspicions, verify trends, and dial up my own prognostication engine. I have been doing some “rumor math” and I have an interesting 1+ 1 that I put together. Check out out the following headlines and see if you can follow my arithmetic:

    + Medsphere Moves Offices, sends Press Release
    + Perot wins Jordan VistA deal
    + Medsphere takes on the DoD’s VistA replacement strategy (Even though the DoD does not use VistA).
    + Perot will buy someone (see below)

    = Perot to Buy Medsphere

    With press releases like the above (which scored 21 out of 100 for relevancy), it appears that Medsphere is positioning itself to be sold. Also, while Perot has done some VistA related work, they have no practical VistA deployment experience in a clinical environment. I wish them the best in a high profile, non-English, international, 10 time zones and 7,000 miles away, and entirely different health care system environment. Seems Perot would benefit from some project assurance. Furthermore, a Medsphere acquisition could help catalyze Perot’s new stated focus on smaller delivery networks and community-based hospitals.

    Adding it all up, perhaps Perot should pounce on the opportunity.

    * I have no financial stake whatsover in any of the companies mentioned, am reporting on publicly available information, and my opinions are not intended nor could reasonably be construed to disparage or be derogatory in anyway. Highlights in the referenced press release below are mine.

    – –

    Perot eyes healthcare acquisition to drive growth

    Fri Aug 15, 2008 1:31pm EDT

    By Bijoy Anandoth Koyitty

    BANGALORE (Reuters) – Information technology services company Perot Systems Corp (PER) plans to make an acquisition for its healthcare segment, which accounts for about half its revenue, as large contracts get difficult to come by in a slowing U.S. economy. An acquisition in the healthcare space from anywhere in the world is one of the areas that Perot is concentrating on,” Chief Executive Peter Altabef told Reuters in an interview. However, he did not reveal if Perot identified a potential target or how much money it would spend on such a deal.

    . . .

    The company, which was founded by former U.S. presidential candidate Ross Perot, is also shifting its focus from large contracts, which are drying up amidst the slowdown, to mid-sized players in the healthcare segment. “Clients such as community hospitals (Medsphere’s target market) and government healthcare (Perot has a whole VistA division), who had not spent much earlier, are playing catch-up for competitive purposes, and Perot is now using this opportunity,” Altabef, who has been with the company for about 15 years, said.

    According to Bernstein Research analyst Rod Bourgeois, Perot is gaining traction in healthcare opportunities in specific Middle East countries, Europe, government healthcare and community hospitals. CEO Altabef said Perot is also focusing on strengthening its position in markets like the Middle East, Europe, China and Latin America to boost revenue. “Perot has been grappling with a dearth of large-sized sales deals in the provider space of healthcare, but its backup strategy of exploring smaller players in the sub-segment has now started bearing fruits,” Altabef said.

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    Filed under Healthcare, Open Source, Quality