December 17, 2007

1. NAHIT Calls for a Voluntary Patient Identifier

Facts and Background

Healthcare technology advocacy group National Alliance for Health Information Technology called Wednesday for the creation of a voluntary unique patient identifier system for electronic health information.

Opinion

Despite the entirely real need to manage patient information more effectively, this political hot potato will go nowhere. Fallout was extensive even under a benign Democratic administration in which most Americans had little fear of Big Brother. In an election year under an administration with a reputation for privacy indifference, politicians will steer a wide berth around what sounds like a purely technical problem that isn't worth losing votes over. In addition, NAHIT claims the need is due to interoperability requirements, which are minimal considering that few organizations are interoperating anyway.

Musings

• NAHIT says current probabilistic matching techniques work 90% of the time, which isn't accurate enough for interoperability.
• This should tie nicely into the growing movement toward health record trusts since individuals would control their information in both cases.
• Several vendors sell profitable systems to perform records matching. They would obviously be hurt by an easily implemented unique number system.
• You don't want to be the spokesperson who has to face the lay public with a "government-issued ID" proposal after widespread stories about stolen laptops, hacked credit cards, and government privacy intrusions.

2. RHIOs Failing Miserably, Survey Says

Facts and Background

A Harvard study of 145 RHIOs shows that a fourth are defunct and only 15 are actively and broadly exchanging clinical information. The study estimates the chances of collective RHIO survival "tenuous at best."

Opinion

While everybody already knew that RHIOs were in deep trouble, some optimists may have held out hope that a significant number were actively doing the job and would figure out a way to keep doing so. Well, they aren't, and the study proves it. Turf and business issues have strangled them, at least quickly and mercifully.

Musings

• At least those 15 RHIOs that claim to be exchanging information are alive so far, although a follow-up study on their financial support would be interesting. Their survical isn't interdependent, but funding issues may persist.
• So this was to be the training wheels and building block for a Nationwide Health Information Network? At least Uncle Sam has shown a willingness to spend inordinate amounts on high-priced government contractors, so maybe even this high-profile bust can eventually be revived for a Round III with enough cash and muscle.
• Let's hope hospitals didn't spend much money and effort on RHIOs (they probably didn't, which must have influenced the pitiful results). How many rah-rah, expensive, and failed projects can hospitals absorb? CPOE, RHIOs, and now massive clinical system rollouts ... all with minimal influence on patient care or healthcare cost. It's beginning to look like localized, niche automation may be the only way that IT drives ROI. The bigger the project, the harder they fall.
• The talk was more grandiose than with CHINs in the 90s, but history will show the lasting results to be just about the same.
• HIMSS, which couldn't blow hot air hard enough on the dying RHIO embers trying to fan them to life, seems to have backed quietly away from the whole mess in embarrassment. Its website entries are all outdated or with invalid links, the regional forums seem to have disappeared, and the news isn't all that new. That probably means it's time to orchestrate the Inevitable Next Big Thing that keeps people joining, sponsoring, and exhibiting.

3. Simple Checklists Improve Care, Expert Says

Facts and Background

A Monday article in The New Yorker magazine describes the work of Peter Pronovost, MD PhD of Johns Hopkins University and Health System. His recommendation to create simple checklists for performing critical hospital functions resulted in major quality improvements. A profile on NPR's All Things Considered credits his techniques with saving 1,500 lives in 18 months in Michigan, along with $100 million.

Opinion

Pure genius. Certainly previous work showed some chance for improvement (standard care plans, reminder systems, predefined order sets, etc.) but this puts it directly in a puzzled public's eye that makes it hard for stubbornly independent caregivers to cling to seat-of-the-pants care practices that carry unacceptable risk from preventable mental slips and poor communication.

Musings

• Pronovost is motivated to improve patient safety. His father died from a hospital's medical error while he was in medical school.
• The lengthy article describing Pronovost's ideas appeared in The New Yorker. Recent examples suggest that such consumer exposure drives quicker results than a dry study printed in a medical journal years after the actual work was performed. Hospitals will change only when patients demand it.
• The exact same checklist practice created today's airline industry. Fiercely independent pilots resisted conformity and oversignt, resulting in regular aircraft crashes, deaths, and expense. Now, the idea of the pre-flight checklist is ingrained into every aspect of aviation, with the resulting high safety levels.
• Anesthesiologists commendably undertook a similar best practices self-evaluation years ago, greatly reducing surgical risk.
• This should be good news for IT. Caregivers resist its use, too, but often because their processes are so disjointed and inconsistent that a package of business rules is seen as inflexible. The lists Pronovost advocates, along with the documentation and communication of them, begs the use of IT to impose order.
• Why is it that cheap Asian tennis shoes are produced in an an ISO-certified factory, but healthcare is overseen only by the industry-friendly and minimally prescriptive Joint Commission? IT folks know a lot more about reproducible process, change management, and process analysis than most hospital executives. If simply following a list can have such a dramatic effect, hospitals and doctors must be screwing up royally.

4. NextGen Enters Physician Revenue Management Business

Facts and Background

Physician systems vendor NextGen Healthcare announced Tuesday that it has formed NextGen Practice Solutions, which will help physician practices with revenue cycle management via Web-delivered software services.

Opinion

Even state school MBAs understand that highly successful companies will encourage new entrants that will compete for their market share. Surely athenahealth's mind-boggling IPO has not gone unnoticed by all those physician system vendors with deep domain and IT expertise. athenahealth tries to develop a more functional EMR system while vendors who already have that will attempt to replicate athenehealth's success in getting physicians paid.

Musings

• The limit to this kind of offering is the number of NextGen EMR customers. NextGen is big, but it has a much smaller potential customer base than EMR-agnostic athenahealth.
• athenahealth showed that medical practices need financial help, especially those small ones with minimal practice management expertise.
• This is one area where the big EMR vendors can gain ground over their rapidly growing, smaller competitors that stick to selling lower-priced software. Don't underestimate the power of the physician office footprint.

5. MedAssets Shares Break Out at IPO

Facts and Background

Shares of MedAssets, already priced at the top of the $14-16 pre-IPO range for its Wednesday IPO that raised over $200 million, jumped to $22.25 by Friday's close. The Alpharetta, GA company offers a variety of revenue cycle, decision support, supply chain, and consulting services.

Opinion

athenahealth II. Wall Street obviously loves services businesses that improve the bottom line of hospitals and physicians. MedAssets sells some software products, but this lends credence to Jonathan Bush's assertion that selling software is a dead business - the future is selling results that may happen to involve software.

Musings

• MedAssets was already acquisitive even without a flush of shareholder cash, recently buying group purchasing organizations, denials management vendors, and financial decision support applications vendors. Expect more of the same since they have the cash and need the growth.
• The company's market cap exceeds $1 billion, with annual revenue of $160 million and net income of $10 million.
• Traditional healthcare IT is relatively dead money compared to these new hybrid vendors who emphasize service and get paid only when their customers benefit.

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