Neupert On Health : standards

Tear Down the Walls and Liberate the Data

pnblog — Sat, 04 Apr 2009 01:13:00 GMT

(cross-posted on Microsoft on the Issues)

In 1987, President Ronald Reagan gave one of his most well remembered speeches. Few of us could forget his words to Mikhail Gorbachev to “tear down this wall”—proving to be prophetic when the German Democratic Republic announced the re-opening of the border in 1989, and the subsequent destruction of the Berlin Wall. What followed? A new flow of people, ideas, commerce, and capital—creating the groundwork for unification and a better way of life in Germany and Eastern Europe, benefiting all of us economically and politically in unanticipated ways.

A similar type of disruptive change needs to happen in the health ecosystem today. Just as the free flow of ideas and capital were the foundation for dramatic improvements in society, so should the free flow of health data be the foundation for realizing a future of secure, personalized, data driven medicine in health.

Yet many outdated ideas and mechanisms stand in the way of change; the most important of which are the now impractical walls that were erected and still exist around patient-data. And all of us—IT vendors, providers, payers, pharmacy benefit managers, policy makers and others in the health ecosystem have enabled the walls to exist in spite of the obvious benefits to patient safety and the overall health economy.

Real-time, accessible, meaningful and comprehensive data is fundamental to health care as a whole–to make a diagnosis, provide quality care, pay the right bill, discover new therapies, and so on. What’s of paramount importance is liberating the data and making it available for re-use in different contexts. This is critical for improving outcomes, paying for value, creating a learning healthcare system, enabling discoveries and fundamentally changing the dynamics of the ecosystem. We should be treating health data as a vital asset—health enterprises and consumers—to drive an efficient, high-quality, value-based, evidence-focused future for medicine.

So why isn’t there data liquidity or the appropriate flow of data in the ecosystem? There are two major walls preventing the liberation of data and each is starting to have some cracks.

First, there is the “it’s-my-data” wall put up by hospitals, insurance plans, pharmacy benefit managers, and others. They believe there is some competitive advantage by keeping the data inside their walls. And there are lots of excuses supporting their position–patients don’t want it, they can’t understand it, it might do them harm blah, blah, blah. This wall is starting to crack. Many institutions recognize that the consumer has a right to a copy of their data and are making the appropriate connections to personally controlled health data repositories like HealthVault or Google Health. Many others are writing about it too—John Moore asserted in a recent post, “Personal health data belongs to the consumer and the consumer should decide how it is shared. This is a very radical concept that still has most providers, payers and other data holders shaking in their boots.”

The second wall is the “waiting-for-the-right-standards-set-by-government” wall. There are multiple excuses buttressing this wall; the core of which come down to technology, standards or policy excuses. Without debating each point–one inexcusable barrier is the IT enterprise system vendors who make it difficult or expensive to get access to the data, to separate it from the application. They believe that proprietary “lock-in” provides them with a strategic advantage. We’re all in business and need to create strategic value for our products, but let’s do it in the application layer—rules, workflow, user experience, price, or services—not by trapping patient data in a proprietary database structure.

Our customers and partners and their customers need to be able to re-use their health data, and in ways they haven’t always thought of or anticipated. They have to be able to build cross-vendor systems to improve care. If information can be made liquid—flowing from where it is generated to where it is needed, and combining it with other bits of information to provide a comprehensive view—it can be tremendously powerful.

We, in the IT industry, can step up and be a driving force in enabling data to become liquid—specifically, doing this by separating data from applications. This is one of the recommendations from a study by the National Research Council of the National Academies that takes a look at what types of computational technology and investments are best for improving health outcomes. Let the excuse not be that the data is trapped in systems that we built, that we have to wait for standards.

We need to enable this, and we can start to do it today. Just look at the Health Information Exchange in Wisconsin and CVS MinuteClinic. In the former, value is being added immediately to users in the ED, without requiring all the participating EDs to change their systems or to be standards compliant (or CCHIT certified). At MinuteClinics, summary after-visit health data are made available to customers online using the Continuity of Care Record standard.

There’s a proven model for extracting and transforming data in many ways—HL7 feeds, non-HL7 feeds, web services, database replication, XML and XSLT, and more—and along the way we can create value by interpreting the data and adding metadata. At Microsoft, we’re doing it today both in the enterprise with Amalga and across enterprises to the consumer with HealthVault. We hope other vendors follow this lead to drive better outcomes for patients, and we expect buyers of IT systems to demand vendors to meet this standard (excuse the pun). Where standards are available, we should leverage them, and where standards do not yet exist, we should output the information in a consistent consumable format for the install base.

I understand that there are many, many complicated aspects of this problem, including the need to reform our payment system. But we don’t have to work out everything first to begin building a better, more data enabled, data rich and accessible health delivery system now. David Kibbe did a nice job simplifying and laying out some core recommendations in his post, Five Shovel-Ready Health Care Reforms.

I have argued previously that HiTech should focus on investments which leverage existing digital data sources and drive better health outcomes. With the dollars that are being allocated to EMRs, it’s critical that the data is liquid and that the consumer is connected to the data in a meaningful way

I understand that this kind of disruptive change can be uncomfortable because the forces unleashed can lead to unpredictable results for specific stakeholders. But like the fall of the Berlin Wall, it is clear that the most important stakeholder—the citizen or patient—will be better off, and the other key stakeholders—providers, payers, policy makers, etc.—will participate in a healthier ecosystem. There will be profound, new opportunities for everyone in this future.

The time for excuses is over. Let’s tear down the walls and get the data flowing. We can do it now.

The Truth About Health IT Standards – There’s No Good Reason to Delay Data Liquidity and Information Sharing

pnblog — Sat, 24 Jan 2009 03:26:00 GMT

David C. Kibbe and Peter Neupert

Now that the Obama administration and Congress have committed to spending billions of tax payers’ money on health IT as part of the economic stimulus package, it’s important to be clear about what consumers and patients ought to expect in return—better decision-making by doctors and patients.

The thing is, nobody can make good decisions without good data. Unfortunately, too many in our industry use data “lock-in” as a tactic to keep their customers captive. Policy makers’ myopic focus on standards and certification does little but provide good air cover for this status quo. Our fundamental first step has to be to ensure data liquidity – making it easy for the data to move around and do some good for us all.

We suggest the following three goals ought to be achieved by end of 2009:

Patients’ clinical data (diagnoses, medications, allergies, lab results, immunization history, etc.) are available to doctors in 75% of emergency rooms, clinic offices, and hospitals within their region.
Patients’ doctors or medical practices have a “face sheet” that lets any staff member see an all-up view of their relevant health data, including visit status, meds, labs, images, all of which is also viewable to patients via the Web.
Every time patients see providers, they are given an electronic after-visit report that includes what was done and what the next steps for care will be according to best practices and evidence-based protocols, whenever these are applicable.

Some who view this seemingly humble list of achievements will say that we can’t do it, because the standards aren’t ready, or the data is too complex. They’ll say that delays are necessary, due to worries about privacy or because too much data is still on paper.

We disagree. We believe that where there’s a will, there is going to be a way. And we already know most of what we need to know to achieve these goals. We know that:

huge amounts of digital data exist, already formatted electronically, but scattered across many proprietary systems (meds, labs, images).
software and the Internet makes it possible—in a low cost, lightweight way—to get data out of these databases to the point of decision making (to the ER doctor, the patient/consumer, or the primary care physician).
people are hungry for information in whatever form they can get it:

Getting it on paper is better than nothing
Getting it quickly is better than getting it late
Getting it in non-standard digital format is better than paper (software is pretty good at transforming non-standard to standard formats)
Getting it in a standard format is better
Getting it in a structured, standard format is best

An integration “big bang” -- getting everybody all of a sudden onto one, single, structured and standard format—can’t and won’t happen.

We don’t have to wait for new standards to make data accessible—we can do a ton now without standards. What we need more than anything else is for people to demand that their personal health data are separated from the software applications that are used to collect and store the data.

This idea of separating health data from the applications is very important, and a better way to frame the discussion about how to achieve data liquidity than is the term “interoperability,” which we find cumbersome and opaque. Smart people, armed with software, can do incredible things with data in any format – so long as they can get to it.

Customers of health information systems want to re-use their health data, and in ways they haven’t always thought of or anticipated. However, many enterprise system vendors make it difficult or expensive to get access to the data—to separate it from the application. They believe that proprietary “lock-in” allows them some form of strategic advantage.

We understand that IT vendors are in business, and need to create strategic value for their products. And we are very much in favor of that—in rules, in workflow, in user experience, price and flexibility, and so on. However, vendors should not be able to “lock” the patient or enterprise data into their applications, and thereby inhibit the ability of customers and partners to build cross-vendor systems that improve care.

It’s possible for vendors to provide value without the need for lock-in. There are lots of examples of this, for example, the Health Information Exchange in Wisconsin and CVS MinuteClinic. In the former, value is clearly being added immediately to users in the ED, without requiring all the participating EDs to change their systems or to be standards compliant (or CCHIT certified). At MinuteClinics, summary after-visit health data are made available to customers online using the Continuity of Care Record standard. This is where the low hanging fruit is.

There’s already a proven model for extracting and transforming data in many ways – HL7 feeds, non-HL7 feeds, web services, database replication, XML and XSLT, and more – and along the way wecan create value by interpreting the data and adding metadata. Microsoft is doing it today– both in the enterprise with Amalga and and across enterprises to the consumer with HealthVault. We hope other vendors follow this lead to drive better outcomes for patients.

Unlike the physical world where there is a need for dejure standards—think railroad tracks—in the software world, there is much more flexibility and the standards that work are the ones that evolve from USAGE and market acceptance.    The certification and standards road equals conferences, press releases, “connectathons”, caregivers-turned-bureaucrats. The outcomes road equals immediate benefits to actual caregivers AND learning we can apply to the next round, and the next, and the next.

We have given the industry decades to make this happen --- and just in the last 1-2 years have people finally gotten fed up and just started moving. Our great risk here is that the people lobbying for dollars and certification today are the people who are invested in the old road. With the amount of money we are talking about, we run the risk of just giving them another decade to delay and plan.   Instead, let’s put the dollars into rewarding behavior and outcomes, and let the people who live with the problems every day figure out how to solve them.

When we set out to go to the moon in the 1960’s we didn’t say “let’s build a great rocket.”   So, too, in this case we shouldn’t say “let’s buy a great IT system.”   Our measurements should be tied to what we want – better care, informed by the data that is just out there waiting for us to use it.

David C Kibbe MD MBA is a Family Physician and Senior Adviser to the American Academy of Family Physicians who consults on health care professional and consumer technologies. Peter Neupert is Health Solutions Group Corporate Vice President at Microsoft.

Message to Washington -- It's all about Outcomes

pnblog — Sat, 17 Jan 2009 00:35:00 GMT

Yesterday, I testified before the Senate Health, Education, Labor, and Pensions Committee, otherwise known as HELP. You can see a video of my testimony here. Before getting to the substance, I need to highlight how I continue to be awe-inspired about how our government works -- in a positive way. Any body can walk into the halls of Congress and sit in and listen to a hearing. Folks from all walks of life have input via a variety of means -- and while I get it's not perfect and can be better -- I remain proud of our democratic system and feel honored to be able to contribute/participate in it.

My main message to the Senate was: We should really focus on the health outcomes we want to achieve, not just on the technology itself. What the health system needs is to adopt technology in ways to deliver better outcomes, better chronic care management, better hospital effectiveness. We really want to make sure that we have the leadership focused on encouraging the usage of technology to achieve certain goals, like better chronic care management.

We were the only technology company testifying, and I think people were surprised to hear us saying that technology isn’t the silver bullet. It's not that Microsoft doesn't want to see spending on health care technology. Far from it. We just want to see smart spending, on technology that will really have impact. When we decided to go to the moon, we didn't say let's build a great rocket...we said let's go to the moon...I feel a little bit of the conversation has been about let’s build a great rocket and hope we get to the moon.

The other witnesses included Health Leadership Council President Mary Grealy, National Quality Forum President Janet Corrigan, Permanente Federation Executive Director Jack Cochran and Valerie Melvin, Director of information technology for the Government Accounting Office. Their comments were unexpectedly aligned with mine -- namely take a holistic view; incenting the adoption of technology is not a silver bullet; and, we must have reform of the payment system too. So at a high level -- folks understand the challenges of creating the right kind of change in the complex health ecosystem. Where the differences lie -- is how to get started. Unfortunately as is often the case -- the stimulus bill (big incremental spend investing in health IT) is separate from the activities around health reform. Getting the spend without the right payment system reform -- could lead to the unintended consequences the panel was cautioning against.

The legislation is being drafted now -- that is why the hearing was held on a day when there was a lot of other activity going on in the Senate. There is a clear sense that something big will pass in 2-3 weeks - which is like moving at the speed of light. I am sympathetic to the challenges of the staffers trying to find the right language -- it is not easy to figure out how to guide the spend of $20billion over two years! The scale of spend is still hard to put into perspective for me -- in my last post I tried a per physician number, so this time let's try per day -- it is $27M/day! I am very confident there is lots of low hanging fruit to generate a return on investment in the health system (waste, overuse, misuse, error reduction) that technology can enable -- but still $27M/day!

Since I spend the bulk of my time building software -- decisions about features, hiring great people, how and where to sell -- the hardest question from the staffers to answer is - how do you recommend we spend the money?

My answer is in my closing remarks with the five key things that I think the government needs to focus on:

1. Encourage innovation in health IT by setting out objective goals and criteria, not by mandating specific technologies or development models.

2. Reward innovative doctors who make the Internet the foundation of the patient-physician connection.

3. Provide incentives for sharing data.

4. Focus on making data interoperable today, not waiting for standards tomorrow, and insist that vendors separate data from applications.

5. Enable the private sector to develop an information infrastructure that connects data, systems, and people.

These are really critical, so we don’t end up in the wrong place. They’re based on our learnings as we’ve delved into this complex world of health.

One final thought -- surely it is an exciting time to be in the health information technology business! I personally got passionate about trying to really contribute and make a difference in HIT from my time on the President's Information Technology Advisory Council (PITAC) in 2003-2005. As co-chair of the Health Subcommittee -- we published a report titled Revolutionizing Health Care Through Information Technology with key recommendations for the government to consider. While my depth of understanding has gone up dramatically, what I find is both fascinating and perhaps cautionary -- is the discussion is largely on the same key issues/recommendations. This time there is a lot of money at stake -- but it goes to show that change is hard and probably slow.

I had a great exchange with Fox News --- video embedded below.

You can also read more about Microsoft's general views on a number of topics here.

Healthy Debate

pnblog — Thu, 21 Aug 2008 06:52:00 GMT

I love the fresh debate about standards and the evolution of Health IT raised by the three Health Affairs articles. I agree wholeheartedly with the perspectives of Carol and Clay - and frequently reinforce these comments to customers, policy makers and audiences alike.

It's about the patient - not about the standards. Value in the form of patient care and business results can be improved by moving/reusing the data already in the system! There is no need to wait for 'standards'. Ultimately we need to be focused on solutions that provide value to patients….better quality of care.
If it's about the patient, we need to empower consumers to be active and engaged participants in the system and they will demand 'connected' care and more health and wellness choices. They will increasingly make physician choices based on the ability and willingness of physicians to leverage communications/connected care to improve patient convenience and outcomes. In order to have more choice, consumers need to be able to access and leverage health IT solutions: the same ones that are being used by their physicians and other stakeholders across the spectrum of care.
Health IT is a great enabler for many things (outcomes, safety, results, employee productivity, employee satisfaction) but not an end in itself. System design matters a lot - metadata is the answer to enabling exchange of info today to evolve to standard exchange tomorrow. Health IT is only one piece of the puzzle, but we can't wait for all the pieces to be in place; We need to start improving outcomes today. These beliefs have informed the design principles of the software products we introduced in the marketplace - both HealthVault and Amalga.

In addition to consumers as a change agent, I remain hopeful that the buyers of large health IT systems will wake up and demand more from their vendors; Not in terms of custom features, but in terms of a real commitment to interoperability and to unlocking the data that exists in systems already. Health IT buyers are critical stakeholders/components of the ecosystem and need to demonstrate leadership in getting us to real solutions that extract the value from HIT - and not let themselves be positioned as victims controlled by the vendors. Unlocking the data that providers and patients need to make the right decisions should be the priority, with the goal of improving patient outcomes.