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.

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. 

The mad dash for health reform continues in earnest as stakeholders from all parts of the health ecosystem work to inform, engage and encourage the incoming Administration.   The need for reform is obvious and the dialog is positive -- I continue to worry that 'soundbite solutions' will get in the way of a serious discussion of principles, desired outcomes and alternatives to achieve a good return on investment on 'change.'

As a business guy -- one that has worked on startup initiatives over most of my life -- I tried to put into context what it means to invest an 'incremental $50B' in health IT.    It sounds like a lot of money -- something on the order of $83k per practicing physician -- we ought to be able to do something spectacular for that kind of money.

There is a new study out 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.   I recommend folks read it (full disclosure I was both interviewed and a reviewer).   Many folks I talk with in the computer science industry recognize the huge benefits that will be gained in medicine and health outcomes with thoughtful investments in information technology.   Many (myself included) are technology optimists and believe that information technology will ultimately disrupt and transform health delivery.

But to achieve this transformation -- we have to acknowledge the reality of the institutions and systems currently in place; we have to invest in the new kinds of architectures and IT systems that will deliver real value over time.   This report is bi-partisan and a timely reminder of key principles by experts -- one that I hope informs the health reform spending debate before folks finish their HIT shopping list and count too much on electronic health records as a simplistic cure-all. 

The study acknowledges the need for comprehensive patient data, empowerment of consumers/families with personal health information and for flexibility in systems design to enable new advances in biology to be integrated effectively -- among many other principles.

Here are a few of the topline recommendations (pages S-9 and S-10) from the report I chose to highlight because they are so important and often get lost in the 'soundbite solutions' debate:

• incentivize clinical performance gains rather than the acquisition of IT, per se
• encourage initiatives to empower iterative process improvement and small-scale optimization
• develop the necessary data infrastructure for health care improvement by aggregating data regarding people, processes, and outcomes from all sources.
• insists that vendors supply IT that permits the separation of data from applications and facilitates data transfers to and from other non-vendor applications in sharable and generally useful formats

If the country is going to invest $50B in incremental health IT -- we all want it to be invested wisely.   The question is; what will generate the most benefit and how can we accomplish it?  We should be building an asset with this investment - and the asset is not an application per se -- but a health data asset that can be used to improve both individual outcomes and the performance of the institutions and the system overall.    Individuals should be encouraged to create and manage their health data asset and to learn how to share it to achieve better outcomes and interactions with the health delivery system.   Similarly - health enterprises should invest in building and sharing health data assets that enable them to have a culture of process improvement over time.