Friday, August 08, 2014

Small Independent Practices - Big Transformative Potential

A post by Dr. John Brady titled My oasis of care is being threatened examined the dilemma small practices (the "little guys") are now facing. Should they become extinct, being consumed by large organizations (the "big guys")? Or does the little guy have an important place in the healthcare? How can the little guys autonomy have the power to transform our healthcare system in very positive ways, especially when centralized control by the big guys is so prevalent these days? Here's what I wrote ...

As a clinician and health IT software architect working in several Federal (ONC) workgroups over the past three years, I can confirm that government focus has been on the “big guys,” i.e., large provider organizations and EHR vendors participating in health information exchanges (HIEs). I’ve been fighting to have the focus extended to supporting the needs of small practices and EHR vendors (the “little guys”).

Having had a solo practice in NY for twenty years (as a clinical psychologist), I empathize with Dr. Brady’s sentiments about the importance of autonomy and independent practices in terms of clinicians’ quality of life and the well-being of their patients. This extends to primary care practices and specialists of all disciplines.

While I contend that care coordination and next-generation decision support are important to increasing healthcare value to patient, it is unwise to ignore or destroy the little guys in the process.

A case can be made for the government’s centralized, top-down, tightly-coupled network (TCN) model that it benefits larger organizations. Primary benefits of the TCN are control and consistency because this model limits participation to people within the same discipline, department, region, organization, etc.; who have access to the same information sources, share similar experiences; who do things in similar ways; and who are under the control of central authority.

An equally valid though opposite model can be made for decentralized bottom-up loosely-coupled network (LCN) of independent collaborators that benefit small practices and organizations. In addition to the professional autonomy benefit, the LCN’s other benefits include creativity, innovation, and attention to differing needs and circumstances of different parties. This is because collaboration among people with wide diversities of knowledge, ideas and points of view provides a larger collection of resource intellectual pools, and offers access to a greater variety of non-redundant information and more content on which to base decisions. As such, the LCNs provide the greatest opportunities for stimulating multifaceted discussions, out-of-the box thinking, and creative clinical and economic solutions.

An example of an LCN is the communities of referral that form patient centered medical homes/neighborhoods in which a primary care physician and specific specialists and facilities collaborate in the care of a specific patient. These LCNs can interconnect with each other on a nation-wide and even world-wide basis, as well as connect with TCNs. Given the political will and adequate business incentives, this global interconnectivity can be achieved rather quickly, easily and inexpensively. It can be done using a software architecture in which pub/sub nodes exchange information via simple encrypted e-mail (such as the ONC Direct Project).

Realization of this vision would enable independent-minded individuals to maintain their autonomy, while at the same time enabling them to collaborate in regional and international LCNs for the purpose of improving clinical decision support to increase value to healthcare consumers and reward providers who do so.

Wednesday, November 06, 2013

Dealing with EHR Dissatisfaction (Part 5)

This post is a continuation; Part 1 is at this link. In this post, I describe a examine the question: When it comes to EHRs, whose satisfaction is important?

Someone commented that EHR “satisfaction is in the eye of who? The physician? patient? government? business?... I only hope it is the patient that wins out.” This comment is intimately tied to the question: Who should gain the most VALUE/BENEFITS from EHR/health IT use?

I contend that if they improve clinical outcomes and quality-of-life (through prevention and treatment), while they contain or lower costs to providers/clinicians and prices to consumers/patients (i.e., increasing value/benefits to the providers and receivers of care), then our society (and species) wins in the long haul. A business model that focuses on short-term gains for “me & mine,” rather than on realizing a longer-term vision that focuses on the common good, inevitably harms consumers and those who care for them.

Beneficiaries of this dysfunctional business model are manufacturers, politicians, lobbyists, providers, consumers and others who line their pockets by “gaming the system” through all sorts of unscrupulous (and at times illegal) tactics. Some might conclude that this is just “the American way,” but based on the huge waste of money and resources in the in the UK's health IT system (NHS IT system one of 'worst fiascos ever'), I believe it’s a consequence of capitalism that has lost its way, along with its sense of virtue.

I contend that the underlying cause of our broken healthcare system is our pathologically mutated form of capitalism —a term coined by John Bogle, named by FORTUNE magazine as one of the four giants of the 20th century and by TIME magazine as one of the world's 100 most powerful and influential people—which he said is a “fundamentally a blight on our society…It says something very bad about American society…ultimately, the job of capitalism is to serve the consumer. Serve the citizenry. You're allowed to make a profit for that. But, you've got to provide good products and services at fair prices…What we've done is have…a pathological mutation of capitalism” (see this link).

The rational way forward with regards to EHRs, I contend, is for clinicians to demand health IT tools that enable them to increase value to the consumer and demand fair compensation for doing so (Pay for Value). These tools should be low cost, flexible, ever-evolving, interoperable, and highly useable & useful for the clinician, patient, and researcher/informaticists. It should combine the best (and simplest) methods for data entry, analytics, decision support, and presentation (display), as well as secure transport and storage. They should also be efficient and accommodate workflows (including referral point-of-care, and mandatory reporting processes), and they should include the capabilities that include clinical concept parsing & processing (i.e., tools that improve the use of clinical notes and aid in inductive and deductive reasoning). In addition, they should provide ongoing risk-adjusted information to clinicians about their individual patients and population (cohort) outcomes.

The use of innovative EHR add-ons (companion applications) is a sensible way forward, even though EHR vendors may resist for business reasons that run contrary to the goal of increasing value for patient and provider, which is not surprising as per Bogle’s criticism and the need for "real capitalism, not crony capitalism that we have now in many industries, especially healthcare.” And while EHRs should be able to incorporate information directly from patients, it should also be able to associate and substantiate it with clinical technicalities.

These capabilities are simply way too much for any EHR today, but they can be achieved over time through collaboration that expresses our views and needs, embraces creative destruction, and suppresses regulatory capture that increases complexity, cost, and inefficiency.

Tuesday, October 29, 2013

Dealing with EHR Dissatisfaction (Part 4)

This post is a continuation; Part 1 is at this link. In this post, I describe a vision of an ideal EHR system that can developed today.

Based on the complaints about EHRs, one can conclude that there would be increased satisfaction if EHRs are thought to be a component of an all-encompassing HIT system. This next-generation computerized system would manage clinical information, as well as administrative data, in a way that increases provider efficiency, enables providers to deliver high-value (cost-effective/safe/quality) preventive and acute care and rewards them for doing so, assists patients/consumers in taking better care of themselves (self-maintenance), and promotes population health.

So, imagine coming together to build a novel EHR-based HIT system that continuously improves clinical and economic outcomes by (in no particular order):

• Capturing clinical information accurately and automatically at point-of-care in real time in a way that requires little effort and workflow change

• Clearly presenting—to clinicians and patients—the biomedical, psychosocial (biopsychosocial) and economic information they need to: (a) bridge the knowledge gap ( ; (b) make wise prophylactic, diagnostic, and treatment decisions; and (c) promote patient-centered cognitive support (

• Enabling networks of collaborators to: (a) perform clinical research in the field and lab through the streamlined collection, sharing, and analysis of large quantities of diverse clinical data; (b) build evolving health science knowledgebases with for clinical research, which transform this knowledge into evidence-based practice guidelines/protocols/pathways; (c) promote the continuity and coordination of care; (d) share observations, lessons learned, and best practices; and (e) effectively run PCMHs and ACOs

• Integrating sick care with well care (see

Also imagine that this next-generation EHR system:
• Facilitates ongoing biosurveillance and post-market drug & medical device surveillance

• Streamlines mandatory regulatory reporting.
• Connects providers/clinicians to one another in (a) loosely-coupled, occasionally connected, near-real-time, asynchronous, peer-to-peer mesh networks (e.g., DIRECT e-mail) and (b) tightly-coupled, continuously-connected, real-time networks (e.g., corporate VPNs)

• Secures PHI while it’s being exchanged (in transit) and while stored in a device (at rest), as well as protecting patient privacy
• Provides a hybrid approach to information access and exchange that includes Web-based tools, services and deidentified information stores in the cloud, along with standalone applications on users’ devices

• Provides useful business intelligence

I claim that, by working together, we can realize the vision described above by adding common off-the-shelf HIT tools and custom-built applications to EHRs. I know how this can be done!

Part 5 examines the question: When it comes to EHRs, whose satisfaction is important?

Saturday, October 26, 2013

Dealing with EHR Dissatisfaction (Part 3)

This post is a continuation; Part 1 is at this link. In this post, I discuss what's needed to make EHRs more satisfactory and answer questions about my claims.

I wrote:
What’s needed is a paradigm-busting shift in which clinicians and software developers collaborate to create tools that are truly clinically useful and promote (rather than destroy) efficiency. We can start by redefining Meaningful Use – see my blog post at
I then answered a question about my claim that over-reliance on XML and Web services is a big problem with HIT standards:
I'm not saying that XML can't work; just that XML is being over-used. When data sets are rather simple or XML is used for sending messaging operation instructions for web service, I have no problem with it. But when it comes to representing complex data, as in a CDA-based document or a complex form definition file, XML sucks!  
Here’s why: When you use XML in such cases: human readability is a joke, verbosity is huge, and parsing requirements and complexities are immense. It also forces conceptual incongruities just to keep data in hierarchies when such parent-child relationships are unnecessary. See and fact, I’ve seen XML-related complexities bring the Query Health initiative to its knees (see
I fought against this "let's use XML for everything" mentality since the mid-90's, but to no avail. Now the crap is hitting the fan!  
Bottom line is that there are much easier/simpler and more rational ways to represent complex data than XML, even hierarchical data. We've got to start busting maladaptive paradigms.
Regarding the web services issue, I have no problem with this architecture for the most part, but bringing SOAP and RESTful into the DIRECT Project, and relying on them exclusively in other Federal initiatives, adds similarly increased complexity, as well as vulnerability, as I discuss at
What we need is a hybrid approaches that balances web services and XML with simpler elegant methodologies.
These issues came to a head during the standards-making process at the S&I Framework Structured Data Capture (SDC) initiative where I fought for the inclusion of a much simpler approach to capturing data using electronic forms, but was voted down by the community (see To their credit, however, they are allowing our team to pursue a pilot (on our own dime) even though it will demonstrate use of technology/methods that aren’t fully compliant with the implementation guide they are developing.
In any case, the kind of change we need isn't going to happen by EHR industry lobbyists or the Feds ... As I said before, it's got to be led by clinicians and researchers working closely with creative software developers (including nimble EHR/HIT vendors) who focus on designing and deploying clinical tools that are truly useful and useable.
In part 4 at this link, I discuss a practical vision of a next-generation EHR system that can be built today, which addresses the many criticisms of what is happening today.

Dealing with EHR Dissatisfaction (Part 2)

This post is a continuation; Part 1 is at this link.

The next issue turned to who should ultimately control a patient's data. Should it be the patient (patient access control), provider/clinician, care team/ACO/PCHM, HIE/gov't/CMS?

Here's what I wrote:
Some believe patients should have granular control of who gets to see their health data and, if de-identified and aggregated for population health research, that the patient should be compensated financially for authorizing such use of their data.
Concerns about PHI privacy and gov't control are certainly warranted and, I agree with Randall, that legacy systems have been incapable of doing what's needed to give patients peace of mind that storing their PHI in the cloud provides a high enough level of privacy protection. We cannot achieve the Triple Aim unless we have wide deployment of a secure, low-cost, always available, and simple way to exchange data from EHR to EHR, EHR to PHR, EHR to Population Health and After Market Surveillance repositories (with de-identified data), and from Person to Person (patient to clinician, clinician to patient, and clinician to clinician).
A pub/sub, loosely-coupled, mesh node network, with identity management and endpoint-to-endpoint encryption, is one way to achieve this.
The next issue raised is whether the actual goal of healthcare reform is to make it fail. I responded by saying:
I've heard from more than one person that current healthcare reform efforts were designed to fail. While I'm not sure about that, I AM confident that the cost, complexity, inefficiencies, and insecurities built into current implementation regulations are too big NOT to fail.
Nevertheless, the underlying goals of ARRA HIT--to improve care quality and contain costs/prices (i.e., increase value to the consumer)--are absolutely essential. We have a real big problem if all the spending and hassles are just a manipulation to funnel taxpayer's money into the coffers of certain big corporations under the guise of helping the common good.
As such, I believe physicians and other clinicians, researchers/informaticists, and HIT developers have a duty to participate in loosely coupled collaborative networks focused on ensuring that the HIT being developed is designed and used to improve patients' health and wellbeing, to minimize the burden and maximize the competency of providers, and to reward delivery of high value care.
I then went on to describe my experiences as a committed member of the government's HIT standards bodies:
Having been involved over the past few years in a half dozen HHS/ONC technical workgroups that determine EHR/HIT standards, my associates and I have been like David facing an arena of Goliaths. I've been dealing with the biggest EHR vendors, as well as Federal contractors and agencies. It's been a very frustrating and enlightening experience. We entered the arena with the faint hope that the powers-that-be would compare our simple, low-cost, highly capable, disruptive innovations to the complex, convoluted, expensive mainstream technologies currently being adopted.  
What we’ve found is that the standards-making process is rife with regulatory capture in which new standards are built on top of old standards without due consideration of modifying those standards in light of new and better technologies. Simplicity, efficiency, and usability are an afterthought. The result is an extraordinarily complex set of monolithic processes that few (if any) can implement and few are willing to use.  
Examples include, in no particular order: (a) an over-reliance on XML data representations and Web services, (b) long delays due to HL7 voting processes, (c) changes to DIRECT taking it from what was supposed to be one step above the fax to a convoluted amalgam of HISPs that make PHI vulnerable with exposure to man-in-the-middle attacks, (d) incestuous relationships between vendors and ONC that block innovation from “outsiders,” (e) reticence to deal with difficult clinical workflow issues, and (e) the natural tension between making huge leaps in EHR system capabilities and the “let’s just keep crawling until we can walk” mentality. The result is that money continues to be spent with dismal progress in enabling HIT to increase value to the consumer while enabling and rewarding providers for delivering such value.
It seems to me that most of these problems are due to business strategies and tactics supported by regulatory capture; it is not a technology issue, per se.

In part 3, at this link, I elaborate about the problems identified above.

Dealing with EHR Dissatisfaction (Part 1)

For the past few days, I’ve been involved in a very good conversation at LinkedIn HIMSS titled: Can we turn EHR dissatisfaction around?

Here’s a comment from person that struck a chord:
It took the doctor 2 minutes to dictate as opposed to 30 minutes to use speech, edit and/or type. In addition, if the text is not edited in most cases except for those of you have it down perfect, you get crappy documentation that is (oh my goodness) actually used down the road to treat a patient. I can also introduce you to several law suits filed due to the poor documentation of a physician who refused to edit his dragon speech and just let it go into the chart. I can also introduce you to a neurologist who spends 4 ADDITIONAL HOURS a day documenting in an EHR. He has been at it for over a year so apparently this brain surgeon is an idiot who can't be trained. All of your responses to this, even the "this is off topic" are very revealing as to one source of the problem. Like typical programmers, no one wants to hear they have a bad design or the product actually needs more work.
So, to stay on topic, "Can we turn it around?" yes but only when you listen to the experts in the field you are dealing with - medical record specialists and physicians - they seem to be the people you have left out of the equation.
I'm a clinician (clinical psychologist) and HIT software inventor/architect/developer with 33 years’ experience in both areas. What I've noticed is that programmers routinely rely on healthcare subject matter experts regarding product content, the same is often not true regarding workflow adaptation, usability and usefulness issues.
It's relatively easy to create databases and forms for data entry and presentation, but it's quit difficult to construct the inputs and outputs in ways that streamline workflows, integrate and organize complex interdisciplinary data in clinically meaningful manner, generate clinically useful information that supports decisions at point of care, and present that information in ways that promote knowledge and understanding that lead to greater value for the consumer/patient.
Herein lies the problem, imo, and it is where disruptive innovation is sorely needed!
Unfortunately, such creative destruction is often hindered by governmental regulatory capture in which big bucks direct the regulators who dictate the rules that constrain innovation, focus on appeasing big business, and drive up complexity and cost.
A short while later, Randall Oates, MD posted a comment that ended with:
It is time for more enlightened physicians to step up and assist/collaborate the transitions to processes generating EHR notes that are more clinically useful, while meeting basic billing/legal/reporting needs of others as well. Otherwise, physicians have to mainly blame themselves for systems that don't meet their needs.
To that I replied:
Randal, I'd to add to your excellent statement: "...and present, in a concise integrated view, the relevant interdisciplinary information needed to support their clinical decisions, at point of care, that is focused on continually improving outcomes and care value.
For past year and a half, I've been volunteering my time in a Federal workgroup (WG) called the 360X initiative and work alongside Cerner, Epic, and several other large EHR vendors and HIEs on implementing closed-loop referrals. In the WG, I'm a "little guy" offering novel ideas and methods to the "big guys."
I sincerely believe that the clinical and technical folks in the workgroup do want to improve their products, despite the fact that I have had to repeatedly insist that instead of focusing on doing the minimum; we focus on dealing with the big, complex issues, especially regarding workflows.
I'm also involved in several other Fed workgroups that create HIT meaningful use standards. What I've noticed is a general tendency to keep things complicated, while at the same time, minimizing the scope of their efforts. Many times, when I’ve tried “push the capabilities bar” higher--and even offered innovative ways to do it)--I’ve heard the phrase: “We should first crawl and then walk before we try to run.” Unfortunately, after all these years, when it comes to enhancing EHR systems' clinical usefulness and security, there's too much crawling under the "low bar," and a general aversion to trying to "leap over the high bar."
I believe there are many reasons for this and they mostly relate to the “business layer” supported through regulatory capture by HHS/ONC.
After three decades of HIT involvement, I’ve come to the conclusion that what we need is to transform EHR products into “EHR systems” (a term I helped add to the Fed’s lexicon and workgroup charters). These EHR systems would be enhanced through integration with low cost, easy-to-use “companion applications” that fill in gaps in EHR usability, usefulness, interoperability, and protection of PHI.
The companion apps are likely to be disruptive innovations created by loosely-coupled collaborative networks of small nimble companies and individuals with diverse backgrounds and experiences, who share, discuss, evaluate, and continually evolve models (types of apps) focused on different use cases and types of end-users.
 [Continued in Part 2 at this link]

Saturday, September 21, 2013

Should "Value" Be the New Mantra in Health Care?

On  the Commonwealth Fund blog at this link is a new post titled: "Should "Value" Be the New Mantra in Health Care?"
This is good to see! I began blogging about the need to focus on Value to the Consumer back in 2007, starting with a post at

 Value is a complex issue that brings into light the notion of cost-effectiveness and how to compensate providers who demonstrate a commitment to high-value care via Pay for Value (P4V) models.

 I contend that a firm focus on value is the ONLY way to solve the daunting problems plaguing healthcare delivery. If we don't, costs will continue to rise without corresponding quality improvements, and cost reductions will likely result in worse care outcomes.

Friday, September 20, 2013

Reluctance of nursing homes to give residents copies of their medical records

Patients and nursing home residents have a legal right to obtain copies of most portions of their medical records. Yet at least some nursing homes are very reluctant to give competent residents their information. My question is: Why?

The benefits of providing such access to residents (and their families) include:
  • Gaining resident (and family's) feedback as to errors in the record
  • Enabling resident (and family) to share that information with others for second opinions and advice
  • Increasing trust between resident and nursing home staff
  • Respecting resident's wishes
  • Providing a greater transparency 
  • Complying with Federal regulations.
With all these important benefits to the resident's rights and wellbeing, then why it that (at least some) nursing homes do whatever they can to prevent residents from accessing that medical information?

For example, some nursing homes create policies that residents must follow to gain access to their medical records, such as signing a paper, but they do not make such policies readily known to residents and staff. Instead, staff is told to say things to the resident such as: "You need a doctor to see your chart so s/he can review the with you" instead of disclosing that the resident could simply sign a piece of paper and obtain their records for a few cents a page (assuming the staff person even knows about the paper-signing process).

Now I'm not talking about obtaining a psychotherapy session note, which may not be appropriate for certain residents to see, but rather something like obtaining a copy of a radiology report or medication orders.

Why does this happen? Is there something to hide? Is it an issue of power and control? What should be done about this?

Monday, August 06, 2012

Defining a Rational Healthcare Value Network

A value network is a marketing concept that describes the social and technical resources (supply chain) within and between businesses. They account for the overall worth of products and services, including the collection of upstream suppliers, downstream channels to market, and ancillary services that support a common business model within an industry. The kind of value network that the healthcare system needs focuses on bringing increased value to healthcare patient (consumer) and reward providers for delivering high-value care.

Such a value network has four primary interacting components, as depicted in figure above. These components enable cyclical data flows—affected by drivers and impediments—that increase care value to the patient:
  1. The green box refers to three types of data required to build the information and knowledge people need for increasing value across the supply chain. The education data refers to formal and informal ways that people share their knowledge, ideas, and experiences. Research data, on the other hand, is used in controlled clinical trials, outcomes and performance studies, various types of biosurveillance (e.g., post-market drug and device, public health), preferred clinical guideline development, and other types of research. Technology data refers to the date collected by EHRs and other health IT tools, as well as streamed through durable medical equipment.

  2. The five blue boxes refer the transformation of the data using a variety of HIT tools and clinical processes that promote the kinds of knowledge and understanding that fosters more effective and efficient care (services and products). They include (a) use of evidence-based guidelines, personalized care plans, decision support tools, and communication networks; (b) methods of information sharing and care coordination; and (c) patient empowerment. Each activity (process) in the blue boxes supports value by requiring quality handoffs and continuous measurement, assessment, feedback and acceptance at each breakpoint (the gap between each activity) to ensure value creation via continuous quality improvement (CQI).

  3. The red box on the bottom refers to the technological, psychological, economic, and regulatory factors that promote or inhibit value to patient by influencing (driving or impeding) the blue box processes. Some of the key influences are listed in the box.

  4. The purple box represents good patient outcomes; it is the desired result of using the data, tools and processes to increase value to the patient. The curved purple arrow pointing to the Data Types box indicates the need to provide data about the process, influences and outcomes of care across the entire supply chain via continuous feedback loops. The blue box activities and their related influences that help achieve the goal of higher quality at lower cost are reinforced; those that do not are modified or eliminated.

Leveraging health IT to promote value through CQI is a strategy that focuses on (a) learning from our past, current and futures practices to determine what results in the best outcomes at reasonable cost and (b) transforming this knowledge into high-value healthcare. This solution fosters greater care quality and affordability through (a) use of appropriate evidence-based guidelines and lessons learned; (b) implementation of personalized care plans and decision support tools; (c) information sharing among collaborative teams in social and technology networks; (d) informed decision-making; and (e) fostering patient compliance and responsible behavioral choices.
This CQI solution does not strive for zero defects (no errors of omission and commission) because perfection assumes infinite resources and knowledge, both of which are unrealistic. Instead, it is based on the Michael Porter’s value chain model, which assumes defects (errors) will occur and, therefore, we had better accept some reasonable level of tolerance, reconcile mistakes and poor outcomes, and strive to ensure ever-better outcomes at reasonable cost for a given condition.
Ensuring patient access to high-quality healthcare at reasonable cost through the value-driven CQI solution requires adherence to these critical process transformations:
  • Supporting value for each primary activity through quality handoffs (the transfer of information, as well as authority and responsibility, during transitions in care across the continuum) along with ongoing measurement, assessment, feedback, and acceptance at each breakpoint (the gap between each primary activity).
  • Assuring that all infrastructure or support activities (a) promote a seamless support relationship that benefits the primary activities, (b) avoid impeding the primary activities, and (c) follow CQI rules for each component across the entire healthcare spectrum.
  • Operating with awareness of current healthcare system shortcomings that focuses on areas with quality improvement is warranted.
  • Addressing the problems associated with defining quality in real time versus retrospective analysis, for both individual patient and aggregate data.
  • Focusing on root cause identification to determine the factors preventing clinical outcome and cost improvement, instead of playing a “blame game,” which only exacerbates the problem.

Thursday, July 26, 2012

ONC’s Direct Project: In Defense of Simplicity

Over the past year or so, I’ve been deeply involved in various Federal gov’t health IT initiatives, including the Direct Project and Query Health. This is first time, I believe, that the public (private sector “outsiders”) has had access to the inner-workings of the Office of the National Coordinator for Health Information Technology (ONC). While I’ve been delighted with this new level of transparency, I’ve been dismayed by the way the process tends to transform simple ideas and sensible goals—aimed at improving care quality and efficiency—into overwhelmingly complex, convoluted and costly technical specifications and requirements!

One of the reasons for situation is that people often “come to the table” with preconceived notions of what is possible and how do it. These narrow/closed mindsets are either unaware or prone to reject  technologies that provide simple inexpensive solutions through the “novel combinations of existing off-the-shelf components, applied cleverly to a small, fledgling value network”) in favor of conventional technologies (commodities) that lack those positive qualities. Following is just one example.

A few months ago, Dr. John Loonsk (CMO of CGI Federal) wrote a widely cited article at this link in which he criticizes the Direct Project’s reliance on SMTP (Simple Mail Transfer Protocol)—the simple method for transporting e-mail messages that’s been widely used since the early 1980s. His criticism is based on the fact that SMTP uses a “store and forward” process in which messages are stored locally (in the user's computer) and then sent to the recipient. He claims that SMTP is insufficient and thus should be augmented by types of Web Services, such as SOAP or RESTful methods, which tend to be considerably more complex than SMTP.

In his critique, Dr. Loonsk takes a “closed inside-the-box” view of SMTP-based e-mail. Following are my responses to his key issues. In contrast to his narrow conventional point of view, my replies take an “open outside-the-box” perspective of SMTP’s capabilities that incorporates a novel publish/subscribe (pub/sub) node-to-node desktop architecture (see this link for technical details).

Issue 1: Dr. Loonsk wrote that “the store part of SMTP…introduces new security concerns even with encrypted data.”

My reply: Since when is the encryption of stored files not enough? These days, it is free and easy to encrypt not only individual files, but even entire hard drives (or partitions) can be protected with bit-locker encryption. With this kind encryption of stored files, along with encryption of e-mail in transit (e.g., using PKI), Protected Health Information (PHI) is protected end-to-end (in transit and at rest), which is about as secure as you can get!

In contrast, the Web Services approach can leave PHI exposed at the web server, e.g., when Web Services provide the in-transit encryption and when they transform the PHI format as it passes between disparate EHRs. With the SMTP pub/sub node-to-node architecture, on the other hand, all encryption and PHI transformations are done by the sender prior to transporting the e-mail.

One more thing about XML security: Encryption vulnerabilities. According to an interesting (and technical) blog post by a cryptographic engineer, encrypting XML securely requires extra steps to prevent a "ciphertext" attack that exposes the encrypted XML content. The author concludes: "If your system is online and doesn't have a solid, well-analyzed protection against them, don't pretend that you're doing anything at all to secure your data. I wish I had a funny, pithy way to sum this all up. But honestly, I'm just a little depressed."

Issue 2: Dr. Loonsk wrote that “Because SMTP store and forward infrastructure can only do the push transaction, it is a limited platform standard and a technical dead-end in trying to address other transaction needs…a true U.S. health system all seem to need more [which does] not stop with the data that one provider anticipates another provider will need…[nor] with the assumption that providers will reliably initiate a store and forward SMTP transaction to move the right data to all that need them.”

My reply: The SMTP pub/sub node-to-node architecture actually enables both “pull” transactions whereby the request for the transmission of information is initiated by the receiver, as well as “push” whereby the request for a given transaction is initiated by the sender. To perform a pull transaction, the party who wants to receive the PHI (1st party) e-mails a request for it to the party with whom the PHI resides (2nd party). Upon receipt of the request, the 2nd party responds by sending the requested PHI to the 1st party. Either or both parties can do his manually or have it done programmatically (automatically) by the software. This simple solution resolves the SMTP push-pull issue. Nevertheless, as reported by ONC in 2009, push messaging is crucial because it is "...less complex and will be far more readily available to a broader range of providers than so-called 'pull' technologies.

Issue 3: Dr. Loonsk wrote that, unlike Web Services and REST, the SMTP infrastructure does not support HIE functions such as “unanticipated needs, unanticipated providers, reliable data access from unreliable senders, accumulation of data into longitudinal and population records, accessing registries and data for decision support, accumulating quality reporting data, querying to get more data when needed, a raft of directory services, and with team care, the shared management of care plans, problem lists and other data.”

My reply: The SMTP pub/sub node-to-node architecture actually does support these functions and we’ve demonstrated such capabilities with our software tools using SMTP.

Issue 4: Dr. Loonsk wrote that “One argument for SMTP has been that it is more accessible to small providers. In practice, implementations to date have involved more complexity than predicted and…[rely] on an outside organization – a Health Information Service Provider (HISP) to carry the technical load. If a HISP is necessary, a more robust platform standard like Web services or REST would seem to be just as achievable as SMTP.”

My reply: Unlike Web services or REST, the SMTP pub/sub node-to-node architecture I’ve been describing does NOT rely on a HISP since the desktop e-mail client (MS Outlook in our case) carries the technical load, not the HISP. To comply with the Direct Project requirements, however, we use a HISP for PKI certificate management and provider registries, but the actual e-mails pass right through the HISP from senders (publisher) to their recipients (subscribers).

In conclusion, the view of Dr. Loonsk and many others fail to realize how breakthrough (disruptive) innovations, like our novel SMTP architecture and apps, can accomplish what seems impossible to folks focused conventional technology. Though no doubt well-intentioned arguments by intelligent people, their criticisms do not provide good reason for denigrating the simple, sensible, survivable solution SMTP provides.

Tuesday, June 26, 2012

Data->Information->Knowledge: Formula for improving healthcare

As a clinician, health IT architect and computational model-builder, I’ve been focused for the past three decades on how to use health IT to transform data into information and information into knowledge, in a way that improve care value. I’ve come to realize that highly effective and efficient care delivery (including prevention, assessment of risk, and the diagnosis oand treatment of health problems) depends on useful, valid clinical knowledge providing evidence-based decision support.

This knowledge can help continually improve care outcomes though methods and tools such as patient-centeredcognitive support, computerized clinical decision systems, and evidence-based clinical practice guidelines/pathways. These things are necessary if we want bridge the knowledge gap.
 In any case, gaining this crucial knowledge depends on creating, continually evolving and disseminating useful, actionable, valid information and presenting it in a way that avoids overloading the clinician and patient.

 And generating such valuable information requires adequate amounts and diversities of valid and reliable data. Some of these requisite data can come from today’s "Big Data" stores, which are typically insurance claims (administrative) data. While such claims data have usefulness, they are grossly inadequate when it comes to creating the kinds of information and emerging the kinds of clinical knowledge necessary to improve care quality and cost in any truly meaningful way.

Tuesday, August 30, 2011

Understanding Patient Centered Medical Homes and Accountable Care Organizations: Part 1 of 2

I’ve been blogging about patient centered medical homes (PCMHs) for the past five years and accountable care organizations (ACOs) for the past two years. In this post, I discuss how these healthcare delivery models are similar and where there are significant differences. In a follow-up post, I will explain why we need both.

According to the American College of Physicians, a PCMH is:
...a model of care that puts the needs of the patient first. The medical home is the base from which health care services are coordinated to provide the most effective and efficient care to the patient. This includes the use of health information technology, the coordination of specialty and inpatient care, providing preventive services through health promotion, disease management and prevention, health maintenance, behavioral health services, patient education, and diagnosis and treatment of acute and chronic illnesses...Each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care. The medical home is responsible for providing for all the patient's health care needs or taking responsibility for appropriately arranging care with other qualified professionals. The personal physician leads a team of individuals who collectively take responsibility for the ongoing care of patients...Quality and safety are the hallmarks of the medical home. Evidence based medicine, health information technology, and clinical decision support tools guide decision making to support patient care, performance measurement, patient education, [whole person orientation] and enhanced communication. Ensuring the coordination and comprehensive approach of the medical home model over time will improve the efficiency and effectiveness of the health care system and ultimately improve health outcomes (Reference).
The ACO model, on the other hand, is loosely define and has different sub-models. According to a recent article in ModernHealth titled “Forging the way: ACOs taking hold despite loose definitions,” an ACO is:
...a fashionable name for a loosely defined fix for U.S. healthcare, are the center of debate, gossip and conjecture among policymakers and the healthcare leaders. But the murky state of the model and poorly received draft regulations intended to clarify the sketch included in the healthcare reform law have not deterred plans among some hospitals, medical groups and payers to…reduce medical errors and waste with financial incentives for quality and lower costs…[by] more closely coordinat[ing] medical care. Markets with competitive or highly independent providers would likely need more time and options to develop accountable care than large health systems with an existing network of employed physicians…Providers who agree to join these endeavors are vulnerable to costly missteps that could put finances and patients at risk…Success will depend on several factors…including hefty financial incentives tied to quality measures and freedom for patients to choose providers (Reference).
ACOs can also be described as:
…vertically integrated organizations of care, which are at minimum composed of primary care physicians [PCPs], a hospital, and specialists…The intent is to coordinate care under the auspices of one organization…[and] providers are held directly responsible for the health of their patients and are evaluated based on their effectiveness, efficiency and quality of care in treating patients. [P]rovider members of ACOs work together across all of the specialties to develop care delivery programs which focus on outcomes and coordinating care…ACOs encourage physicians and hospitals to integrate care by holding them responsible for quality and cost (Reference).
Similarities between a PCMH and ACO

Based on these definitions, PCMH and ACO models both attempt to increase healthcare quality and reduce costs (i.e., deliver high value products and services) by (a) coordinating care, (b) being accountable for the care’s quality and efficient delivery, (c) having a strong primary care core, and (d) consolidating multiple levels of patient care.

According to a recent NY Times Op-Ed piece titled “Cut Medicare, Help Patients,”professors Emanuel and Liebman explain how PCMHs and ACOs provide “seeds of a solution” to controlling Medicare spending by enabling the country to take “a path to smart cuts” by focusing on the:
…need to stop paying for wasteful procedures…and empower doctors, nurses and hospitals to provide higher-quality and more efficient care… these reforms allow [bundled] payments…based primarily on the number of patients cared for and the quality of that care rather than on the volume of services provided [and can] eliminate spending on medical tests, treatments and procedures that don’t work — or that cost significantly more than other treatments while delivering no better health outcomes. And they can be made without shortchanging patients…Smart cuts can also be achieved through better coordination of patient care.
These smart cuts would be an antidote to the “…ill-conceived cuts that…got serious consideration in the recent debt limit negotiations.” These ill-conceived cuts include: (a) Meat-cleaver cuts hack spending indiscriminately…across-the-board”; (b) “Cost-shifting cuts don’t actually reduce health care spending; they just shift costs from the government to the private sector;” and (c) “Penny-wise, pound-foolish cuts reduce current spending by a little but raise future costs by a lot. Raising co-payments for office visits and medications is a good example. Both PCMHs and ACOs would receive financial incentives for controlling care costs and improving quality:
  • "The incentives of the ACO are clearly different from the current fee-for-service reimbursement system. The focus of the ACO is to streamline its processes and care while exceeding the norm on quality and outcomes. If the organization spends less than projected, all members of the ACO share in the bonus payments thereby incentivizing effectiveness and efficiency. If, on the other hand, an ACO underestimates the cost of operation, the providers will earn less, thereby institutionalizing ‘accountability.’” (Reference).
  • Different financial incentive models for PCMHs are just beginning to emerge. There are a few pilot projects of financial incentives for PCMHs. For example, (a) Health Plan of Michigan has announced an incentive program that encourages providers to become PCMHs by providing financial assistance during the practice certification phase (Reference; (b) six health plans in New York are paying $1.5M in incentives to create medical homes (Reference); and (c) the multi-state Safety Net Medical Home Initiative (Reference).
 PCMH and ACO Differences

While PCPs are core to the care delivery process in both models, a single independent PCP practice heads a PCMH; this is unlike an ACO in which many coordinated PCP practices working together headed a single organization that is typically a hospital or health plan. That means a PCMH is accountable for care cost and quality rendered by one PCP and the specialists treating a particular patient. In contrast, an ACO is accountable for care delivered across multiple PCPs, specialists and hospitals.

Other differences include the following ...

In an ACO, providers form a “tightly-coupled” network in which everyone operates under the same “global standards” by using the same preferred practice guidelines, health IT and centralized communications. This can:
  • Streamline central management and control of patient information
  • Promote “top-down” (hierarchical) decision making in which “weak voices” (i.e., people not high in the hierarchy) do not have much influence in how things are to be done
  • Reduce clinician autonomy and empowerment.
In contrast, each PCMH is a “loosely-coupled” network of PCPs and specialists with its own “local standards” for clinical processes, health IT and point-to-point (decentralized) communications. This can:
  • Provide personal management and control of patient information “owned” by each clinician
  • Promote collaborative “bottom-up” decision making in which all involved clinicians have a meaningful say in how things are to be done
  • Increase clinician autonomy and empowerment.
In my next post, I’ll discuss why both PCMHs and ACOs have an important role to play, as well as how they can operate within a health information exchange (HIE) to emerge clinical knowledge that is useful to everyone.

Friday, August 05, 2011

Webinar: Live Demonstration of our Medical Home Health IT Invention

Join us for a Webinar on August 10   

An idea conceived 30 years ago—for a simple, secure, low-cost way for people everywhere to collect, exchange and use relevant health information—is now a reality.

During this webinar, we will demonstrate and discuss how the ReAsure HealthNode™ (RAHN™) MedHome software offering enables the right people to share the right information at the right time, and to do it securely and for the right price. RAHN™ uses four beneficial methods to achieve this:
  1. It obtains, combines and analyzes all types of health data from any sources with a powerful electronic processing engine
  2. It protects the health data under lock and key with a state-of-the-art electronic file cabinet
  3. It turns the health data into useful information with an ingenious electronic document designer
  4. It sends the information through the Internet quickly and easily by secure electronic mail.
From a technical perspective, these software programs provide a desktop-to-desktop solution that bridges the HL7/middleware interoperability requirement to provide HIE-to-HIE interoperability in a fragmented clinical information exchange environment. They can work with any databases and data formats.

From a clinical perspective, our easy-to-use programs add translation and collaboration capabilities to help simplify a provider’s workflows and support clinical decision-making.

The webinar will focus on one of the RAHN™ MedHome programs, the Referral Manager application, which is currently in pre-production testing. This flagship software program enables primary care providers (family physicians, GPs, etc.) to manage referrals and coordinate care in patient-centered medical homes and other care settings.

It costs only $49.95, and you can download and install it yourself. There’s truly nothing like it! Come see for yourself.

Clinicians, researchers and health IT developers are welcome. We are very open to collaboration.

Title: Live Demonstration and Discussion of the ReAsure HealthNode MedHome Software Offering
Date: Wednesday, August 10, 2011
Time: 2:00 PM - 3:00 PM EDT

Space is limited.
Reserve your Webinar Seat Now at:

System Requirements

PC-based attendees
Required: Windows® 7, Vista, XP or 2003 Server

Macintosh®-based attendees
Required: Mac OS® X 10.5 or newer

Monday, August 01, 2011

Is the Annual Wellness Visit Program a Farce?

Jane M. Orient, M.D.—Executive Director of the Association of American Physicians and Surgeons—recently sent an e-mail titled “The Medicare ‘Wellness Farce’ that ridicules the value of Medicare’s annual wellness visit (AWV) program. This is a healthcare reform program of the Federal government’s Affordable Care Act, which is meant to cut healthcare costs by promoting good health. While she believes it is likely to control spending somwhat, she conjectures that the “well care” is not a good thing for people who are ill because it will take money away from their “sick care” they need. Here closing sarcastic statement was: “It is much better for society to keep healthy people healthy than to lavish resources on keeping sick people alive. Isn’t it?

My response to that last comment is this: Keeping healthy people healthy AND keeping sick people alive are BOTH good for society. However, lavishing resources on keeping sick people alive insinuates uncontrolled spending since the word lavishing could mean extravagance and excessiveness.

A much better statement, therefore, would be: It is equally important to society to keep healthy people healthy as long as possible, as well as helping sick people manage or overcome their health problems, while wisely/prudently/judiciously distributing our limited resources. This statement implies the need to focus on two things largely absent from in our current healthcare system

1. It is crucial that the patient/consumer gets true value for the care received. That is, care cost-effectiveness must be the primary factor in determining how to spend our healthcare dollars.

2. A whole-person integrated care approach is the most rational way to go. This model does two things: It (i) brings together well-care and sick-care and (ii) focuses on improving a person's health and wellbeing by addressing one's physical health (body), mental/psychological health (mind), and the mind-body connection ("holistic" health). In other words, it views an individual as a whole entity, whose body, emotions, thoughts (e.g., attitudes and expectations) and behaviors are interconnected. See this link for more:

Thursday, July 28, 2011

Are Healthcare Services and Products Merely Commodities?

I had a discussion with someone who brought up an interesting point about insurers/payers who treat healthcare services (tests and procedures) products (medications, lab work, medical devices, etc.) to be commodities that are by paid piecework. This model is in sharp contrast to the Pay-for-Value/Value-Pricing model I've been proposing.

The idea that healthcare services and products as commodities is based on faulty reasoning. In reality, the services rendered by different providers, and the products produced by different manufacturers, are often not equally (a) effective in terms of safety and quality (degree of risk and benefit to the patient); (b) efficient in terms of speed and resource consumption; and (c) affordable in terms of overall cost. In other words, they are not equally cost-effective. As such, it is irrational to pay the same amount across the board for a particular type of healthcare service and product. A more sane approach would be to use a value-based model of pricing that pays more for the services and products that deliver greater value to the patient/consumer by being more cost-effective.

There are many reasons why American healthcare does not have such a value-based model. An excellent article recently published in NEJM (at this link) addresses this issue directly: The $640 Billion Question—Why Does Cost-Effective Care Diffuse So Slowly? Bottom line: There is little financial incentive, and great disincentive, to promoting cost-effectiveness in the current US healthcare system. Here’s a brief quote:

“To avoid financial crises in federal and state governments and turmoil for health care stakeholders, U.S. health care must become more cost-effective. The United States spends much more per capita on health care than do other developed countries, with broad outcomes no better than those of its peers...There are, however, individual U.S. physicians and health care organizations that deliver high-quality care at a cost roughly 20% lower than the average. If the rest of the U.S. health care industry followed their example…$640 billion would [be saved. The reasons for our failure to focus on cost-effectiveness] lie in the perceptions and behaviors of the major participants in health care.”

I’ve been writing about the need for a value-based healthcare system since 2007 (see and It seems to me that fixing healthcare in the US (and our economy in general), requires (in part) that we transform our pathologically mutated model of capitalism (see into a rational model based on rewarding delivery of value to the consumer!

Tuesday, June 28, 2011

Personal Health Information Security

We’ve been having an interesting technical discussion at LinkedIn (at this link) about health information security when trying to share patient data among multiple data silos. We’re examining issues concerning the security of cloud computing, e-mail, and information stored in local computers and mobile devices. We’re discussing the strengths and weakness of encryption, exploring reports of data breaches, and identifying the incremental risks of different security prevention approaches.

We’re also presenting and evaluating innovative security solutions, such as: (a) allocating a specific IPv6 block just to healthcare; (b) using a novel method that is impossible hack (even with brute force) by “scrambling and padding” patient data using multiple keys; (c) separating patient identifiers from the person’s clinical data; and (d) using globally unique IDs (GUIDs) to name patient data files and mapping the GUIDs to the actual patient identifiers.
These kinds of creative discussions and brainstorming are essential when seeking solutions to the daunting challenges facing healthcare reform. The important thing, imo, is to be open to all ideas and critically examine them in terms of strengths, weakness, problems and risks.

Related posts:

• Should Personal Health Information Reside in Silos?
• Who should Own a Patient’s Health Data, Where should they be Stored, and How should they be Exchanged (Part 2 of 2)
Personal Health Information Privacy

Monday, June 27, 2011

Healthcare Reform "Value Promotion & Reward" Strategy

I've been writing about the need for high value healthcare for over four years. In the past year or so, more and more people have begun discussing the notion of value with regards to healthcare reform.

I've recently participated in one such discussion at KevinMD in a post about the tension between physicians and health policy experts (at this link) and another about how physician consolidation places health reformers in an ironic dilemma (at this link).

My comments focused on making the case that success healthcare reform models must be built on strategies focusing on (a) delivering high value care to every patient (client/consumer) by (b) enabling and rewarding the efficient delivery of high quality (safe & effective) “sick-care” (treating illness and dysfunction) and “well-care” (prevention and self-maintenance) within (c) a trust-worthy learning environment that promotes continuous, demonstrable improvement in care value.

Such strategies measure value as quality divided by cost, which is a measure of cost-effectiveness.
Key tactics of this value promotion & reward strategy are:
  • “Value-pricing,” which means paying more for healthcare services and products proven to be more cost-effective (and vice versa)
  • Patient-centered cognitive support, which consists of advanced health IT systems that help practitioners/clinicians/providers avoid information overload as they: (a) gain deep knowledge patients’ problems and risks, along with sharp awareness of the most cost-effective diagnostic, treatment and prevention options and (b) use that knowledge and awareness to make valid decisions, take competent actions and achieve good outcomes 
  • Shared decision-making, during which health practitioners educate patients about their treatment options in understandable language that takes into account patients’ individualized needs, circumstances and preferences
  • Practice-research collaboration (knowledge networks) that generate and disseminate ever-evolving evidence-based preferred practice guidelines and self-help recommendations
  • Healthcare delivery models assuring access and availability of high-value care to everyone.
Related posts:

The Need for a Value-Pricing Model in Healthcare
Enabling EHRs to Improve Care
Healthcare Reform Models Focusing on Value to Consumers - Part 1
Healthcare Reform Models Focusing on Value to Consumers – Part 2
Healthcare Reform Models Focusing on Value to Consumers – Part 3
Four Interlocking Issues about Fixing American Healthcare
Patient-Centered Life-Cycle (PCLC) Value Chain--Process Reform: Pay for Value

    Friday, May 27, 2011

    The Need for a Value-Pricing Model in Healthcare

    We must reduce overall healthcare costs and improve quality, which would increase value to consumers (patients/clients), improve their quality of life, and increase access.

    The metric for Value is Quality divided by overall Cost. Quality is the effectiveness of (a) treating illness/dysfunction treatment (as measured by risk-adjusted clinical outcomes, such as changes in a patient’s signs and symptoms); (b) preventing illness/dysfunction (wellness); and (c) stabilizing chronic conditions (disease management). Overall costs—including the cost of meds, tests, treatments and equipment/devices—rises because of inefficiency, waste, errors/malfunction resulting in additional care, excessive tests and procedures, over-prescribing, excessive risk, failure to select good lower cost alternatives, administrative & operational overhead (including malpractice insurance), etc.

    From a consumer’s perspective, therefore, greater value care is more cost-effective care.
    I contend that we should all be focusing how to increase healthcare value by:
    • Rewarding providers and manufacturers who deliver higher-value services and products
    • Enabling physicians and other practitioners to deliver high-value care through health IT, care coordination, ongoing clinician-researcher collaboration to build and evolve value-enhancing evidence-based guidelines, etc.
    • Enabling consumers to distinguish between high- and low-value services and products
    • Reducing providers’ economic burdens by lowering medical school costs through subsidies and malpractice insurance rates for high-value providers.
    This is the essence of a “Value-Pricing” (Pay for Value) model of healthcare; it is a sensible alternative to the insane open-ended fee-for-service (pay for volume) model and the restrictive salary-only model.

    The policy wonks, healthcare providers, researchers, payers and consumers ought to be debating how to make Value-Pricing a reality since it is the only rational way to achieve the ultimate goal presented above. All other conversations simply miss the point!

    Related posts:

    Healthcare Reform "Value Promotion & Reward" Strategy
    Healthcare Reform Models Focusing on Value to Consumers - Part 1
    Healthcare Reform Models Focusing on Value to Consumers – Part 2
    Healthcare Reform Models Focusing on Value to Consumers – Part 3
    Four Interlocking Issues about Fixing American Healthcare
    Patient-Centered Life-Cycle (PCLC) Value Chain--Process Reform: Pay for Value