Doing The Right Thing

Having just returned from HIMSS, the Supershow of Health Information Technology, I'm trying to shake off the flashing lights, Health IT booth-turned-pub, the DeLorean silver car and other attention grabbers to see what the potential of $40B of our tax money to be spent on incentives means for improving the state of health care information technology in the country. The sad truth is not much. It's still really hard and really expensive to get clinical information from point A to B, (unless the same company is at both ends, and then it's just expensive) and to get well edited and timely information on mobile devices. These are basic fundamental needs that any other industry has, and yet the most curious thing to me is that there is no anger, no outrage, from the hospitals that are forking over the money, year after year. As a former CIO in two other industries, I know that until the clients start voting with their wallets, no change will be forthcoming.

Like any other industry where a lot of money is at stake, there are major companies that control a lot of the market. In our industry, these include well known names like GE, and, Siemens, and industry specific powerhouses like McKesson, Epic, Cerner and Allscripts. Historically, these companies have been selling primarily to hospitals, but with the new HiTech act of 2009, they are expanding their products to reach physicians as well.

It's been pretty clear for decades that these big companies' strategies include total ownership of the hospital's information. But health care never happens just in a hospital setting, and very infrequently in a single doctor's setting. There needs to be a simple, low cost way to get this information around--just like you can order on-line from multiple places and track your package on UPS, or go to a bank anywhere around the world and get cash.

So thought our government, when they spent 800+ pages detailing "Meaningful Use" for our country. To boil the law down to its essence, there are two parts to it; first, you must have an electronic system of record where patient information is kept securely in standard form. Second, you must make that information available electronically so a person or another system can use it. Pretty straightforward, right?

After two years of teeth gnashing and hand-wringing, led mostly by incumbent vendors, who led a charge to water down the requirements to meet them, I was eager to see our new, improved, interconnected world. As my grandfather used to say, "A leopard can't change its spots." What have these big companies done to help systems talk to each other? More of the same. It is still hard to communicate between systems, and if you insist on it, it will cost you a small fortune. Two software practices, bundling (making you buy a lot more than you wanted to get a specific feature), and forced upgrades seem to be the commercial methods in play if a hospital wants to achieve compliance.

As an experiment, I went to all six of the major vendors to see how we, a small company, could interface with their systems. This isn't a unique question, according to our government's tax roles, there are over 5000 smaller Health IT companies, devices, and system integrators that would like to make their systems work with the big systems.

"Oh yes, as soon as our mutual hospital client upgrades to our newest version, and then requests an integration specialist"--Upgrade cost? Over $10M dollars for a 500 bed hospital (assuming they already have paid tens of millions for the system). Three of the six gave a similar answer. Fine print--there are many other upgrades included in these new versions, but if you just want to be able to read/write HL7, you must upgrade)

"If our clients buy our whole system, they have no need to integrate with anything else." Really? Does your system links with PACs? "That's a special integration project." Labs? "Hospital labs are special integration projects." Mobile devices? "We have a Citrix client to display things on a browser." How much does your system cost? Anywhere from $30M to $250M dollars..."

Best answer, two of the six had a special HL7 services pack that was a separate module for purchase that didn't require a total system upgrade, (price not given), but the red tape, the information comes out standard in a pdf format, not machine format. Why not? "We believe our system should be the center of all the information for that hospital."

All these big companies have followed the letter of the law, not the spirit of the law. You still can't get a basic hospital system without spending tens of millions of dollars--going up to hundreds of millions for a full implementation. A hospital IT system is expensive, but these bundling and upgrade practices make simple interoperability very expensive.

And it's not like the costs of these systems are hidden costs--Moses Cone, a 500 bed hospital near us in Greensboro, chose the rip-and-replace strategy (taking out an old system and putting in a new one) had this in their newsletter...

"A team of more than 90 Moses Cone Health System employees will begin training in October on a comprehensive medical information system that will be built through a contract with Epic Systems Corp.

The Health System has committed more than $80 million for purchasing and installing the software and hardware, as well as more than $30 million in staffing costs related to the electronic health record over the next five years. The system, which will be in place in two to two and a half years, will result in integrated billing, registration and clinical software packages that seamlessly “talk” to each other."

To each other, yes, but not to anyone else.

Let's put this in some perspective. During that same time 2 1/2 year period, a 500 bed hospital will see about 250,000 emergency patients. About 25% of them will be uninsured and without primary care. At $80 per primary care visit, each patient could get to see a doctor 20 times for the same money. Ultimately, it's all the same pot of money a hospital has to utilize. Better continuity of care for uninsured patients, or a systems project that ultimately locks in the hospital to speak only with other physicians with the same system.

At Axial, we believe all health systems should speak to each other safely and securely at a fair price. To back that claim, we put our technology in the public domain. We are building a library of public "connectors" that will let any legacy system speak to another legacy system. I challenge hospital CIOs and CMIOs to demand open access to the information they've paid dearly for. I challenge anyone operating in Health IT to do the right thing. Charge for innovation and health improvement, not linking billing and clinical systems--something that every other industry did decades ago. We challenge the rest of the industry to follow our lead.