The Savvy Tech Strategy Behind Obamacare

snydeq writes "The U.S. health care industry is undergoing several massive transformations, not the least of which is the shift to interoperable EHR (electronic health records) systems. The ONC's Doug Fridsma discusses the various issues that many health care IT and medical providers have raised regarding use of these systems, which are mandated for 2014 under the HITECH Act of 2004, and are all the more important in light of the 2010 Patient Protection and Affordable Care Act, aka Obamacare. Key to the transition, says Fridsma, is transforming health IT for EHRs into something more akin to the Internet, and less like traditional ERP and IT systems. 'I think what we're trying to do is the equivalent of what you've got in the Internet, which is horizontal integration rather than vertical integration,' Fridsma says. 'We've done a lot of work looking at what other countries have done, and we've tried to learn from those experiences. Rather than trying to build this top down and create restrictions, we're really trying to ask, "What's the path of least regret in what we need to do?"'"

Comments

Too bad someone didn't figure this all out

[hsmith]

Before the govt started handing out $44k for docs to adopt shitty EHR systems and collect free money. We now have a plethora of shitty EHR systems in hospitals that don't solve any issues at all.

So, the government created this incentive (Which made a few companies insanely rich, like Epic, Cerner, and Athena) - and created this massive siloed data mess. Anyone who has worked in HIT knows what a complete failure this EHR rollout has been on every front.

Even better are the CHIIT "certification" standards (aka, a complete pile of shit) which were to ensure that EHR software met a bunch of standards to get that $44k. One of the hallmarks was "Interoperability" - which to CHIIT meant "systems can communicate with themselves" - derp.

The EHR rollout was a complete failure, mainly due to the govt pushing shit out on the marketplace with their stupid incentives. It is going to take over a decade to untangle the mess of complete crap.

Re:Too bad someone didn't figure this all out

[intermodal]

This is from the same government that brought us the VA hospital system. I work in HIT myself, and I see nothing good coming of these new technology mandates.

Re:Too bad someone didn't figure this all out

[cs668]

Actually makes things worse. Because when the EHR's are in place they usually make sure to maximize the billable services provided in the back office so that you make sure to submit every claim possible. This helps to raise healthcare costs instead of lowering them by reducing paperwork......

Re:Too bad someone didn't figure this all out

[hsmith]

Good idea, but in reality it should be all revolved around creating true standards and interoperability. Systems communicating together should have been the single desirable element in all of it. Instead, it was an afterthought. Now we get garbage like Commonwell (From the 5 largest EHR vendors) that will create more proprietary garbage.

The people that created the mess we are in want to fix it? Please.

Re:Too bad someone didn't figure this all out

[h4rr4r]

The best way to do that would have been to recreate a FOSS reference implementation. Let this be the BIND of these types of systems. Also it would give an inexpensive starting point for all the other systems, so many vendors could compete for integration and management, or even alternate implementations.

Re:Too bad someone didn't figure this all out

[PatHMV]

Right on. Moreover, who benefits from all this, anyway? The idea is that the patient benefits, because an ER doc at one facility can see all of that patient's health records when treating him. But what if the patient doesn't want that? The reality is that all this centralized electronic data will benefit insurance companies, not patients. Once certain things (epilepsy, say) are flagged in your electronic, accessible to any person authorized by law to see them (and that will be insurance companies, governments, and probably your own employer at some point), then it's there, and you're tagged for life. Good luck getting a driver's license. Or overcoming the stigma of some unpopular disease.

I don't WANT all of my medical records out there. I don't think it will benefit me or my health. But these days I have little choice.

Re:Too bad someone didn't figure this all out

[AK Marc]

As opposed to the EHR before Obama, where I literally had to pay $200 for a hard copy of my X-ray to walk it two doors down the hall to give it to the doctor, who had to go walk down the hall the original place to see the electronic stored copy because the resolution wasn't sufficient on the hard copy, but it was stored electronically. I never had a patient system that talked to any others.

I moved out of the US, now any doctor I go to in the country, can look me up by name and DOB and see my entire medical history (or health care number, which nobody ever has on them).

The problem the US commits every time is that they ask the people who profit from the systems, how to make them. Every solution I've seen could have been done better by a bunch of high school students. The pros have a vested interest in making it fail. The worse it works, the longer they have jobs. And never are there financial penalties in government contracts.

Re:Too bad someone didn't figure this all out

[flink]

It's already well underway: http://openehealth.org/

Re:Too bad someone didn't figure this all out

[brentrad]

So what you're saying is, if you have epilepsy, you want the ability to hide that from the DMV, so that you can still drive your car while having a potentially very dangerous condition to have while driving? You want the "freedom" to continue to endanger the lives of others so that you're not inconvenienced by having to take public transportation. Gee, thanks for your concern for your fellow man.

Not really that convincing an argument for keeping your medical diagnoses secret.

Re:Too bad someone didn't figure this all out

[ideonexus]

This. This. This.

My wife and I had our second child two weeks ago. Despite the fact that we had spent nine months working closely with a clinic that had been monitoring the pregnancy, dispensing the proper medications, and who had midwives and doctors working at the hospital we would be delivering at, when we arrived at the hospital we found that they had NOTHING in their systems regarding my wife and her medical history. We then spent an hour telling the triage nurse everything we knew about the pregnancy from memory, until a doctor from our clinic finally showed up at the hospital with a big folder of printouts that no one had time to look at because my wife delivered a half hour later.

When we asked afterwards why the hospital had no record of us despite the fact that they knew we would be delivering there, they explained their system had no way to transfer electronic records and that they were still relying on printouts that would have to be entered by hand. Amusingly enough, they were launching a new networked electronic system while we were there that would enable the transfer of records.

Of course, the hospital staff freely admitted the new system was a complete headache to learn and that they had resisted it as long as possible, but thanks to "Obamacare" they were now required by law to implement such a system. Let that sink in for a moment. Hospitals are perfectly happy to have absolutely no information on the patients that arrive in their emergency rooms in America because upgrading their information systems is a hassle.

People complain about government regulations, but in this case, I'm perfectly happy to have government give the Medical industry a swift regulatory kick in the ass on this. There is no excuse for endangering human lives like this.

Bingo

[Anonymous Coward]

I just filled out my BS bingo card when they called both "horizontal integration" and "vertical integration".

On topic: The path of least regret would have been single payer system, but we somehow ended up with a Republican profit-utopia called "Obamacare".

Re:Bingo

[h4rr4r]

Infinity Imaginary mod points to you sir.

Re:Bingo

[Geste]

In the Clinton era (think HRC and Ira Magaziner) the arrogant, doomed approach was to use the Democratic "Big Tent" and invite all players -- pharma and insurers included -- to invent some fanciful "Health Care Reform (TM)" that would make all parties happy. Instead, insurers and pharma burned down the tent, scattered the ashes, then stabbed Health Care Reform to death.

Fast forward to the Obama admiserablestration, and there's not even a pretense of making anybody happy beyond the guys with the knives. You might call Clinton's failure a blunder born of hubris, but Obama's "success" is a tawdry monument to special interests and avarice.

The one rational chance for "reform" would have been a hard-fought, progressive fight for single-payer. That chance sank to the ocean floor in 1993.

This article is built on a bad premise.

[intermodal]

There is nothing necessary about what they're mandating.

Thanks to the way Washington, D.C., works, the end result will be smug bureaucrats patting each other on the back, and doctors wondering if they should just find a different field to work in.

It uses the standard government tech strategy

[Richy_T]

Costs three times as much as the originally budgeted cost, is delivered five times past the deadline and doesn't do a tenth of what was promised.

Learning from what other countries have done?

[Hatta]

Other countries have single payer health care, which delivers better outcomes at a lower cost. Try learning from that.

Re:Learning from what other countries have done?

[h4rr4r]

That does not maximize insurance industry profit. Which is in fact the entire point of the ACA.

Re:Learning from what other countries have done?

[Anonymous Coward]

That does not maximize insurance industry profit. Which is in fact the entire point of the ACA.

Nope. The entire point of the ACA is to destroy the insurance industry, causing an emergency for which the only solution will be single-payer.

They told the insurance industry "sure we're bending you over a barrel here, but at least you are going to get a lot more people buying policies." The insurance industry never wanted this, but tried to get the best deal they could to try to weather the storm.

But insurance companies are screwed. If you don't buy insurance, you pay a penalty, which goes to the US federal government and not the insurance companies. The penalty is cheaper than insurance, and because of "no preexisting conditions" the insurance companies have to accept you even if you took the penalty for years. So, when you are young and healthy, you pay the penalty; then when you get cancer, or get hit by a car, or incur any other major health problem, you immediately sign up for insurance, they have to take you. So the insurance company gets one month of premiums and then pays big for care. The ACA makes it so that the rational thing to do is only to sign up for insurance when you know you have bills that will cost more than the insurance payment.

Also, the ACA defines what kind of insurance you must buy: did you want high deductible with low premiums? Sorry, you can't have that, the ACA doesn't allow high deductibles. So premiums are guaranteed to be high, thus encouraging people to just pay the penalty.

Is this by design, or is the ACA incompetently written? I'm pretty sure it's the former.

I remember seeing a YouTube video of a Democrat in Washington D.C. talking to a group. "People say the Affordable Care Act has a 'Trojan Horse' hidden inside it that will lead to single payer. What's hidden about it? It's right there!" The audience laughed and cheered.

I couldn't find that one but I did find this. At about 4:40 a Democrat says "some guy from the insurance industry said the public option would put insurance companies out of business. He was right!"

http://www.youtube.com/watch?v=926bPZiQhgY

Re:Learning from what other countries have done?

[Hatta]

Single payer just makes sense. A centralized, not for profit system is going to be more efficient than a thousand different companies with their finger in the pie.

And what's wrong with a little pressure to conserve resources? Waste is rampant in the medical industry. As it is now, hospitals get paid for an x-ray whether it's needed or not. More needless tests means more profit, exactly the wrong incentive. We need to tie funding to outcomes, not procedures, and a centralized system is the right way to do that.

Re:Learning from what other countries have done?

[CanHasDIY]

Yep. It really amazes me that Obama set up the law so that he had to fight with states to set up health care exchanges.

Ah, well, simple answer there - he didn't

Re:Learning from what other countries have done?

[Kjella]

And those countries do that by either gaming the statistics, or having a homogenized society where social pressure to conserve public resources can be successfully applied.

And several moderators from the USA! USA! USA! crowd have swallowed it hook, line and sinker already. If any country is doing anything better than the US, they must be lying or the situation is not comparable. Here's how it really works, most of our doctors are public employees working for a public doctor's office or hospital which means they don't have any direct incentive to pad the bills. Private institutions mostly do things by public requisition like this patient needs a back surgery, here's $X to do it and there are no kickbacks to the referring doctor. Our patients wants the best treatment money can buy (without paying the money) just like yours and we too have limited funds. The difference is that we mainly leave it to the doctors to decide what is a medical necessity rather than the insurance companies what is a legal necessity.

Just because our coverage is universal, it doesn't mean that we're handing out treatments and medications and aids left and right. You have to go through a whole system with your general practitioner, specialists and an application process who employ their own reviewers to be issued an aid, yes you might eventually get a free hearing air or wheel chair but chances are very good that you have a real medical need for one and you don't want to "lose" it to start the paperwork all over again. Not that there's much of a domestic market anyway since those who need it eventually get it for free so you'd have to smuggle it out of the country. Besides it's not like you're getting pampered there, unless I have a real reason for being there I don't want to be stuck in the doctor's office - or rather the waiting area.

Speaking of waiting, we have queues for many kinds of surgery - even if you've passed the medical requirements and everyone has signed off that yes you should have it you're still going to wait for capacity and they have priorities there as well, it's not the person with the right insurance policy who pays the most it's the person with the most dire medical need. I'm not going to pretend that it's all flowers and sunshine and that every patient is actually treated perfectly equally, but we're at least working towards that goal. To that end we also have guest patients, if your local hospital doesn't have capacity you can have the surgery at any other public hospital in the country that does. It's not like in the US where you're stuck with the hospitals your insurance company has a deal with. But hey, social pressure sure. Let's pretend.

Re:Learning from what other countries have done?

[Hatta]

What good is freedom if you can't exercise it for fear of medical bankruptcy? Social safety nets make us all more free.

Re:Learning from what other countries have done?

[brentrad]

The entire point of the ACA is to destroy the insurance industry, causing an emergency for which the only solution will be single-payer.

We can only hope. That would be the best possible outcome. Tell me again what the point of insurance companies is?

Re:Learning from what other countries have done?

[brentrad]

Nope, I'm just opposed to health insurance (in its current form.) Auto/fire/theft insurance is one of those "just in case" things. If you are careful, you may never need to use that insurance, and therefore your insurance costs will be lower, and that's a great thing.

Health insurance is a different thing altogether, because everyone is going to need to get health care throughout their life. Even if you're careful, exercise all the time, eat well, you could still have a incredibly costly genetic disease that will bankrupt you even with good insurance. If you avoid getting health care throughout your life, you're going to tend to be less healthy...and then eventually you'll need costly care, and in the end you haven't saved any money at all.

I agree we should extend the benefits of Medicare. In fact, let's extend it to cover everyone in the US, i.e. Medicare Part E (for everyone.) Great idea, I'm glad you recommended it. You do realize Medicare is a single payer system right?

Cato Institute? Puh-lease. Why don't you just link directly to redstate.com or huffingtonpost.com? It would be just as fair and balanced as anything from the Cato Institute, a well-known libertarian think tank that is opposed to the government being in charge of anything.

The free market has had plenty of time to demonstrate to us exactly how they handle healthcare insurance. If the free market worked, healthcare in the US wouldn't be in the state it is today. Instead what we get with free market healthcare is preexisting conditions, yearly and lifetime benefit limits, insurance companies that spend all their time figuring out how to not pay claims, insurance companies that will cancel your coverage if you have an expensive claim and forgot to mention on your insurance application that you had acne treatment when you were 17, etc.

I've worked in the healthcare industry for over 10 years, and I've been on both ends: I worked for an insurance company, and I work now for a healthcare clinic. Please don't try to tell me that insurance companies' hands are tied by the government, and that's why costs are high and coverage is bad. Insurance companies are in the business to make as much money as they can, and they do that by paying as little as they can, and charging as much money as they can get away with. Any savings they pass on to shareholders, they don't cut costs to their customers. They also raise costs to providers by each one having their own highly specific rules about how claims must be submitted and formatted, what information needs to be sent with each claim, etc. If the insurance companies would get together and decide on a set of common rules, we could reduce complexity and cost for providers and patients. But instead we have a Business Office with around 20 employees, processing claims for 30 physicians. It's sure great for providing a lot of jobs, but increases the prices for everyone.

Not sure where you got the part about "everyone who disagrees with you is an inhuman monster who just wants poor people to suffer and die". Was that directed at me, or just at some caricature Democrat/liberal/socialist that you are assuming I am?

Standardization is the right approach

[msobkow]

Remember the EDI systems of old? Have you worked with XML today?

Those data transfer systems only work because the information formats are standardized amongst the products that claim to support them.

Unfortunately, EDI standards were often a "kitchen sink" approach with a bazillion "optional" message components to cater to the "special features" of vendors who had enough clout to demand that they be supported.

A rational, clean, genuine reworking and reengineering of data streams would lead to interoperability and the ability to share information between all the different components involved, while allowing specialized features to be tailored to the vertical segments of the marketplace (doctor's office, hospital, pharmacy, and so on.)

The unfortunate thing for the IT industry is that there are very few verticals within the horizontal, so if the "big players" provide for those markets, there is little to no market left for anyone who wants to get a foot in the door. I'd be willing to bet that 90% or more of the negative comments in this thread about the initiative are from people who work with or for those smaller players, and who see their jobs disappearing as the megaproviders take over.

Re:Standardization is the right approach

[h4rr4r]

Instead of all of this why not have the government provide one piece of software that does this for free to doctors and let that also be the reference implementation?

I'll Bite

[Cornwallis]

As one in the field the only thing "savvy" about the [fill-in-the-blank-government-agency] strategy is the salespeople getting the government to throw boatloads of money at shit that once again WILL FAIL TO DELIVER.

Apples and Oranges

[Anonymous Coward]

Other countries have single payer health care, which delivers better outcomes at a lower cost. Try learning from that.

Those are free, democratic and egalitarian societies with a socialist bent.

We in the US, OTOH, are a feudal republic with an ignorant population that is under the delusion that all they have to do is work hard and they'll be rich.

Mod up parent!!!

[Presto Vivace]

it's not too late, we could still pass HR 676, Medicare for All.

Re:Mod up parent!!!

[CanHasDIY]

it's not too late, we could still pass HR 676, Medicare for All.

Doesn't matter if it's the best idea humanity ever came up with, it won't go anywhere in its current form.

Now, were it to be renamed the Anti-Terrorism Immigration Marriage For the Children to Protect America Act, we might actually be able to move the ball forward...

Remind us how many Republicans voted for it

[Anonymous Coward]

It's kind of hard to blame any of it on the Republicans since they were not at all involved in the meetings and didn't vote for it.