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Last week, to the disappointment of health information technology project managers and consulting firms nationwide, the Department of Health & Human Services (HHS) announced a decision to delay the implementation of ICD-10.

The story broke on February 14, with a comment by the Acting Administrator at the Centers for Medicare and Medicaid Services (CMS), Marilyn Tavenner, at the American Medical Association’s National Advocacy Conference in Washington, DC. The AMA had recently argued strenuously to delay ICD-10 owing to the significant administrative burden it would place on providers, so we can’t help but wonder if the AMA begged her to spill the beans at their party.

Two days later, in a clarifying press release, HHS Secretary Kathleen G. Sebelius announced that the department would “initiate a process to postpone the date by which certain health care entities have to comply” with ICD-10. While we still need more clarification. “Certain health care entities” sounds like government speak for HIPAA covered entities but one can’t be sure. But we are fairly sure our clients will not be exempt from the postponement.

HIMSS joined the fray Friday with a late to the party rebuttal of the HHS announcement, calling on HHS to keep to the deadline. We get their point.

Anyone who knows something about running large projects knows that momentum is the key to success. Institutional memory lasts no more than a month or two. Nearly every dollar that has already been spent on ICD-10 will need to be re-spent when the project is taken out of the box again. While the government has grown accustomed to this kind of start-and-stop on giant projects—think expensive bombers and warships—the private sector fires people for decisions like this. It seems an incredible waste to shelve ICD-10, especially since every dollar spent must ultimately come from patient service revenue.

In a way, you can’t blame the government. They’ve created a mess. While one part of HHS is mandating that codes become more granular, the other half—CMS—is joining them up again in the form of hierarchical condition categories (HCC). While providers continue to be required to choose a billing code, Meaningful Use is pushing SNOMED (Systematized Nomenclature of Medicine — Clinical Terms) for a problem list. ICD-10 running right next to Meaningful Use was a recipe for failure right from the start.

In truth, we at athenahealth are pretty disappointed in the decision.  Like most organizations, we have already invested a boatload of people and time and, like Y2K, HIPAA, ANSI 5010 and Meaningful Use, we knew we were going to make it as painless for our clients as possible. Mandates like these are bellwether opportunities for us to illustrate the failure of the traditional software model and the power of the cloud-based services in helping our clients manage change. We were ready to take on the next big thing.

The real story is that our industry just could not cope with the change. Technology remains so far behind in health care that most vendors just could not shield their clients from the enormity of the transition. If the vendor community at large had its act together, the replacement of one code set for another would not have been so daunting.

But it doesn’t. So it was.

For many people in America, this Monday means a day off from work to honor the history of this nation’s executive leadership.

For many of us at athenahealth, February 20 will also mean observing executive leadership, but from a hotel balcony deck, high above Las Vegas during the HIMSS 2012 Conference. And we’ll be observing our chief executive, Jonathan Bush, making a few remarks about the value of cloud-based services in health care, addressing others in the health IT industry, fellow disrupters, interested media and prospective and current clients. There was talk of another kimono-style splash involving a superhero suit, a wrestling mask and bungee cords. But this time will be more buttoned-down. Maybe …

If you’re a prospective client interested in attending our Cloud Party at HIMSS, shoot us an email here at the blog. We’ll make room…

If you can’t make the party, please be sure to come by our brand-new HIMSS booth at #1029. We are always excited to see you and share the latest details about our cloud-based services like athenaCoordinator, our new service that can help grow your physician network and our EHR, rated Best in KLAS for practices with 11-75 physicians, by the way…

In the meantime, take a look at our updated YouTube channel by clicking on the image below. We’ve been putting out some really cool stuff including a new User Conference video, to get clients ready for our upcoming 2012 event. On top of a jam-packed schedule, the keynote speaker will be Abraham Verghese, physician and New York Times bestselling author. If you haven’t signed up for the User Conference by now, you should. (Sign up by close of business on Feb. 17 for early-bird pricing.)

And if you’re a prospective client, check out the User Conference video anyway to see what you can expect when you join athenahealth. Where else can you play a few rounds of blackjack with the head of product strategy dealing the cards?

So far in this blog series, I have talked about “the good” in health care IT. For example, EHR interoperability—when it exists—is really good. I’ve also shared some of “the bad,” like data entry and data access in light of a 400-page paper chart. Today’s entry focuses on “the promise” of health care information technology. That is, the potential of HIT to act as a foundational service in which to share research and protocols across providers, to benefit all patients, no matter where they are or who they know.

Here goes …

I had a really good cry just after I was diagnosed with Stage 4 colon cancer. The tears were laced with fear—I was scared. I cried for me, my wife and our kids—I couldn’t think of anyone else during the first 12 hours. I felt better, temporarily, as if the tears washed away a bit of the fear. But then, by the following morning, the fear was back. I was less scared of the diagnosis, and more anxious about the unknown process of how to cure it. Or whether it was even curable.

When the poking, prodding and questioning finally stopped and my diagnosis was launched into the cosmos, my wife and I had to figure out who my doctor would actually be. More accurately, we had to figure out how to figure out who my doctor would be. Also, we obviously had to determine what my treatment plan would look like. In short, we needed a route back to health.

This, I soon came to realize, is where connections who possess both extreme compassion and access to leading edge research and physicians intersected to create my health care HOV lane—a channel in the vast highway system of health care options that the patient firmly believes gives them the best shot at arriving at a safe and healthy destination. And like an HOV lane (high occupancy vehicle for the uninitiated, a smooth-sailing highway lane), if I could find a way into it, I could get back to health faster than the rest of the traffic because I had a few friends on board with me.

Stay with me on the HOV lane. The analogy may not hold for everyone, but let me explain what I mean and how it relates to a larger problem in health care. This is a solvable issue greater than just me trying to overcome my diagnosis and get back to wellness.

First, we had a connection who exhibited an immense amount of compassion for us. A few short hours after awakening the day after my diagnosis, a distant family friend (the mother of my wife’s sister’s college roommate… I did say distant) and a veteran leader at the hospital, walked into my room. She advised us to meet with the medical and surgical oncology teams that I’ve already referenced (Dr. R and Dr. T). She is a strong woman and I took her words as gospel the second I met her. 

It was clear that, in advance of her visit, she had pulled my chart, seen that I was 39 years old, read about the state of my disease and decided she was going to help. In an unexpected turn of events, I went from crying over the fear of “figuring out how to figure out how to get a doctor” to being assigned to two of the hospital’s leading physicians—both of whom had already discussed a very progressive chemotherapy and surgical strategy to get me back to the “Kingdom of the Well.” 

And with that… I was officially in my version of health care’s HOV lane. I was comfortable with the team and the very aggressive plan of attack. We were on our way.

While unbelievably grateful for the connections and compassion exhibited by our physician friend, I thought  a lot about the other 20+ million current cancer patients who may lack proximity or any connection to a leading edge cancer institution. 

This led me to another set of questions: Do patients who receive care at more remote or less research-oriented hospitals question whether they’re getting the best care possible? Further, could these doubts somehow compromise the efficacy of their treatment? Further yet, do huge swaths of patients miss the opportunity to follow what leading research deems the most effective protocols for care?

I have to assume the answer to at least one of these questions is “yes,” at least some of the time, for some patients. But it doesn’t have to be that way.

This is where HIT companies, in collaboration with the world’s finest research institutions, have an amazing opportunity—and maybe a responsibility—to pave the way for cancer patients (and their families) on their often harrowing journey to beat this ravaging disease.  

If you watched any of the NFL playoff games, you saw several large corporations advertising that their “super computers” are being used to cure cancer. The commercials show huge 3D servers and scientists viewing holographic images of DNA—all with an eye toward unpacking the riddle that is cancer. 

Having all that information makes for impressive advertising but it needs to be deployed to huge numbers of physicians in order to see demonstrable results—such as people staying healthy.

Here’s what I mean. With any diagnosis, limitless amounts of information can be gathered and analyzed to guide treatment. Many of these data—tumor markers, for example—guide oncologists toward specific treatment protocols. However, when you couple clinical research advances and protocols with the ever-expanding vastness of personalized data for a cancer patient, I see an emerging disconnect. This disconnect relates to the ability to readily identify relevant information from these massive data structures and surface those data into the hands of the oncologist… and then, directly into the treatment protocol of the patient. 

The collaboration between HIT companies and research institutions needs to enable promulgation of cutting edge research using patient-specific markers. It needs to find its way into the hands of the physician.

In perfect alignment, the match of patient-specific markers against leading edge treatment protocols would be used to create situational awareness for a specific patient as a standard part of the care process. It’s possible; we’re just not there yet. But like my HOV lane, I can see there’s a road to get us there.   

I don’t believe this information or the situational awareness to guide care should come for free. Massive amounts of funding go into aspects such as research advancement and universal information access.

And there is most certainly a market for it.

Leading institutions are already beginning to market their care protocols, but merging these protocols seamlessly with the care process must happen to ensure a reliable entrance onto an HOV lane, not just from a research institiution, but from any physician’s office in the country. It can and should be done, in an economically rational way.

When we reach this point as an industry, and a nation, it will be possible for any cancer patient to be comforted in knowing that a region, nation or world’s worth of clinical research is behind him or her—even if location or a family connection doesn’t enable them to align with the most prestigious hospitals in the world. 

It took collaboration on my care team—my fellow passengers in that HOV lane—to get me to where I am today. Someday soon that same collaboration and the connection and compassion coupled with access to leading edge research and physicians, will be writ large across health information technology. And the HOV lane will be wide enough for everyone. It needs to be.

The first half of January was quiet for the Government Affairs team with the nation’s capital having been closed for the holidays. OK, fine, and maybe I was being a lazy blogger as some of you have pointed out.

But last week, to the delight of idling cab drivers and bored policy wonks alike, lawmakers came back from their districts and DC was back in business! And it quickly became clear that the spotlight will continue to shine hot and bright on health care—and our HIT corner of it.

Here’s how 2012 started off inside the Beltway:

Monday, Jan. 23

The Senate returned, joining the House, to begin their longest combined work period of 2012. Because of the presidential election, this year will likely be light on legislation after a more permanent solution to the payroll tax holiday-UI- Sustainable Growth Rate (SGR) extension is passed. Fortunately, we can count on the Centers for Medicare and Medicaid (CMS) and the Office of the National Coordinator (ONC) to keep us busy with… Meaningful Use!

Tuesday, Jan. 24

The House and Senate Conference Committee for H.R. 3630, the “Temporary Payroll Tax Cut Continuation Act of 2011” held its first meeting, which fondly brought back divided Super Committee memories, with high level statements coming from both parties. You can check out the meeting and read statements from Sen. Max Baucus, D-Mont. and Rep. Dave Camp, R-Mich. We in health care are paying close attention to their decision-making because without a fix to the SGR, physicians face a 27.5% cut to Medicare reimbursement starting on March 1. Ultimately, the debate will come down to the funding source  for an extension of some sort. The committee met again on February 1^st and, right now, with so many details up in the air, many expect a decision to come down to the wire.

President Obama also gave the 2012 State of the Union address. He surprised many of us by leaving health care almost entirely off the agenda. He did reference Medicare and Medicaid, but mostly focused on job creation, education reform, energy and personal responsibility. We were, of course, happy to hear him call out the need for innovation. (Cloud! Cloud! Cloud! Just sayin’…)

Wednesday, Jan. 25

CMS sent Meaningful Use (MU) Stage 2 Notice of Proposed Rulemaking (NPRM) to the Office of Management and Budget (OMB) for regulatory review. CMS had previously sent the proposed rule for new and revised standards, implementation specs and certification criteria for electronic medical records (EHRs). In case you were wondering… the rules get sent to the OMB because they have an effect on our budget.

Besides the budget implications, the Stage 2 NPRM matters because it will define the Stage 2 criteria eligible providers must meet beginning in 2014, using a certified EHR, in order to meet Meaningful Use (MU). In contrast, the certification proposed rule will inform HIT vendors of standards that they must incorporate into their development for Stage 2 certification. Some items we expect to see include more specialty-specific measures, usability requirements, certification process details and interoperability and standards specifications.

The HIT Policy Committee met again on Feb. 1, though CMS informed the committee that, due to the timing, it would not be prepared with an updated analysis of MU performance results. You can refer to their January analysis for national trends and check out our Meaningful Use dashboard for athenahealth results.  Because of the February 29^th attestation deadline, we don’t expect final Year One numbers until March.

Thursday, Jan. 26

CMS and the ONC hosted The Care Innovations Summit, with over 1,000 attendees from across the health care spectrum. It’s always a treat to hear Atul Gawande speak and see Todd Park, Farzad Mostashari and Aneesh Chopra bring enthusiasm that I’m not accustomed to finding in health IT outside the walls of athenahealth. (As a side note, we’re sad to see Aneesh Chopra leave his federal role.) I’ll focus on the summit in a subsequent post, but the biggest highlight was a clear, broad consensus on the need for VALUE-based care.

Friday, Jan. 27

On Friday, the Bipartisan Policy Center released a report, “Transforming Health Care: The Role of Health IT,” at a morning event in DC. Whether you’re looking for good data, big ideas, or a good summary view of the status of HIT and its role in health care reform, I recommend reading the report. This one is right in our wheelhouse and we’ll circle back to it soon.

En fin

If you find your brain spinning (don’t worry, mine was too), stay tuned for deeper coverage of all these topics and events in the coming months. Think of this as a cheat sheet for what’s on deck in 2012. As always, we appreciate all your comments and questions, so send them in.

In my entry last week, I said that I’d review some additional examples of technology playing a key role in easing my experience as a patient battling Stage 4 colon cancer. I am going to loop back to that train of thought later and instead discuss one of the shortcomings of technology that I experienced just prior to two of my four surgeries.

Have you ever read The Wall Street Journal (WSJ) or The New York Times (NYT) on an iPad? It’s a lovely experience. The iPad is completely intuitive in a way that allows a reader to easily cover a myriad of information. Within seconds, I can go from the front page to the opinion section to the market news. Then, I can see unrelated articles within those sections. It’s ingenious, easy and fun to use.

So, let’s compare that experience to searching the massive quantity of information that is collected in an EMR for a patient like me. You’ve got basic family history, presenting illness, medication lists, op notes, infusion notes, visit notes, scans and reads from radiologists, EKGs, etc. Basically, like the WSJ or NYT on an iPad, a medical record holds a lot of disparate information that is tangentially related. Clinicians want quick and easy access to the data that they deem relevant—they don’t want to lick their fingers and turn pages to find this information.

So, let me talk about my first pre-op visit. I’ve had four surgeries since my diagnosis and all have had the exact same pre-op process unfold. I meet with my anesthesiologist or a stand-in, as well as several nurses and physicians, to talk about prep for the operation and what’s expected afterward. They draw some blood and give me an EKG test.  Standard stuff, I think. 

Well, about 30 minutes into my first pre-op meeting, I almost started to cry. 

That’s because each person I met with during this three-hour pilgrimage was lugging around their own copy of my 400-page chart. HERESY, I thought! An institution that has utilized technology quite well, thus far, was clearly in the neonatal phase of life as it related to sharing (or viewing) vast quantities of information across a wide group of people. 

The computer/EMR just didn’t cut it, obviously. I asked several doctors if the paper medical chart was standard for this part of the care process and the answer was “yes.”  It must be viewed as the quickest way to access random pieces of information buried in various portions of the patient’s vast chart. The format of the EMR must have limitations in this regard – likely designed for quick data input, with little regard given to the consumer who needs a specific view of a patient’s information further down the line.

This scenario was illustrated quite starkly to me. As a patient this time around, I could see the dichotomy between an EMR as a “piece of software” to input and store data, and this institution’s particular EMR as a “piece of software” to share discrete data across a broad group of stakeholders. It’s clear that, in some cases, an EMR can accommodate quick data entry. It’s also clear that an EMR can be useful as a data-sharing tool—when you know what information you need (e.g. when viewing a specific scan or blood tests). 

Having said that, based on the fact I was going through my pre-op process watching physicians thumb through my paper chart for awkwardly long periods of time, it was evident that the EMR does not offer a simple way to organize and render relevant information in all cases. 

Therein lies a massive shortcoming. And it’s affecting the simplified coordination and sharing of relevant clinical information at the time when the clinician needs it most—while standing in front of the patient.  This is where technology can be incredibly useful in determining what information is relevant based on the physician’s guidance. The utility comes from being able to present it in a manner that enables the clinician to quickly digest important information. The comparison to accessing The Wall Street Journal on an iPad quickly comes to mind because their sections, “article titles and summary” and “complete article text” can be accessed with a few finger swipes.

See the comparison for how relevant medical data could be organized for quick and predictable access? 

Although some companies and institutions claim to be making strides in this direction, it is certainly not easy. Done right, it requires the institution to gain access to all relevant components of a patient’s medical history, create algorithms to determine the relevancy of the information for a specific patient case and provide a streamlined ability to serve that relevant information reliably and quickly for consumption at the right time. 

As the amount of discrete data that is populated into an EMR extends beyond the limits of a human’s ability to find… search through anomalies… and digest, it is clear that information technology needs to take on that array of data, regardless of the complexity, and make it easy to access and digest. 

In so doing, the lengthy process of wading through a 400-page chart, as in my case, can be avoided. Relevant information can be teed up for the physician and the chance of overlooking a key data point can be drastically reduced. 

So here’s a question for you to contemplate: As you consider information technology solutions, how do you rate “ease of data entry” and “simplified & relevant data access”? What has your experience been, from either side of the exam?

As you may have read in last week’s entry, I got hit with a pretty hard cancer diagnosis on January 18, 2011.

Like I said, within one day, I went from eating peanuts and watching the Patriots on TV in symptomless bliss to being told I had a ‘significant number of masses’ on my liver… a tough nut to swallow for sure (sorry, couldn’t resist the pun).

Once we returned to Boston from Vermont, I was admitted through the ER, a 9-hour ordeal… Although they didn’t tell us immediately, my wife and I knew the diagnosis wasn’t good. Over the next few days, all suspicions were confirmed and I was diagnosed with Stage 4 colon cancer with metastasis to my liver. 

Although there were several moments during these first few days where I wanted to bolt out of the hospital to escape my new reality, I have to say there was an ironic peace of mind that finally came with the official diagnosis. With it, I quickly realized I needed to focus on how to begin my journey toward health.

And that journey started right away. My information (e.g. chart) traveled across the hospital VERY quickly – and within 24 hours over half a dozen physicians had read my chart and were collaborating on the best course of treatment. They had seen all the scans, reviewed all the blood work, reviewed my HPI (History of Present Illness) and read the notes left by the staff GI physicians and internist. They huddled up to hatch a plan with two of the finest doctors I will ever know—Dr. R (my medical oncologist) and Dr. T (my surgical oncologist).

My first visit with Dr. R was pragmatic in tone, with a solid injection of hope. 

He explained that my liver was covered with tumors… but added… that his plan was to be extremely aggressive. He would start my treatment with a chemo concoction typically used for pancreatic patients.

Although this course of treatment had only been documented in one study out of Germany for patients with metastatic colon cancer, Dr. R was confident that his plan to hammer me with Fulfurinox (the chemotherapy treatment) would be more efficacious than the standard protocol (Fulfox).

He followed by saying, ‘You’re young, and I know you can take it,’ and explained that his goal was a cure me, not just prolong my life. 

Dr. R showed me scans of my liver and the cellular invaders that were looking to bring me down. I could actually see the cancer in 3 dimensions covering my liver. At that point, I knew that my shot at life required this ridiculously tough chemo concoction.

Without hesitation, we wholeheartedly agreed to move ahead.

I’ve got way too much to live for and I was not going to let a little (or a lot of) pain get in the way. Oh, and another thing, if I didn’t go forward with this chemo, they likely would not have been able to perform the subsequent necessary surgeries to remove the liver tumors and I… well… probably wouldn’t be typing right now!

This first visit with Dr. R was also where the seamlessness of their health information technology (HIT) operations and the benefit of even the more mundane IT integration really began to help me as a patient. He opened up the EMR to show me scans, pathology reports, blood test results and explained all of it – the good, bad and ugly. For example, my CEA (Carcinoembryonic Antigen) levels were through the roof, I had tumors ranging in size from 2 to 8mm with eight (of the nine) located in my liver. The colon tumor (the primary tumor, of which there was one) was less significant – just a bit of cutting and it’d be gone. 

Dr. R explained my situation clearly, but it was the 3D images, viewed from within the EMR, that really helped me understand my situation and eventual progress. I am a visual person and would have lost half of what he said if we had just talked through it. These images were also critical to my own psychological therapy. Throughout the last year, I’ve used visualization exercises to create a positive mental environment to help the tumors shrink. Many arguments can be made as to whether visualization and positive imagery can actually aid in the ‘shrinkage’ of tumors – I wholeheartedly believe it can and it helped to know I was doing my part in the battle.

Further, once a month, my day would begin with scans at 8 a.m. followed by a meeting with Dr. R at 9. The one hour between these two appointments is almost impossible to handle emotionally – it is a grueling hour worrying about endless scenarios: would the scans show that the chemo is shrinking my tumors? Would it be ineffective against my tumor type? What if my tumors were still growing or something new appeared? 

Each minute between appointments seemed like a life-crushing day, but thankfully the wait was limited. One of the most comforting parts of this process was knowing that within minutes of my scans being complete, a very readable version of those images would be available for review within my chart. I can’t explain the duress that is avoided by this interface between the EMR and the medical device. Each time I arrived in Dr. R’s office – those scans were ready.

When these images dictate your shot at life… this seamless exchange of information is beyond critical. Upon Dr. R’s arrival in the exam room, we would review the scans and quickly know how we’re doing – good or bad. This illustrates one small example, from a patient’s perspective, of how important the seemingly routine aspects of HIT integration are to the people receiving this life-changing information. 

I am proud to know that on some small level, this is my life’s work.

In upcoming blog posts I will share a few more examples of where HIT helped me navigate the choppy emotional waters of this disease. I will also delve into the shortcomings and the promise of HIT, as I consider it from a patient perspective. In the meantime, thank you to everyone—and there were a lot of you—who read the first blog post in this series. I appreciate the kind words and your thoughts on the subject at hand. I will post responses as we move forward and please keep sending thoughts on what you read. Let’s keep talking…

I hope people are watching the news around the Meaningful Use attestation data released by CMS recently, because it is so instructive as to the difference between where we are in health care and where the deliverers of keynotes THINK we are. Since last September, we’ve been publishing our Meaningful Use (MU) dashboard data and as of this week for example, we know that 83% of our Medicare MU doctors have attested to the measures.

But our constraints as a marketplace are at the practical, tactical level. According to our analysis, some 48% of what doctors order does NOT turn into a documented update to the chart within 60 days of that order. And we all know the average EHR makes docs go slower—causing employment by hospitals in large numbers—at large losses to the hospital. And NOW, based on the CMS data, it looks like a large percentage of docs are on track to miss a bloody lay-up of a bonus from the federal government! Do you guys really think we are going to build integrated ACOs that drive down hospitalization?

Pass it on—we are further behind than we think we are, and we need to hold ourselves accountable for PRACTICAL, TACTICAL outcomes before we even talk about grand outcomes like “total quality.” So what do we do? So glad you asked. I hazard three guesses, and you guys can throw in more… or challenge mine:

1. Make a market for health information exchange. Today, HIE is universally used as a NOUN. It’s a thing you buy from Aetna or Lockheed Martin or IBM. In every other information supply chain I know of, people who WANT info PAY others to give that info to them. They pay only when the info is delivered in usable form. This is, of course, not allowed in health care, but it can be. We should get behind legislation that allows for the most rudimentary mechanism for exchange in the history of man.
2. We should all go at-risk for results. Today, when a doc orders something, she doesn’t lose any money (and neither do we) if that order gets lost. Starting in March, we will be at risk for delivering orders to the receivers (labs, pharmacies, specialists, hospitals, etc.), obtaining the result back, matching it against the original order and either closing it or serving it up to the doc for further review. If we do all this, we get a dollar. If we don’t, no dollar. We will be at risk for clinical quality in the tiniest, most practical, tactical way. Alternatively, we can charge a dollar to the receiver if he or she is in our network, because we can send a value-added clean order with documentation… just the way it’s done in every other information supply chain. Very cool.
3. Face it about the cloud! I know I’m conflicted on this one, but going at-risk for results is against my self-interest and I am still doing that for the good of health care, so hear me out. If so many doctors can’t pick up basically free money from the federal government because they can’t get their legacy, software-based IT systems to make even the most fundamental changes to the information they capture and report, what do you think the odds are that these systems will enable going at-risk for a total hip replacement??? Doesn’t plunking a ton of balance sheet down for a single version of software actually orient docs AWAY from changes that would otherwise be good for them? I know some of you are saying, “Yes, but docs are working for hospitals now!” But be honest with yourself. With athenahealth and Google and Amazon KILLING each other to get competent developers, how many of them are going to take jobs customizing legacy software written in MUMPS (Massachusetts General Hospital Utility Multi-Programming System) at their community hospital system??? We all need to take a deep breath and just dump those old systems. I did it myself just this last year. I had a “fully paid up” copy of a legacy financal system. We finally had the courage to bite the bullet and sign up with NetSuite. We literally had a haze cleared out of our lives that we hadn’t even noticed was there. We can change and grow in basic ways, without “investments” and “project teams.” What a relief.

Okay, those are mine… what are yours?

On Jan. 5^th, we issued a press release about the positive advisory opinion we received from the HHS Office of the Inspector General (OIG) on our athenaCoordinator service pricing. Insiders have observed that it is different from other OIG advisory opinions on referral management arrangements because it enables transaction-based pricing for value-added health information exchange. 

This is an opinion that was sent to athenahealth and only applies directly to athenahealth. However, it was made public, so many in the industry (mostly lawyers!) will look at it for guidance on other health information exchange (HIE) arrangements on which they may be advising clients.

There is a lot of legal language in the opinion, which can make it a little difficult to understand exactly what athenahealth plans to do with its athenaCoordinator service. Some commentary I’ve seen in the blogosphere and elsewhere has mistakenly referred to our service as a “private HIE.”

It’s not.

For starters, athenaCoordinator is cloud-based and it’s a service that provides order transmission, insurance pre-certification and patient registration among physicians, hospitals and other care nodes. It’s intended to eliminate the errors and redundancies that can impede the flow of care in our health system. When you travel through the care chain, you should be a known entity at each stop and not someone who has to re-establish your identity and health information with each iteration.

As for how athenaCoordinator is not a private HIE, let me try to cut through the legalese (as well as a General Counsel can reasonably do) and explain why athenahealth’s plans are innovative and different. 

1. Everybody is welcome – One of the big problems with the effectiveness of HIE is that HIE systems, both public and private, are typically open to only limited regions or markets. With public HIE, this is a result of governance and funding—they tend to be focused on specified regions and the administrative and technical barriers to sharing useful information limits their reach. Private HIE is typically and intentionally targeted within specified health systems or regions based on business considerations. The ultimate intent of athenaCoordinator is to make the data exchange services available to anyone in any market in the United States. We believe that widespread participation results in a stronger network, leading to better information quality and therefore better care coordination.

2. It’s sustainable – Rather than relying on the largesse of public or private grant funders or donors, the transaction-based pricing enables a sustainable market for health information exchange.

3. Information is “on demand” – The idea is that users will pay for valuable information, what they want, when they want it and that they will pay fair value for it. The model de-emphasizes complex legal or administrative structures. Subscription is simple. athenaNet will serve up the information in a usable format. If it’s not eminently usable, customers won’t pay for it!

I will be candid. Effective nationwide HIE is a tough nut to crack. A lot of smart people have been working on HIE for years under more traditional models and most such models have failed.

Many are skeptical these arrangements can succeed. Yet most in the industry acknowledge the immensely powerful benefits of nationwide HIE.

So what makes us think that the athenaCoordinator model will work? It already does work to a large extent through the services offered by athenaCoordinator, known as Proxsys, LLC prior to our acquisition—including care coordination services to hospitals, ambulatory surgery centers (ASCs), and imaging centers. The changes planned by athenahealth for the athenaCoordinator service will expand these services and multiply the value of HIE by leveraging the demographic and clinical data of clients who subscribe to our EMR service, athenaClinicals.

Leveraging the other athenahealth services will enable more streamlined workflows and powerful reporting. This supports care coordination and more effective participation in payment programs that provide incentives for demonstrating adherence to care protocols. Of course non-athenahealth clients will be able to send to subscribing receivers as well. They will realize many of the benefits and their participation will strengthen the network power that enables better coordination.

We are heartened by the OIG’s policy approach that’s reflected in the advisory opinion. It recognizes the potential of free market approaches to accelerate the development of sustainable HIE in conjunction with government programs to support HIE and the use of EMR.

Will it work? Here at athenahealth, we know we’re creating an offering that tackles key barriers to effective, widespread HIE. We are trying to eliminate the silo-ing of information and create an economically sustainable model to exchange only valuable information when and as demanded. We also hope that our continuing engagement in the dynamic health regulatory environment stimulates more innovative models to solve these and other problems.   

Do you have any thoughts on HIE and care coordination? If so, send in a comment and let’s start a discussion…

It was late Sunday afternoon one year ago and I was in Vermont with my family, watching a Patriots game on TV and eating peanuts.

I ate a lot of peanuts.

The next day, Martin Luther King Jr. Day, I felt terrible. I thought it was the peanuts. I was in so much pain that I ended up at the nearest hospital, in Brattleboro.

I arrived late on that Monday afternoon and the team there conducted several tests – ultrasound of abdomen, chest X-ray, EKG, the usual. Before they got to a series of GI tests, they did an ultrasound and spotted something on my liver.

They saw a “significant number of masses on it,” to quote my nurse. She convinced me that I should quickly—like as soon as it’s light again outside—go to a Boston hospital and get a full battery of tests. Ultimately, she said, you will want to line up with an oncologist as soon as possible.

We drove home from Vermont that night comforted by… nothing. Fear, anxiety and an unfathomable feeling of despair blanketed the car. My wife and I were in shock. I was 39… Our two kids (ages 7 and 4) sat in the backseat asking repeatedly what was wrong. We weren’t ready to talk, so we said nothing.

By the end of that week, I knew my life would never be the same.

I have worked in the HIT space for almost 17 years. I’m 40 now, and I’ve spent most of my post-college career thinking about EMRs and the value that they bring to physicians and patients.

In support of athenahealth’s mission, I’ve spent countless days with physicians, nurses and administrators walking through “clinical scenarios” in an attempt to explain the promise of an EMR. Often, this traditionally skeptical group would forgive my awkward clinical examples tenuously linked by clinical relevance, and then they’d ponder… Why? Why would I spend my money on this? What value does it bring to my hospital, my physicians, my nurses, my patients?

During these conversations, many physicians brought up relevant concerns about the ‘value proposition’ that HIT vendors posit – clinical efficiency, better outcomes, a rock-solid ROI, etc…

It is a complicated conversation. It takes great skill to translate the capabilities of an EMR (in the case of athenahealth, a cloud-based EMR service) into real value for the physician, the health care organization and their patients.

Well, many aspects of that conversation—for me—are no longer difficult at all.

On January 18, 2011, I was diagnosed with Stage 4 colon cancer with metastases to my liver (8 “honking” tumors in all – 9, if you include the colon). The conversations relating to EMR technology and their value, conversations that were once theoretical, became all too real.

As I continue my fight today, I’d like to share my experiences in future blog posts about the practical realities versus the promise of the EMR – and information technology more broadly.

I’ll get into this more, but just know that there are absurd examples that clearly illustrate the shortcomings of current technology. There are examples that illustrate where it operates with extreme efficiency and other areas where HIT can fundamentally change health care in the US – but hasn’t. It becomes a question of collaboration and execution.

As I enter month 12 of my treatment, I am incredibly optimistic about our industry and the potential that is stored within the brains of the people who define and move it. We are SO early in our lifecycle as a group of competitive companies, but the opportunity for fundamental health care improvement dictates that we move… collaboratively and quickly.

As I dive into my experience in future posts, it is important to note that I am receiving my care at a major teaching institution in Boston. One can debate whether this implies better technology, systems of operation and care. I can say, assuredly, that my care has been world-class. The physicians and nurses who have cared for me through this brutal process have been nothing short of miraculous—all of them. I won’t mention them by name, but I wish I could.

There’s a lot more to share but in the meantime, please feel free to offer your thoughts. Do you have a similar experience you’d like to share? Send in a comment and we can get a conversation started. Thanks for reading…

We have a lot to look forward to this year. We’re going to Las Vegas for the HIMSS convention in February, the data on Meaningful Use keeps flowing and our annual User Conference is coming up fast in April. (Registration starts Jan. 16.)

In the next few weeks we’ll also roll out exciting new changes to our social media channels and we’re pulling the levers to launch us into the upper reaches of the Twittersphere.

But first, there’s Facebook. We’ve been ramping it up over the past few months and here it is…

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