Will CommonWell solve one of the biggest problems in health IT?

The big news at HIMSS13 was the unveiling of CommonWell (Cerner, McKesson, Allscripts, athenahealth, Greenway and RelayHealth) to “get the ball rolling” on data exchange across disparate technologies. The shame is that another program with opaque governance by the largest incumbents in health IT is being passed off as progress. The missed opportunity is to answer the call for patient engagement and the frustrations of physicians with EHRs and reverse the institutional control over the physician-patient relationship. Physicians take an oath to put their patient’s interest above all others while in reality we are manipulated to participate in massive amounts of unwarranted care.

There’s a link between healthcare costs and health IT. The past months have seen frustration with this manipulation by industry hit the public media like never before. Early this year, National Coordinator for Health Information Technology Farzad Mostashari, MD, called for “moral and right” action on the part of some EHR vendors, particularly when it comes to data lock-in and pricing transparency.

On February 19, a front page article in the New York Times exposed the tactics of some of the founding members of CommonWell in grabbing much of the $19 Billion of health IT incentives while consolidating the industry and locking out startups and innovators. That same week, Time’s cover story is a special report on health care costs  and analyzes how the US wastes $750 Billion a year and what that means to patients.

To round things out, the March issue of Health Affairs, published a survey  showing that “the average physician would lose $43,743 over five years” as a result of EHR adoption while the financial benefits go to the vendors and the larger institutions.

CommonWell is just IHE 2.0. IHE stands for Integrating the Healthcare Enterprise, a decade-long project of HIMSS designed to preserve a business model where neither physicians nor patients buy anything (the industry represented in HIMSS serves institutions almost exclusively) and interface costs account for some 60% of revenues. 60% interface costs should be compared to pre-IHE medical interfaces such as DICOM and the universal Internet business model where interfaces are free and only services are billed.

IHE is a governance mechanism for interoperability practices that is managed by the largest EHR vendors and has brought us a decade of stagnation, consolidation, vendor lock-in, and physician and patient frustration. CommonWell is a governance mechanism for interoperability that is managed by the same EHR vendors under a friendly new name.

The specifics of CommonWell are still undocumented. From what I can tell at HIMSS13, the focus will continue to be on institutional control of the physician-patient relationship, coercive patient ID practices, information silos defined by institutional concepts of what patients trust, and protocols designed to perpetuate the vendor lock-in business model.

So let me summarize what I see so far at HIMSS13. Take $10 to $20 Billion of taxpayer money (depending on how HHS will handle remaining EHR interface regulations and privacy governance issues), use it to consolidate small practices and entrepreneurs out of business then orchestrate rent-seeking behavior on 20% of the US economy to extract value from our own data that we can’t access ourselves.

It’s not easy to waste $750 billion a year by overcharging and providing unwarranted care but coordinated efforts such as CommonWell look like they will continue the health IT industry’s contribution. It’s easy for CommonWell to prove me wrong by announcing that the data liquidity they propose means all interfaces from federally subsidized EHRs will be free and under the control of individual physicians and their patients.

Adrian Gropper is a medical technology developer and consulting on health services strategy at HealthURL.com

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  • Ian

    “Commonwell is just IHE 2.0″

    And accountable care organizations/ medical homes are just capitation 2.0 with the physicians providing the data to the third parties to have themselves graded

    Big companies taking advantage of government programs at the exclusion of competition and start ups. While I wasn’t aware of this recent development in interoperability it does carry the feeling of Dog bites man……

    • amused bystander

      Yes. Yes, it does.

    • Adrian Gropper

      The new point I’m hoping to make is that corporate technology exacerbates the physician’s conflict of interest between working for the institution or for the patient. It can’t be good for patients or the medical profession for physicians to lose trust and respect. Doctors must begin to take as much responsibility for their choice of software as they do for their choice of pharmaceuticals.

      • kjindal

        “Doctors must begin to take as much responsibility for their choice of software …”
        But many (maybe MOST) of the time doctors have no choice in the matter – most new doctors are working for large conglomerate health systems and/or as hospitalists (another by-product of MBAs taking control over healthcare from MDs over the years). Then lousy error-prone products are thrust upon us with no clinician input, and inaccessible support staff.

        • Ian

          Agreed

        • Adrian Gropper

          Doctors can demand control over how data moves out of the institutional EHR but we’ve not picked up on this challenge. The doctor and patient have standing in this issue whereas the institution does not. It’s simply a matter of educating physicians about their professional interest. Once the physician understands that they can move the patient data to place that they and the patient control, they will understand that they can control decision support, quality surveillance, referrals, etc… As long as doctors treat their software the same way they do their office plumbing, the lack of choice is to be expected.

          • Ian

            Have you worked in a hospital system before? “Doctors can demand control over how data moves out of the intitutional EHR?” Sounds exactly what an IT tech consultant would say. IF I have no say in the choice of hospital EMR how on earth am I gonna do what you suggest?

            This is on top of the false equivalency that we took an oath to what’s best for our patients. Doctors study for 11-15 years after high school to learn how to treat and care for patient’s. Independent docs pick the least bad IT option that appears to appease the CMS beancounters and the rest have whatever some IT person, beancounter, and comittee that may or not include a physician ram down their throat.

          • kjindal

            “Doctors can demand control over how data moves out of the institutional EHR …”

            Let me give you a real-world example:

            Me (frantic call to IT dept):”My patient has been getting glipizide 10mg daily for the last 5 days, even though I discontinued it in the computer, and I’m told by nursing that it still comes up in EMAR; and my patient has been hypoglycemic – how should I proceed, and which one of you is going to discuss this mishap with the patient’s family?”
            IT high-school grad (barely):”let me get right on that – I’ll have [my boss] call the vendor and sort it out right away”
            Then nothing happens (except that the nursing staff has to use paper notes to convey to successive shifts not to give the glipizide, since it has been discontinued, even though it still shows up on their end of the system). Yes, paper to support the use of computers. Just to satisfy bean counters and grant writers/recipients. Our charts are actually getting much THICKER with the advent of computerized order entry.
            And this isn’t what the IT guys call a “luddite” – I was a computer science major at a prestigious institution before medical school, and hardly shy to adopt appropriate technologies.

  • Ian

    I believe the bigger threat to trust, respect and conflict of interest in physicians has to do with the large number of physicians that are migrating to hospital employment or hospital affiliation as opposed to independent selection of corporate technology in the form of an EMR. For one, physicians typically have a limited role in selection of a hospital systems EMR. A handful of people, usually IT and beancounters, pick an EMR and then thrust it upon the hospital staff.

    In large corporate hospital systems (and to a lesser extent smaller hospital systems) EMR decision becomes dwarfed by the other decisions that are made by other committees within the hospital infrastructure. Particularly some egregious pharmacy equivalency decisions made with ony the bottom dollar in mind of late are much more disruptive to patient care and trust/respect to physicians (not to mention physician trust/respect to the hospital). This is one of many decisions that are made by committee usually for mostly cost cutting purposes often without sufficient thought on it’s impact to patient care.

    The selection of an EMR is a drop in the bucket in terms of patient satisfaction/trust. Unless it shows improvement for patients to contact their physician (ie portal, e-mail etc which most physicians are reluctant to adopt.) or more importantly the ability to communicate with each other (no I don’t have your cardiologists lipid panel from last week) I’m not certain that patients care what EMR is used. I don’t feel that the selection of an EMR dramatically changes the trust/confidence in a physician, and it certainly is not an eqvuivalency to medical judgement as you try and imply in your article.

    • Adrian Gropper

      The clerks at WalMart are being told what IT to use and I don’t think physicians should capitulate and join their ranks. Software can serve people instead of the other way around. The first step is recognizing the problem and I think you’re starting to do that.

      • Ian

        Let’s re-cap as a summary.

        1st post: nothing new here. Re-tread of care plans, re-tread of politics and business (implied that I know big business and government in bed is a problem and an old problem at that.)

        2nd post Response to Doctor’s can demand……. I will translate/reform my response minus the sarcasm:
        I think you are an out of touch IT technical consultant who hasn’t had a full schedule of patients in some time, and if not you are certainly acting like one. See also: false equivalency between prescribing meds and selecting an EMR.

        Your response: I have 30 years of experience working with medical devices and IT…….. link provided.

        3rd post: Hospital corporations are a bigger threat to doctors (with example of non-EMR bad hospital practicies) than the selection of an individual EMR based on problems that should have been solved by people like yourself before they were foisted on health care providers in the first place. Lastly, EMR’s have little to do with patient satisfaction or trust in their doctors as the entire premise of your article suggets. I only touched on hospital big corporation issues. If you add, time with the doctor, rising costs of co-pays, and the ridiculous costs of insurance, I’m pretty sure intraoperability of EMR ranks at exactly the bottom on patient’s concerns in trusting their physician.

        Your response: Doctors shouldn’t become like Walmart clerks, followed by a useless platitude. Finally, “The first step is recognizing the problem and I think you’re startin to do that.”.

        The problem with the system was obvious to any provider who sees patients before the first EMR was implemented. That’s why doctors didn’t want to implement them and have been forced by the government to do so in the first place. Others abandoned taking insurance and went the concierge route. Doctors have much bigger fish to fry with the coming storm of regulations, mandates, and things that we are already required to do for EMR’s not to mention actually steering the MBA’s and managers (now within the system in addition to those in the insurance system) away from bad medical ideas that harm patient care.

        Full circle: I recognize that the problem is bureacrats in ivory towers and doctors not meaningfully involved in patient care are making decisions and implementing mandates that are ruining the doctor patient relationship and the practice of medicine. This is not news…. Dog bites man. If you think your article has made me realize that as your last post implies, then you are farther down your little rabbit hole than I realized.

  • http://twitter.com/shihjay2 Michael Chen

    Thank you so much, Adrian, for bringing this issue to light. I agree that it is not too late for doctors to make a choice regarding health information technologies. However, the window of opportunity is fading faster as there are decreasing numbers of independent practicing physicians. Doctors cannot hope and wait for corporate entities to be their salvation. It is clear that corporate entities want to dominate the healthcare system and forever be a harmful and costly wedge between doctors and patients. I suggest that an open source health care technology movement be the spearhead and rallying point for doctors and patients. This particular model is desirable since no corporate entity owns the tool (like an open source EMR), doctors have control over the technology to help their doctors, and like a co-op, the development of the tool is entirely accountable to the doctors and patients. This is a viable and perhaps the only real model to overcome the trend towards increasing corporatization of our health care delivery system.

    • Adrian Gropper

      I could not agree more, Michael! Health IT is the only aspect of clinical practice where physicians accept secrecy and lack of peer review. Why would doctors do that if they were paying attention?

      Check out this short article in AMA Virtual Mentor on Open Source Healthcare Software and spread the word. http://virtualmentor.ama-assn.org/2011/09/stas1-1109.html

  • http://www.facebook.com/shirie.leng Shirie Leng

    Doctors are burying their heads in the sand on this. When EMR first came out we just hoped it would go away. When it didn’t, we were too busy to pick systems that worked and think long-term about the consequences. If we did pick a system, it was too expensive to buy as an individual so it was easier and cheaper to let the larger organization buy one for you. Now we have no say. The profession has to step up.

    • http://twitter.com/shihjay2 Michael Chen

      If the profession needs to step up, which I beleive it needs to, it also needs to provide or offer an alternative to what is being offered to us by the current for-profit EHR vendors. That is where open source EHRs are a viable alternative (see my other comment). It is available. Google NOSH ChartingSystem or OpenEMR for examples. NOSH is my own project by the way, so I’m pretty passionate about this issue regarding doctors taking back control of our health care technologies.

  • bill10526

    There is no free lunch or interface.