HIT "Primer"

A twitter friend (and high content value tweeter) @daphneleigh recently asked if she could get a HealthCare IT (HIT) primer. Sure I said, shoot me some questions - and what good questions they were. I've answered these below.

Note that I consider this post a bit of a work in progress and will stamp it final at some later date.

Comments welcome.

1. What, exactly, does HIT include? Are we talking EHR/EMR/PHR, or are we talking beyond these technologies (which I assume we are, but don't know what the "beyond" is...medical devices and equipment? hospital tech infrastructure? etc., etc.).
HealthCare Information Technology – is a catchall category for information technology and systems used within HealthCare. Although some folks use it and healthcare informatics interchangeably, I believe there is a differentiation. HIT is more technical\technology in nature and informatics is more about the acquisition, accumulation and assessment of information, data, having to do with healthcare, for example, quality on episodic care. I think it’s critical this distinction exists because all too often HIT is not approached with the sensible, strategic approach as it should be (more on that below) in healthcare.

a) By extension, HIT covers EMR, EHR and PHR, Medical Devices, Mobile Medical Devices, server systems and other infrastructure used in the conveyance of healthcare – that’s all HIT (not informatics). Note that in many instances the technology is the same for healthcare as it is in any other vertical. For example, server, network and telecom systems are the same. Business Intelligence, Data Warehousing tools remains the same. The key different systems are EMRs, PHRs, EHRs, medical devices and other clinical (lab, radiology) systems – those are unique to Healthcare.

b) I think that sometimes EMR, EHR and PHR also get muddied, I think the differentiation is as follows:

i. EMR’s are used by healthcare organizations to assist in the practice of healthcare, being an electronic medical record of all pertinent demographic, clinical and billing data, surrounded by a (clinical) process automation system and, in better systems, having strong clinical heuristics and analytics around clinical data. Hospital Information Systems (HIS) and Physician Office Management Systems (POMIS) are types of EMR’s

ii. EHR is a more generic term mean to refer directly to the clinical data for a patient that resides in some system, be it an EMR or PHR

iii. PHR is a system that allows users, or users and certain slices of the healthcare vertical, to share, collaborate and otherwise act on electronic health data

2. Alot of back and forth about whether HIT can reduce healthcare cost? Does it? How? And for whom? Patients? Docs? Hospitals? All? Others?
HIT, correctly implemented with a plan and a strategy, using best practices standards and systems, CAN reduce the cost of doing HealthCare business. MOST of these systems are fairly significant in cost and time to implement. We’re talking, for example, seven years and $250M, or more for larger multisystem orgs or around $50k and about three of months for a smaller practice – and that’s just the licensing cost. Extra interfaces to other systems carry a cost as does annual maintenance and support. I’ll reference additional points about HIT in point 4. HIT is one component but not the leading component to bring about change in HealthCare. As with any properly run business it means the difference between surviving and thriving, but herein is the rub: properly run business. A LOT of hospitals aren’t run as a business, in terms of process and fiscal discipline, in terms of strategic planning not just for growth and services but also for infrastructure and IT. Although I can’t comment as to why this would be the case, it’s likely one that has to do with a complex culture that’s inherited the good (process focus) with the bad (emotion, not facts based decision making). When you DO have a properly run hospital – and there are many – where compassion and enterprise thinking work well together – a properly implemented HIT strategy\system can cut costs for all parties concerned. Data is more readily available, transportable and consumed by all parties that need it while respecting the appropriate security needs – this is why something like HealthVault succeeds but most EMR’s fail (more in point 4). This is the reason most enterprises survive or thrive – they know where and how to get to the data they need to run their business effectively. The magic of Amazon is not in their pricing (although that helps) – it’s in how data driven their business is. Hospitals, in particular, need to evolve to the point where they are more data driven as well.

3. Who should care about HIT and why?
Everyone who is or will one day be a patients, should care about HIT. Hospitals likely have their hands full with quality initiatives, patient safety, physicians satisfaction and fighting government contractors on Medicare\Medicaid denials – contractors who get paid a percentage of the takebacks! Smaller orgs and practices also have the added concern of defensive medicine, liability issues and staffing and the cash-flow challenges of being a small business, dealing with third parties (insurers) for their cash flow. Who’s left minding the (data) bank? It should be patients, empowering patients. A patient should care that HL7 is a standard in name only and that almost every single EMR or HIT system out there does not play well with each other. Getting data from system A to system B requires either paying one, or both, vendors a custom interface fee or having an in-house interface team. Two issues crop up here

a) On a simpler basis, the in-house team is typically using HL7 specific tools and technologies that have not evolved in 20 years, or more

b) On a more complex basis, the concept of charging a custom interface fee is a little disingenuous, after all, isn’t HL7 supposed to be a healthcare data exchange standard? The vendors might defensively, and correctly, state that the nature of the beast compels such custom interfaces because the business of providing healthcare is so diffracted and disjoint. My counterpoint to that is that Healthcare is series of repeatable processes and steps – yes every sick patient is unique but a lot of the processes around the sick patient – labs, radiology, treatments fall within established guidelines meant to enforce standard, repeatable processes.

i. This is where running like a business comes in and the needs for an umbrella industry standards (think ISO) comes in not just for the business of running a hospital but also for the systems that supports them to come into play. While I’m not espousing assembly-line medicine, what I am suggesting is that healthcare take a long hard look at itself as industry. It is in that way, an industry like no other where it is responsible for saving lives. As such it lacks the maturity to hold itself accountable to a standard greater than itself, on a local basis. Remember, standards don’t restrict thought or creativity, they govern the known and give freedom to explore the unknown, identify it and codify it. I have little illusions that this is easier said and done – there are a LOT of different opinions on standards of care and they’re likely all right to some extent. The industry owes it to itself to at least try.

ii. As an example, I know of a multisystem organization that had several thousand order sets. They recently started an initiative to reduce those to hundreds. The wailing and gnashing and lamentation of teeth was smoothed over and the effort proceeded regardless. They are on their way to meeting that goal.

iii. It can be done.

4. Is HIT on par with other industry technology? How? Or how not?
Which brings us to HIT – first, a caveat, I’ve been in Healthcare\HIT for 7 of my 17 years and, others from the “outside” who’ve come to work within HIT can attest to what I attest to here. Succinctly, HIT is at least 20 years behind where other IT verticals are. You will be hard pressed to see a more disjoint, backwards, insular, silo’d mindset, which, being an IT professional at heart, is morally and ethically repugnant to me at least. IT exists to codify, encapsulate, secure and transport data for the betterment of some entity, be it a person or a business. HIT exists to force the client into an expensive silo and paint them into a corner. A LOT of the systems are poorly written with a horrible user experience and neither themselves nor their interfaces scale well. In part this is due to the fact that HIT traditionally hasn’t been able to attract a lot of talent (pay being a prime cause, IT strategy akin to aimless wandering being another) so they’ve not had the talent on staff to call bullshit on these vendors – and so, the traditional vendors have gotten away with highway robbery. The other aspect of the problem is that most orgs don’t have time to pay attention to IT or deprecate it (reference running your business as a business) and so buy something off the shelf from a vendor, pay a lot of money to implement it, pay more money for interfaces, then either by more of that vendor’s product or some other vendor’s product for another segment of their business, pay more money for more interfaces, ad naseum. Seeing that most healthcare orgs spend 2%-4$% of their revenue on IT where most other verticals spend closer to 8% and up, it’s not a surprise. In those scenarios it is easier to justify and expend on a capital basis than it is on an operational basis. A nurse takes care of patients and helps doctors who bring in revenue. What’s an IT guy do?

a) This is starting to shift and the smarter, traditional vendors have picked up on it and started to become a lot more part of the solution than the problem. We’ll see. As more attention has focused on healthcare and HIT over the last decade, more folks from other industries have come into the HIT space, motivated by the profits to be made, justifiably. But along the ways we’ve inherited more disciplined folks and folks who work FOR the org or for a vendor who knows that the money to be made isn’t in the traditional Big Blue silo’ing of their customers.

b) Add in some of the newer technologies and platforms, such as Google Health and Microsoft HealthVault, and you’ll see that most vendors want to get on board with the rest of modern IT principles.

5. What are biggest challenges facing HIT right now, and how/why is it important to the whole healthcare reform debate?
The biggest challenge to HIT now is that it get’s incorrectly labeled as the #1 way to save on costs. It simply isn’t. No IT system in the world will help if you can’t run a business properly and, most importantly, don’t have good interoperability between systems. Throwing money at docs to implement HIT systems, or worse throwing money at vendors, isn’t going to help the situation. There are fundamental, process-based & cultural changes that need to occur before IT even enters into the picture. A good example, I know of an in-house development shop at a large org that has demonstrably shown that it can deliver value and products far faster than the org can absorb them. In a recent project 40% of the time was spend on product development and 60% on making up for the failure of clinical leadership on integrating that product, which they asked for\demanded, into their clinical workflows. The product was very well received and is now in active use, yet talk about a lot (60%) of effort expended outside of development and deployment. You could have the best EMR system in the world with every feature under the sun – clinical transformation is still required, and cultural adjustment, before it will be meaningful enough to make change.

a) For what it’s worth, clinical transformation and cultural adjustment are change. Change is scary. I understand that. IT changes every day, sometimes twice a day. So while I don’t expect change overnight I do expect that change does at least start to occur and that folks compartmentalize their fear. Folks should be allowed to fail and be encouraged to learn from those failures. Finally, at some point, after the healthy debate is over, someone needs to make a decision and folks be held accountable to follow in that decision.

b) There is an aside here that begs to be talked about which is process. The development and deployment process is all too often also mired in decades old processes or heavyweight processes that do not work. There are newer, more up to date HIT processes that should be leveraged.

6. What are biggest myths/misperceptions about HIT among general public?

This is a good question. I think most folks, especially these days, would be aghast to find out how backwards HIT is and how non-transportable and paper based their health information is. When’s the last time you wrote a paper check? Or got a paper utility statement? Or got a letter in the mail or sent a roll of film in to get developed? Sure you can still do those things but you can just as easily do without them. ebanking, paperless statements (save the tree’s and my filing cabinet please!), email (grandma sends emails to her grandkids!), Flickr to Walmart. Yet more clinicians than you would guess are stubbornly married to their paper. And you can’t, not if you are a large hospital beat them over the head (they are revenue streams remember!) nor can you easily incentivize them (Stark law). If there’s an ugly secret anywhere, it’s how distinctly Cro-Magnon HIT is when it’s surrounded by Homo Sap Sap examples of cogent IT around it.

So, what’s the bottom-line then, right?

The bottom line is that HIT is sclerotic and backwards and everyone owns and is accountable to it being so. Patient’s for not demanding more and that it keep pace. Clinician’s for some of the same but also for being resistors to change instead of change agents. Organizations for not making IT strategy part of their life blood. But especially vendors, vendors who should be living, eating and breathing technology, who know better, but who have like a drunk driver who knows he’s drunk, gotten behind the wheel and wrapped the industry around a tree.

But there is a silver lining. The driver didn’t cry, turns out they only side-swiped a sapling and the car, the industry, is repairable. Folks from outside Healthcare are coming into HIT. There are CEO’s, CIO’s and CFO’s cropping up internally and from other verticals that understand that Healthcare fundamentally only succeeds when it’s run like an enterprise business. Docs, usually younger, are demanding more electronic mediums for healthcare and the older docs are glomming on as they get fed up with the fragmented continuity of care. Vendor’s, perhaps driven by crowdsourcing, open source and the twin titans of Google and Microsoft are realizing they need to bring about a change in how they structure their solutions. Finally, the consumer, the Alpha and the Omega, the Patients, are waking up, connecting, getting educated and, lead by Mom’s everywhere, are asking tough questions and demanding more.

The pity of it is we didn’t have to get to this point, but at least we can recover from it and are starting too. Now, if only the government will listen to what works instead of throwing money around and focus on universal process guidelines, liability reform and enforce real interop standards, well, we might see a change for the better sooner rather than later.