The other kind of HIE is a health insurance exchange. The 2010 “Obamacare” health reform law called for each state to open its own insurance exchange where consumers can shop for policies and tap health insurance tax credits. But for states that chose not to or couldn’t get it up-and-running, the law called for the federal government to step in and handle the exchange.

The Wall Street Journal reported last week that a number of Republican-led states such as Wisconsin and Florida have rejected on political grounds setting up a state-run HIE.  A number of other states have indicated they will run their own exchange but made little progress to date. As the WSJ reports

“Only 28 states and the District of Columbia have made significant progress in setting up their own insurance exchanges.”

As a result, the Obama Administration asked for $860 million in its new budget to implement the HIEs at the federal level. As the Washington Post reports

“There’s little expectation that Congress will actually appropriate the funds the White House has requested, especially when the ask is so big and would pretty much go directly toward health reform implementation. What happens to the federal exchange if Congress turns down the request? Center for Consumer Information and Insurance Oversight director Steve Larsen tells Bloomberg that the government ‘will work with existing, available funding sources.’”

For the states that have committed to operating their own exchanges, the pressure is on. The Colorado Springs Gazette recently interviewed Patty Fontneau, the CEO and executive director of what is formally called the Colorado Health Benefit Exchange.

Ms. Fontneau, an attorney, made these points:

“The exchange does make sense to do regardless of what happens with the Affordable Care Act. It’s a smart business decision. It allows a competitive marketplace. It will allow a competitive marketplace to have appropriate influence on the cost of health insurance.

“I can’t tell you how it’s going to different from the federal plan. I would be surprised if the federal plan met the unique needs of Colorado. In order to get both individuals and small employers to act to purchase insurance, to use the services available to them, we’re going to have to have a tremendous education campaigns. The really broad-based education efforts won’t be until 2013 — you really want to get people aware of this project a little bit closer to when it’s going to launch.”

Stage 2 Meaningful Use rules

Interoperability, health information exchange

Mobile device software (iPads)

The HHS has said it will introduce the final version of the Stage 2 MU rules next week. While no one is sure exactly what will in the new requirements, they are bound to be tougher than Stage 1. Explanations of what they mean and suggestions for how to meet them are bound to be popular topics. There are already half-a-dozen educational sessions scheduled on MU, with one promising to include senior HHS officials on the panel.

Another hot topic will be interoperability and exchange of health information. To use the current buzz phrase, crossing enterprise boundaries. This need is driven by the success of MU Stage 1 in spurring the widespread adoption of EHRs. As several industry analysts have noted in recent weeks, for the first time in the 30-year history of healthcare information technology, we now have widespread and diverse collection of healthcare data by physicians and hospitals.

The challenge now is to collect, share and analyze the data. My client ChartLogic is participating in the Health Story Project, which will be giving demonstrations in the interoperability booth at HIMSS. Based upon the preview information I’ve seen, some very dramatic capabilities are going to be displayed, including the use of Apple’s Siri natural language processing program to move “hands free” between EHR applications and send specific data to remote locations.

Apple devices, along with Android tablets and phones, are very popular with physicians. One study claims 80% of physicians own a smart phone. These highly sophisticated devices can have a major impact on the collection and display of clinical information. Many vendors will be showing how their software can be used on iPhones or iPads.

I’ve been attending HIMSS for eight years and it gets bigger and crazier every year. The HIMSs organizers are predicting record attendance this year, more than 38,000. Fortunately, Las Vegas has some 200,000 hotel rooms, so there will be plenty of places to stay.

Some readers may remember the 2007 HIMSS, held in New Orleans, just five months after Hurricane Katrina. Several large hotels were closed, forcing some people to stay in motels miles from the convention center.  Las Vegas won’t have that problem, but will add a note of weirdness to this annual spectacle of wealth and technology

Several recent articles suggest that EHR sales will soon plateau and then slowly taper off.

Healthcare IT News, reporting on a conference on recent healthcare finance conference in Nashville, reports that a leading bank analyst predicts just 5 to 10 percent growth this year. Factors contributing to growth in 2012 include more meaningful use requirements and the impending conversion to ICD-10.

Separately, John Moore, founder of Chilmark Research, opined in his blog recently that “There will be plenty more EHR sales in the year to come, but over 2012 we will also see EHR sales growth begin to plateau and level off by end of Q4 ‘12.”

Other studies are more optimistic. According to a new study released last week by Millennium Research Group, the EHR market will enjoy 12 percent growth per year, and is expected to reach more than $8.3 billion by 2016. The report comes on the heels of a Frost & Sullivan report that predicts that market revenues for EHR systems will peak at $6.5 billion in 2012 for new licensing and upgrades.

In the current, heated-up environment for healthcare information technology, a “mere” 5-10% growth seems disappointing, but some other industries (e.g. airlines, utilities, retail)  would rejoice in those numbers.

Venture capital firms still take a very positive view of healthcare info tech.  They poured $633 million into the field last year, InformationWeek Healthcare reported. That was the highest amount since 2001, when they invested $759 million.

One unknown is the exact rate of adoption by small physician practices, where 60% of the nation’s physicians work.

Mickel Phung, a market analyst for Frost & Sullivan, said he expected higher growth, since “Early reports from 2008 and 2009 indicated 20 percent growth. That didn’t happen.”

He said many office-based physicians are still “hesitant and confused” by the number and type of EHRs available. There are currently more than 350 EHR systems being actively marketed, he said. Physicians are starting to gravitate towards “the bigger, better known vendors.”

If you needed proof that yes, overuse of health services is going on here in the U.S., it comes in a new study out last week.  It reports with alarm that over overuse of therapeutic procedures accounts for as much as 30% of healthcare spending in our nation.

The article, published in the current issue of the Archives of Internal Medicine, reported on a review of 241 separate studies of overuse published between 1978 and 2009. Overuse was defined as interventions in which negative consequences, including unnecessary costs, outweighed the benefits of care.

The 4 most common health services examined in the studies included in the review were antibiotics for upper respiratory infections, coronary angiography, carotid endarterectomy, and coronary artery bypass grafting and revascularization.

One healthcare service that appeared to be significantly overused was follow-up screening colonoscopies, with up to a 60.8% rate of overuse; also hysterectomy, at up to 70.0% overuse.

“Despite broad acknowledgment that overuse is common and costly, overuse research has been underemphasized compared with research on underuse of health services,” the authors write.

Captain Renault attempted to deal with the gambling “problem” by closing Rick’s Casino for one night, thus averting a fight between the Free French citizens and Major Strasser and her evil Nazi thugs.

Here in the U.S., one attempt to quantify and reduce overuse is the new Patient-Centered Outcomes Research Institute (PCORI) which issued its much anticipated first report on national priorities on January 23.

The 22-page report stopped short of specifying any diseases or conditions that would be targeted for comparative effectiveness research.

Instead it made a series of general statements, intended to “define the boundaries” and “define the types of questions that we want to invest in,” said one panel member.

In Casablanca, Humphrey Bogart was forced to abandon the girl (Ingrid Bergman) and along with Claude Rains (Captain Renault), was forced to flee the city, heading for a French army camp deep in the North African desert. An initial setback for the two men, but “the beginning of a beautiful friendship,” said Bogart.

Let us hope the PCORI panel members maintain their sense of optimism as they begin a long struggle against the huge problem of overuse which may generate opposition from some entrenched interests.

“Three Best Buy stores in the suburban Chicago area are now selling four wellness programs offered by Aetna focused on fitness, weight management, smoking cessation, and stress management. Shoppers can buy hanging cards that explain each of the online programs that they can then access online. Each program costs $19.99.”

The article doesn’t define exactly what the consumer gets for $19.99, although it must be guidance or online advice, not actual health insurance. My first reaction, as someone who spent a decade working for a health insurance company, is that this marks the rehabilitation of the HMOs. At the height of the managed care hatred, 1995-2005, Best But would never have wanted to be associated with Aetna or any other health insurer. At one point, health insurers vied with tobacco companies as the most hated corporations.

According to the news article, Best Buy has created “health departments” in some of its stores and is selling “health devices like Withings’ blood pressure cuff, iHealth’s weight scale, the Basis B1 Band, Fitbit Ultra, or Jawbone’s UP.”

The article reported that an Aetna spokesperson said

“If shoppers are at Best Buy to purchase a pedometer or blood pressure cuff, they might also be interested in a program that helps them achieve health goals associated with the device. Best Buy employees at these three particular stores have been trained specifically to help shoppers in the health department sections.”

Will the new effort succeed?

The report points out that in 2004, Best Buy attempted to launch a new chain of retail stores, called Eq-Life, which “which aimed to help women shoppers buy technology and resources to manage their family’s health.”

The idea never gained traction and was quietly folded.

I don’t know if the having Aetna products will make money for Best Buy, but I know it is a winner for the health insurers. This is a major marketing coup. They are displayed on Best Buy’s shelves along with Apple, Microsoft, HP, Samsung, Symantec and many other highly respected consumer brands.

CMS  will begin its value-based purchasing initiative in October 2012. This is just one step in the long march healthcare is taking from claims-based reimbursement to pay based on quality measurement. The targets for delivering quality care are almost entirely based on data.

The AHIMA report, available here, notes that “the more accurate and managed a facility’s data, the better their reimbursement potential.” This assumes the hospital is hitting the targets for high-quality care.If you’re facility is providing poor care and patients are dying right and left, high quality data reporting is not going to be in your best interest (at least for Medicare payments).

According to one AHIMA executive,

“People are going to have to leverage the data and use what they have available. That is what’s going to make the difference between success and failure.”

The report says that as senior executives at hospitals start analyzing data, they will learn something AHIMA has been warning about for years, that  data integrity “isn’t what it should be.”

For example, integrating information from different facilities raises information management challenges when multiple terms are used for the same items.

The AHIMA report cites this example

“A hospital has a psychology division that participates in an ACO. The division sends a record named ‘treatment plan’ to another facility, which assumes it is a general health treatment plan and fails to provide the record with the advanced security that behavioral health records require.”

The report adds that because of these issues

“work will be done to leverage metadata tags to manage patient identity, patient privacy and security, and health data provenance.”

Editorial note: data is a plural noun and normally takes plural verbs. However, when a unit of data is referred to (” the data is sound”) it becomes a collective noun and takes a singular verb.

According to a fun article by Cheryl Clark in a recent Healthleaders column, change fatigue is one of the top new buzzwords we’ll be seeing in 2012. She explains

“There’s change in leadership, areas of responsibility, accelerated workload and expectations, and requirements for new skills and training in people who may not be prepared for it or want it.

“Some providers have expressed frustration with this ‘new flavor of the month’ attitude. Now managers are trying to find productive ways to make these transitions, so there is enough stability and constancy mixed in to prevent change fatigue.”

Another buzzword cited is “accountable care skimping.”  Clark reports

“In the Medicare Shared Saving Program’s final rule released in October, the word “skimp” comes up four times.

“Officials for the Centers for Medicare & Medicaid Services used the word to address a concern that when physicians in accountable care organizations are paid to avoid unnecessary expenses, they may—unconsciously or not—avoid necessary expenses for their patients. Heaven forbid, they may ‘skimp on care.’

I think that skimping is just another word for rationing. The concept of rationing care is understood and accepted in countries such as Canada and the UK which have national health care system. Rationing has become a taboo word in health policy in the US.

Another buzzword noted by Clark is “positive deviance or disruptive innovation.”

She explains

“In healthcare settings, these two phrases, which have different origins and meanings, can be used to express the same idea. They imply a strategy in which providers look at peers—be they controversial individuals or entire institutions—that function differently, but still achieve excellent results.”

This is a good way to explain certain phenomenon, although the term positive deviance will be hard for many people to grasp.  The terms deviance and deviants (a homonym) have some strong negative connotations, not only in healthcare but in political and social thought as well.

Will anyone  champion skimping as a disruptive innovation?

One can categorize them in two broad areas: technology (e.g. new software, hardware) and policy.

HHN notes several key events: the continuing struggle over the deficit, the implementation of the Affordable Care Act and the Supreme Court ruling on the law’s constitutionality.

From the business standpoint, Helen Darling, President and CEO, National Business Group on Health, notes that employers are employers are struggling to provide health benefits at an affordable cost at a time when employees and dependents are “not as healthy as they used to be” and “younger workers are joining the work force with significantly more risk factors.”

Darling points out that employers will also face growing administrative burdens due to the ACA, she said.  ”For some employers, especially small employers, the option to obtain coverage through (health insurance) exchanges may be a better choice.”

If, however, the economy stumbles and health costs grow at the projected 7.2 percent rate, “we will watch our standard of living decline and consumers will have even higher out of pocket costs.”

For some good news, readers can turn to predictions about new technology.

Bill Crounse, MD, Senior Director, Worldwide Health at Microsoft, predicts that “Broadband internet, computers, gaming systems, and digital television merge to become a platform capable of delivering on-demand health information, instruction and medical services into our homes.  Much of this has already happened.  In other words, the platform and technology already exist.  What’s needed to make it mainstream are the business drivers and incentives that will bring it all to life.”

In his blog (http://blogs.msdn.com/b/healthblog/archive), Dr. Crounse  says that if the right regulatory and reimbursement reforms are implemented, the market will deliver “more cost-effective modalities for both preventive services and care.

“That will increasingly include the delivery of health information and medical services directly into the home whenever possible.  So much of what healthcare providers do is focused on the analysis of signs, symptoms and results, dissemination of information, and prescriptions for treatment.  Much of this can, and increasingly will be done, virtually.”

Remember the adage, “water, water everywhere and not a drop to drink?” In healthcare 2012 we may have “technology, technology everywhere, but not a business model to use it.”

This statement was contained in a comment by a physician who was complaining about the usability of EHRs in a response to an article in Healthcare IT News.

My first reaction was this was an insightful, true statement (and a good use of neat French phrase). Then I realized that it is noble-minded, but basically flawed. There have  been patients since humans evolved on the plains of the Serengeti two million years ago. The rise of the highly compensated medical profession, however, has come in the last 50 years.

Consider the statement “No diners, no restaurant industry,” or “No new cars, no auto industry.”

Health care is fundamentally different from other industries such as food, retail and banking. The customer rarely pays for his services; the check is usually picked up by a third party (the government, an employer).

If people had to pay 100% out of their own pocket for healthcare, we would not have 400 MRI machines in Los Angeles County, nor would we have cancer drugs that cost $600,000 per year.

These are not bad developments; when I need an MRI or a new drug, I’m glad it is available (I have good insurance) without flying 500 miles or mortgaging my house. The point is how physicians define good patient care is very different from payers define it.

That brings us to EHRs. Why are EHRs being mandated? Who will benefit?

In the short run, adopting a new EHR system may be an inconvenience for many solo practitioners. The EHR mandate is being driven by the need to control costs. The old business adage “if you can’t measure it, you can’t manage it” applies here.

Will a new EHR system in a small physician practice lower costs for the patient or raise revenues for the physician? Maybe, maybe not. But that is not the raison d’etre for EHRs. The data that is captured and analyzed will improve overall health quality and lead to efficient delivery of care.

Ca fini.

This phrase was mentioned by an Intel executive in an address to the mHealth Summit in Washington DC last week. Several publications including iHealthbeat and the Chilmark Research newsletter had very interesting articles about the conference.

According to iHealthbeat:

“Rick Cnossen — director of worldwide health information technology at Intel — said he believes in the next 10 years 50% of health care could provided through the “brickless clinic,” be it the home, community, workplace or even car. Cnossen said the technology – such as mobile tools, telehealth, personal health records and social networking – already exists to make this possible. He said, “We have the technology. … It’s time to move out on it.”

And why has mhealth adoption been so slow to date? The iHealthbeat article reports that

“Cnossen said, “The challenge is not a technology problem, it’s a business and a workflow problem.”

This last statement can be applied to every single sector of the U.S. healthcare industry: mhealth, clinical diagnosis, billing and payment. It is never a technology problem, it is always a workflow problem. In our fee-for-service delivery system, one person’s workflow problem, whether it is a series of unnecessary tests, a too-long hospital stay or hours of transcription and billing by paper, can also be an important revenue source.

The other issue is the imperfect state of wireless connectivity. An anonymous comment posted at the end of the iHealthbeat article captured the problem brilliantly:

It’s time to apply some common sense here.  Ever had a battery problem with an iPhone? Ever had a problem getting consistent WiFi reception or had a call dropped or had a problem with the 3G network? Wanna bet your life on Dr. Topol’s iPhone reception in, say, Manhattan versus his stethoscope?