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Back to the Future of EHR

by Dan Haley, SVP and General Counsel

“I feel like I am in a time warp; at a meeting of record company executives 15 years ago….” Neal Patterson, Chairman, CEO & President of Cerner Corporation

Looking around the room packed with CEO-level executives from a baker’s dozen of the largest HIT vendors in the country recently, I saw that each expression asked the same question: “Did he really just say that??!!”

The occasion was a meeting requested by the Electronic Health Records Association, or EHRA, with National Coordinator for Health IT, Dr. Farzad Mostashari, and several senior ONC and CMS staff. Many of athenahealth’s major (software-based) competitors were represented: Cerner, Epic, Meditech, Siemens, sitting around a large conference table in the Health and Human Services offices. Also on hand was athenahealth’s own Jonathan Bush and executives from our plucky compatriots in the cloud.

A Quickly Apparent Agenda

There were three topics on the agenda: Meaningful Use (MU), payment reform/accountable care, and the catch-all “future direction of the health IT industry.” The true agenda, however, became clear within five minutes of the opening gavel. Our competitors came to D.C. to complain about Meaningful Use standards.

I’ve become a bit of a broken record on this point, I know, but it bears repeating: nothing underscores the fundamental difference between static software-based electronic health record (EHR) technology and athenahealth’s cloud-based services than the difficulty that the static system vendors have meeting the standards. Our 21st century technology can do it with relative ease.

And so one legacy system CEO complained that his customers “feel rushed” by the need to “install new hardware and software” to keep up with government standards.

Another jumped in and asked for a “staggered cooling-off period” of one year between MU stages (in addition to the already-implemented delays) to allow vendors to “catch up,” and added helpfully/hopefully, “I think I speak for all vendors here.”

That made Jonathan twitch a little bit.

Then a senior executive from Epic (EPIC!!) lamented that Meaningful Use is “killing innovation,” and that was just too much for Jonathan.

He asked me for a list of the Meaningful Use Stage 2 standards and, scrolling through them, incredulously asked the group to tell him which of the “SO EASY!” standards are difficult to meet. He then launched into a lengthy discourse on the difference between cloud-based services and static software platforms.

Barely taking a breath, Jonathan transitioned to our D.C.-facing message-of-the-month: Reform the law to allow for creation of a true two-sided market for exchange of health information, which will incentivize true information liquidity and empower real systemic reform. This discussion yielded what might have been the most encouraging aside of the day, when a CMS official acknowledged the need for “a system to monetize information exchange.”

You can be sure we will follow up on that one…

Candor on Interoperability

To the extent that there were any points of agreement between Jonathan’s remarks and those that preceded him, they were:

  • Scrambling to meet sometimes arbitrary government standards DOES divert resources from innovations that customers really want
  • MU standards are too prescriptive and do not allow enough flexibility to achieve desired outcomes in innovative ways
  • MU Stage 3 (MU3) should be more about desired outcomes and less about mechanics
  • “Interoperability” doesn’t exist in today’s reality

On that last point there was surprisingly candid agreement from some of the major players in the room. Although they didn’t admit that their companies are specifically guilty of the practice, the executives did concede that too much “interoperability” is geared toward communication within proprietary networks, and virtually none of it is outward-facing. Jonathan opined that MU3 should be purely about the exchange of information and “forget all the rest.” Then came that shockingly candid bit of self-awareness, from Neal Patterson of Cerner, one of the biggest, baddest software-based platforms in the business: “I feel like I am in a time warp; at a meeting of record company executives 15 years ago….”

He pegged the vibe exactly. We only needed cigarette smoke hanging over the table to complete the 20th century ambiance. That, and a conversation on the limitation of technologies still hobbling health care, but that the rest of the economy shucked at end of the 1990s.

A '90s Flashback, With Biospheres

The same conversation dynamic carried over into the “Payment Reform/Accountable Care” portion of the program. After listening to a number of big-company CEOs talking about system consolidation and information lock as though they were good things, Jonathan again went off—this time deploying his “biospheres” speech. He talked about the top players protecting their “pavilions,” told the group that if they ever need a construction crane, they should just follow the “H” signs to find one, and said that the unintended consequence of consolidation and doc-lock is the “elephant in the room” on Accountable Care Organizations that nobody is talking about. In other words, "nonprofit" hospitals dump a lot of money into buildings that they then need to turn around and fill with patients. The “Pavillion” of 2012 is a large, static server-based stand-alone software product.

This triggered an excellent back-and-forth with the fellow representing one of the largest market players in the room, who in another moment of surprising candor admitted fairly openly that his company deliberately designs its systems to “interoperate” within closed systems, but not with the rest of the world.

One often hears the expression, “the first step is admitting you have a problem.” And some of the largest HIT vendors in the country admitted to big problems. Now if they’d just set about solving problems like true system interoperation instead of pushing incessantly to slow progress at the leading edge of innovation and locking doctors, patients, and information in proprietary silos. Then maybe we’d have a chance at a true technological revolution in health care. That’s what we’re in D.C. fighting for.

There were a few other stops on this trip to Washington. Extra credit if you can name the location of this picture...

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