Q: If Kaiser Permanente spent $4 billion over 10 years for a level 7 EMR (HealthConnect ®) to cover 3.6 million members ($465 per capita), then what would be the cost to cover all 309 million US residents with a similar level 7 EMR?

A: $144 billion or 1% of GDP or 7.5 times the amount provided under ARRA/HITECH

Less fat or half baked?

hattip Movin’ Meat

Should Doctors Reject the Government’s EHR Incentive Plan?—David Kibbe

It’s a big hill to climb for a carrot that may not be there when you reach the top.

Is health information technology (IT) being set up to fail? Might we be facing a lost generation of health IT investment? Will Kaiser Permanente and Mayo Clinic get windfall profits while small practices receive nothing but hassles? It’s beginning to seem that way.

Valid questions in this excellent article by Kibbe. A physician must consider many factors in coming to a decision on whether and when to participate in the HITECH incentives program.

HITECH Medicare Physician Incentives

HITECH Medicaid Physician Incentives

Physician incentives under the federal Medicare program are offered over five years. There is a penalty (percent of total Medicare reimbursements) for failure to adopt starting in 2015. Physician incentives under state Medicaid programs are offered over six year without penalties per se. However, any incentives are contingent upon the states’ voluntary participation—which are dependent upon states’ budgetary discretions.

Choice of product(s), certification, updates and upgrades to the product(s), ongoing certification, and the reliability and complexities of the governmental payouts over five (Medicare) to six (Medicaid) years may all contribute to turning any positive remunerations negative. The meaningful risk balancing equations are:

Medicare: reimbursement v. failure to adopt

Medicaid: reimbursement v. state’s failure to offer

The physician contemplating participation must weigh the meaningful risk of that participation v. non–participation.

Meaningful Risk

1. Incentives: governmental monetary–inducements to implement an electronic health record (EHR)
2. EHR
3. Certification: a process, conducted by a third–party entity (e.g., TJC), certifying that an EHR passes governmentally defined regulations and standards and capable of producing meaningful use.
4. Meaningful Use: the necessary work products of a certified EHR required to substantiate eligibility for governmental incentives.
5. Eligible Hospital or Professional: is a hospital or professional (e.g., physician) that is eligible to receive governmental incentives because their certified EHR produces meaningful use.
6. Risk: potential and real

Incentives–induced certified EHRs producing meaningful use (data) creates a closed loop or cycle—a meaningful use cycle (MUC). An MUC, if a machine, takes incentives and passes certification and produces data. We hope a physician’s MUC will be benefiical to his practice and his patients, but it’s neither guaranteed nor required. This cuts to the core of the physician’s meaningful risk—potential money for an EHR, potential value to the practice, and potential value for his patients.

Meaningful Separation

1. Incentives
2. EHR
3. Certification
4. Meaninful Use
5. Eligible Hospital or Professional
6. Risk
7. XaaS: everything (else provided) as a service

Can the MUC be separated and reassembled in a manner where the physician receives the benefits of an EHR service and the incentives? Can certification (obtaining and maintaining), meaningful use (data), and the offering of an EHR be provided as a competitive service? Such a reconfiguration would require a zero–footprint practice installation—everything (else provided) as a service (XaaS).

Such an XaaS might have the following features:

• no hardware to purchase, install, maintain, or replace;
• no software to purchase, install, update, upgrade, modify, or make compatible or legacy–resistant;
• created, stored, and backup data would be standards–based and external to the practice;
• web browser user interface allowing for the use of any device that can be secured and offers a standards–compliant browser;

Meaningful Integration

1. Incentives
2. EHR
3. Certification
4. Meaninful Use
5. Eligible Hospital or Professional
6. Risk
7. XaaS

A reconstituted MUC might be created where an XaaS is used to move real and potential risks facing the physician to the competitively procured XaaS provider. Because the XaaS only handles standards–based data this creates a low threshold to shop and change XaaS providers based upon competitive features. An underlying premise here is that health information (HI, data) should never be held hostage to a particular hardware, software, or data form.

Meaningful use might be extended beyond the originating EHR by an XaaS to such offerings as a personal health record (PHR) and deidentified uses in secondary data markets. As an XaaS scales in size, with the number of EHRs hosted, it begins to resemble a health information exchange (HIE). But with the striking difference that no exchange is necessary because it handles only standards–based data. A competitive aspect of a sufficiently sized XaaS provider might be in the cost savings (HIE infrastructure) that is created because no exchange in HI is required—only an exchange in content, not syntax nor semantics.

Meaningful Design

1. Incentives
2. EHR
3. Certification
4. Meaninful Use
5. Eligible Hospital or Professional Enterprise–Centric HI
6. Risk
7. XaaS
8. PHR (expanded to include participatory input: patient initiated, sensor initated)
9. Patient–Centric HI

Can a service be fashioned that addresses the health informational needs of the enterprise (eligible hospital or professional) and the patient? Can the risk, inherent with the adoption of present generations of health IT (including beliefs and practices), be shifted to a competitive third–party service model (XaaS)? Can anything be done with the massive costs coming as we attempt to integrate HI nationally across innumerable disparate data silos? Yes, but only with eyes that see farther than the present incentive–induced vision. The false horizon is 2015. The true horizon is beyond where the government’s carrots and sticks lie. The balancing is not the monetary cost equation of participation v. no participation, but balancing the design needed to accomplish what is much more than meaningful use.

Meaningful eXtras

The putative XaaS provider needs to address privacy and security practices found in HIPAA, state laws, and other applicable federal laws (e.g., Red Flag Rules). They will need to handle communications between enterprise–centric and patient–centric HI spaces, including the facilitation of person–to–person communications. The expectation will be for realtime (or just–in–time) communications (or deliveries).

As the XaaS scales up with increasing numbers of hosted EHRs and PHRs—the value of its informational stores will be greater than the sum of its constituent sources. It will be able to offer a near–complete representational rendering of a person’s HI derived from multiple sources. In a similar fashion the value of its deidentified data in secondary markets will be enhanced. Configured properly, it will be able to contribute to and compete against HIEs because its informational stores are standards–based and requires no exchange–step(s).

Sebelius, Solis Announce Nearly $1 Billion Recovery Act Investment in Advancing Use of Health IT, Training Workers for Health Jobs of the Future

Health and Human Services Secretary Kathleen Sebelius and Labor Secretary Hilda Solis today announced a total of nearly $1 billion in Recovery Act (ARRA) awards to help health care providers advance the adoption and meaningful use of health information technology (IT) and train workers for the health care jobs of the future. The awards will help make health IT available to over 100,000 hospitals and primary care physicians by 2014 and train thousands of people for careers in health care and information technology. This Recovery Act investment will help grow the emerging health IT industry which is expected to support tens of thousands of jobs ranging from nurses and pharmacy techs to IT technicians and trainers.

Looking at the tables in this press release I’m wondering what will $3.17 per capita over four years purchase? Similarly, is $1.24 per capita over four years sufficient to build a national system of health information exchanges? If a billion dollars is considered sufficient to start this system, what happens in 2015? What will the steady state cost per capita be for a national health information system?

ARRA Investment ($): Total and Per Capita (x̄ = 3.17)

ARRA Investment ($) for HIE (Interoperability): Total and Per Capita (x̄ = 1.24)

Above tables created from this spreadsheet.

Meat stylus for the iPhone

It seems that the sausages, electrostatically speaking, are close approximations of the human finger.

Cool Technology of the Week—Life as a Healthcare CIO

Do you have large fingers and find typing on the iPhone to be a problematic experience?

Both problems are solved by a capacitance friendly stylus from Ten One Design.

Companion posts: Meaningful Absence, Meaningful Use: rules, not people!

When behaviors (broadly construed) are incentivized, and exchanges amongst behavioral–states likewise incentivized, are we not summing the behavioral constraints of all? Will meaningful absence lead to a meaningful barrier?

The three goals of meaningful use:

1. Incentivize certified EHRs.
2. Incentivize exchanges amongst certified EHRs.
3. Self–validate a certified EHR with the production of meaninful use measurements.

Meaningful Use (1x): incentivized behavior

1. Incentives
2. EHR
3. Certification
4. Meaninful Use
5. Eligible Hospital or Eligible Professional

Meaninful Use (zoom out 10x): incentivized exchanges

Meaningful Barrier (zoom out 100x)

Hattip to Heather on the title.

Adapted from Federal Register January 13, 2010: Medicare and Medicaid Programs: Electronic Health Record Incentive Program , 1844–2011 [E9–31217] (TXT)(PDF)

Meaningful Use (Stage 1, 2011): Responsible Entities, Patient Recipient

Meaningful Use

1. Incentives
2. EHR
3. Certification
4. Meaninful Use
5. Eligible Hospital or Eligible Professional

Meaningful Absence

1. Incentives
2. EHR
3. Certification
4. Meaninful Use
5. Eligible Hospital or Eligible Professional
6. Meaningful access, control, ownership, and sharing?

The obvious horiztonal markets are the consumer markets. The vertical markets are the enterprises, specifically: education and healthcare. Will this be the death of PCs in many enterprises? Many enterprises have needed appliances for years, but have been sold PCs—failing to understand what their markets really needed.

Perhaps the iPod and iPhone are the best examples of the Trojan Horse being smaller than its occupant.