Has tech's time arrived? (Towards the Electronic Patient Record conference)

Technology companies and physicians now seem to be on the same wavelength. Companies finally are selling what doctors want to buy.

By Pamela Lewis Dolan — Posted March 2, 2009

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For more than two decades, technology companies hawked their wares while physicians mostly yawned.

The problem: selling doctors expensive, deskbound equipment that required reworking everything they did in their practices, while it likely would not save enough money nor improve efficiency. Even though officials from the president on down talked up the need for health information technology, that wasn't enough to overcome the unfavorable cost-benefit analysis that many physicians saw.

But as both sides are forced to make changes to ensure financial survival, the tech industry and physicians may have reached a point at which technology is finally starting to meet the needs of doctors.

In particular, less expensive mobile technology is allowing some benefits of large-scale electronic medical records without the huge upfront costs, while greater collaboration between companies is moving the emphasis away from the kind of proprietary technologies that don't speak with other systems or struggle to adapt to physicians' needs.

And as physicians see practice income fall, particularly as fewer patients have insurance, they are growing more open to using that cheaper technology to shave costs.

"It was strictly financial viability issues that forced doctors to get computers in the office," said Alan T. Falkoff, MD. It was the need for viability that inspired many practices to invest in practice-management systems to keep patient data organized and make billing easier. Now viability issues are forcing physicians to invest in clinical IT, said Dr. Falkoff, a family physician in a five-doctor practice in Stamford, Conn.

Evidence of this change in attitudes and strategies was apparent at the 25th annual Towards the Electronic Patient Record Conference, held in Palm Springs, Calif., in February.

When C. Peter Waegemann, founder of Boston-based Medical Records Institute, a research and consultancy organization that organizes the annual conference, held the first TEPR 25 years ago, he had a vision of every doctor having the capability to store and transfer patient records electronically. There have been milestones reached along the way, he said, although most have been good intentions and false starts.

More gains have been made in the past year than in the past several years combined, he said. A big reason for that success is the rise in everyday technologies, such as the Internet and mobile phones, that are being integrated into health care.

The organizers of TEPR "are achieving," said Louis Cornacchia, MD, president and CEO of the online physician community Doctations. "Maybe not what they thought they were achieving, but they are achieving."

In a keynote address, American Medical Association Board of Trustees Chair Joseph M. Heyman, MD, noted that the challenge for doctors is not a "lack of health IT, but rather information management. Health IT is simply a means to an end, not an end unto itself." Dr. Heyman uses an EMR system in his solo ob-gyn practice in Amesbury, Mass.

Change in strategy

When presentations by James Mault, MD, director of products and business development at Microsoft, Roni Zieger, MD, product manager of Google Health, and Adrian Gropper, MD, chief science officer of MedCommons, concluded on the second day of TEPR, the three, at the prompting of the moderator, shared a group hug.

Besides the laughs it drew from the crowd, the hug was noteworthy. The TEPR presentation was on building a personal health information ecosystem and all three spoke of the importance of working with others to make health data more portable.

But while software vendor MedCommons has collaborated with both Microsoft and Google on their respective personal health record platforms, so far Google has declined Microsoft's offer to collaborate. Dr. Zieger later said that although no plans have been announced, Google is in talks with Microsoft about making their PHRs compatible.

Experts are crediting cooperation for moving IT adoption forward as technology companies move away from proprietary systems and focus on ways to make mainstream technologies useful in health care. Mainstream technologies are tools physicians can use with systems they already have, rather than buying new hardware and software that can be used with only one product.

For example, as use of the Internet and cell phones have become ubiquitous, the way people communicate with physicians and other caregivers has changed. Now some technology companies are focusing on how those technologies and interactions work, rather than producing large-scale systems that might interfere.

"It's not just about the EMR anymore," Waegemann said.

The most compelling evidence of this change was in the conference's topics. There was less focus on stand-alone EMR systems, and there was a three-day track revolving solely around mobile health IT.

"Last year, I and another presenter were the only ones talking about mobile technology. Now that's all we're talking about," said Frank Avignone, PhD, director of business and sales development for AllOne Health, which developed a cell phone PHR platform that was unveiled at the 2008 TEPR conference.

Waegemann said the mobile technologies being introduced to health care have too much of an impact to be ignored. "A few years ago if someone said, 'Put your health information on Microsoft,' I would have said, 'You're crazy.' "

In response to the growing interest in mobile health technology, the Medical Records Institute formed a new organization, mHealth Initiative, and is holding mhealth workshops throughout the year. Whether TEPR even will be held next year remains unclear, but the inaugural mHealth Initiative meeting has been set for December, and the organization plans to make it an annual event.

"It's the Googles and Microsofts who will change health care in the next few years. It will not be the HITSPs and HL7s," Waegemann said, referring to the regulatory groups that are developing standards for the health IT industry.

In the past, physicians were keepers of all the patient records. Now patients can monitor and keep track of their own health using the same devices they use for other aspects of their lives. This evolving patient-physician relationship has sparked a renewed interest in the patient-centered medical home concept, of which many of these technologies are a crucial piece.

The medical home concept, as defined by the American Academy of Family Physicians, encourages things such as e-mailing with patients, remote monitoring and patient portals.

Shifting responsibilities

Physicians such as Dr. Falkoff have found that the more responsibilities practices can place on patients using technology, the less time physicians and their staffs are forced to spend on nonreimbursed activities.

There are many technologies small practices can afford as a way of reducing staff time and resources, said Dr. Falkoff, who shares his practice with two other family physicians and two pediatricians.

The practice has adopted such technologies as a kiosk that patients use to check in, freeing up staff. Patient portals can be accessed via the Web so patients can view and print their records, or send e-mails to physicians or staff. Patients even can send a note before an appointment alerting the doctor to the reason for a visit, freeing up time at the front end of the exam.

Beyond economic pressures, there also have been government pressure on practices to adopt health IT. For the first time, physicians are starting to see cooperation -- and money -- from government agencies.

Alan Greene, MD, a pediatrician and clinical professor of pediatrics at Stanford University School of Medicine in California, compared the health care industry with a revolutionary war. There is a realization that the old system is no longer working but it is still in charge.

"We are at about the stage of the declaration of independence in the road to EMRs," said Dr. Greene, who in 1995 pioneered the concept of physician Web sites (link).

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Evolving truths

In a session about building an interoperable ecosystem of personal health information, Vince Kuraitis, president of Better Health Technologies, a Boise, Idaho-based consulting firm, spoke about changes that are leading to a more cooperative environment for health IT adoption.

Conventional wisdom: Health care incumbents act as if patient data are their own.
Emerging reality: Patients say, "It's my information, hand it over now."
What it means: Physicians will no longer be in control of patient data -- patients will be.

Conventional wisdom: Proprietary IT and processes are a source of competitive advantage.
Emerging reality: Collaborative care management networks are required to coordinate care: It's a team sport.
What it means: Proprietary IT and standards have given way to a more collaborative environment.

Conventional wisdom: Planning for the National Health Information Network has involved a strategy of, "Ready, aim, fire."
Emerging reality: Building a personal health information network involves a strategy of "Ready, fire, aim."
What it means: The personal health record market is leading the way in developing interoperable systems, while the NHIN focuses on creating standards.

Conventional wisdom: People don't understand PHRs; adoption rates are low.
Emerging reality: Patients value integrated PHRs.
What it means: People will use PHRs if they deem them valuable.

Conventional wisdom: It's a battle between the titans -- Google and Microsoft.
Emerging reality: It's a new ecosystem, and the competition is paper and non-consumption.
What it means: Former competitors are now collaborating with each other to facilitate IT adoption and create a paperless health care system.

Source: Vince Kuraitis, "Future of the Personal Health Information Ecosystem," presented at TEPR 2009, February

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How patients value information sources

Patients are relying more on Internet resources for health information, but still value conversations with their physicians.

Becoming more important Becoming less important
Conversations with my doctor 30% Corporate and product advertising 34%
Conversations with
family members or friends
22% Web-based video-sharing sites 22%
Medical journals 21% Social networking sites 18%
Consumer health Web sites 19% Personal blogs 16%
Government agencies 17% Radio news coverage 11%
Conversations with someone
like me
14% Newspaper articles 10%
Google or other Internet
search engines
11% Online message boards,
forums or newsgroups
Health expert blogs 10% Films or documentaries 8%
Health-related newsletters 8% Web sites for specific brands
of medication
Nonprofit or health
advocacy Web sites
6% Magazine articles 6%
Wikipedia 6% TV news coverage 5%
Publications or brochures
from nonprofits or NGOs
5% Health companies' Web sites 3%
Books 4%

Note: The percentages were derived from the difference between respondents who said "more important" and those who said "less important," or vice versa.

Source: "Health Engagement Barometer," October 2008, Edelman, as presented at TEPR 2009, February (link)

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Focus on patient data exchange

AllOne Health, creator of the cell phone personal health record platform AllOne Mobile, said a partnership with Microsoft HealthVault forced the company to scrap its plans to release results of its yearlong pilot program.

It was scheduled to release the results at February's Towards the Electronic Patient Record conference.

Frank Avignone, PhD, director of business and sales development for AllOne Mobile, said the company signed a contract with Microsoft HealthVault in September 2008 that would allow easier exchange of information between patients and physicians. The HealthVault platform allows the input and output of data between the patient and anyone he or she chooses. The HealthVault data could then be viewed from the patient's mobile phone.

Avignone said the lack of control groups didn't allow for hard evidence on the technology's effectiveness for certain populations. The company is collecting user data on particular populations, including those using mobile devices for disease management, and plans to release those data later this year.

While the pilot targeted individual consumers, the group is now focused on contracts with insurers that are rolling out the service to members. The technology would let insurers populate PHRs, to which patients could add information either themselves or from their HealthVault accounts.

Physicians could download a reader, which is Web-based and free, that will accept any information a patient might choose to send to them.

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