My name is John Quinn I represent Ernst & Young LLP and I am also the Technical Chair of HL7. Within Ernst & Young’s Health Care Consulting Practice I am responsible for tracking and reporting on information systems technologies as they relate to the Health Care Industry.
I interpret the Congressional instruction as a general request by Congress to the Secretary of Health and Human Services to provide information and advice to Congress. I interpret that Congress is somewhat frustrated that the efficiencies of computer science, when looking at the US Health Care Industry, are not being applied to reduce overhead and increase the access for care givers to the medical record. And that Congress is asking the Secretary for recommendations on what, if anything, it could or should do to move the US Health Care Industry to make better use of computer technologies.
As many of you are aware, this US Health Care Industry relies heavily on a set of software and systems integration vendors that are typically referred to as “Health Information Systems” vendors or HIS vendors. In fact, the Health Care Industry Segment makes overwhelming use of “packaged solution sets” from these vendors to meet specific functional business and clinical automation needs. The Health Care HIS market has self-selected the demarcation lines for functionality between these package solution sets. There is no consistent “grand design” for the specific solution sets that are offered. It is, instead, a clear case of vendors producing what customers require.
Historically, vendors first found a market for business automation systems that streamlined the ability of a provider organization (i.e. hospital, physician’s group practice, home health agency, etc.) to bill for and receive reimbursement for services. The use and need of these billing and practice management systems accelerated dramatically during the 1970s as the Federal Government, and specifically the Health Care Finance Administration (HCFA) introduced DRGs and Prospective Payment etc. and the other payers similarly increased the complexity of what was needed to get paid. Recent developments over the last 10 or so years in this area has produced an environment where one could safely say that it is probably not a viable economical proposition for anyone to attempt to produce a health care insurance claim for an acute care episode without a computer system.
At the same time, clinical automation systems that assisted in the communication of information (e.g. orders for diagnostic tests) and the storage of information (e.g. the record keeping associated with these same orders and the diagnostic results) also took hold. Both types of systems (business and clinical) have their own peculiarities that are tightly related to the business, science and art of health care that make them significantly different than similar analogous software applications in other industries (e.g. invoices, manufacturing orders, etc.).
This can best be understood by looking at the collection of vendors that support Health Care Information Systems needs. Functional areas that have little to no distinction have a significant overlap with other U.S. “vertical businesses”. Examples of these include: General Ledger, Accounts Payable, Human Resources and payroll. Current vendors such as People Soft, Lawson, SAP and many others have a significant presence in all industries including Health Care. Functional areas such as patient billing, diagnostic services such as the pathology lab, radiology etc. and the entire area of the electronic medical record have few, if any, parallels in other industries and there is no significant market penetration of these software solutions into other industries.
In short, the US Computer Software Applications Industry has not been able to “leverage” its successes from other industries to the Health Care Industry. Among the reasons for this include:
1. The Health Care Industry, as mentioned above, has application needs that are unique and do not allow for the easy re-use of applications from other industries.
2. The vendors in this industry are significantly challenged by a significant lack of standard processes in the Health Care Industry. All packaged software vendors profit from a business formula that says: build it very well once at significant expense, and then sell a huge number of copies (e.g. office software products such as word processors, spreadsheets, etc.). The initial applications development is a significant capital investment, the reproduction costs should be a faction of a percent of that initial investment. Health Care has few standard processes among the buying institutions and even fewer between physicians who rely on personal knowledge, experience and, in some cases, intuition to determine what to do and how to do it. I don’t want to over dramatize this point, but I do need to point out that any vendor who produces Health Care Industry software invests a disproportionate amount, when compared to other industry software, to support process variability that applies to this industry only.
3. Clinical Health Care Data is extremely complex and heavily codified. These are significant technical challenges for anyone trying to build a database to hold clinical information. More importantly clinical information needs to be updated and retrieved quickly in order to “not slow down” the physician.
As a high-level example, the HL7 reference information model has about 830 complex data items (or attributes) the similar model produced by some of the same modelers for X12N contains about 160 of the same data items. There is clear overlap in some of these items. But, even if there was total overlap, which there is not, HL7 is still about 4 times as much data in the non-X12 (or primarily demographic and administrative) portion of the model. The fact that a significant part of this information is codified adds another burden to the database designer who must come up with a database design or “schema” for this information while managing and mapping the time-varying code sets which are most likely different code sets for each participating institution—even when they “share” the same information systems.
4. Technology is complex and changes rapidly. The HIS vendors require a significant amount of time to design and implement solutions for processes as complex as the medical record. The Information Industry has recently gone through an “explosion” of new technologies over the last 15 or so years that has been driven by a huge expansion of the general computer market to the consumer (i.e. read PC here). In short, the technology industry is based on relatively simple consumer applications. The HIS vendor community has not been able to capitalize on these changes and get them to market before the next wave of changes hits. This next wave causes buyers to stop and say, for example, “let’s wait for the thin-client version of this application”...a possibility that may be several years away from delivery and everyday use.
5. The technologies that HIS vendors use are general Information Industry technologies (e.g. relational database systems, programming tools, etc.). There is insufficient evidence that some of these technologies can support the scale of application deployment that a ubiquitous medical record will require. In fact, one can arguably state that the largest single commercially available electronic medical records system is only supporting about 4,000 devices at one of Kaiser Permanente’s smaller regional groups. The largest custom built academic electronic medical records system that I am aware of is supporting about 20,000 devices at Partners Healthcare in Boston. The message here is: in spite of any claims, no one vendor has demonstrated the technology and the ability to support the electronic medical record at a large health care provider or a truly large group practice. This must be done before we can consider the technology for the amalgamation of medical records across a region, state or the country as a whole.
First of all the private sector is probably doing as well as it can. Given enough time and patience it will eventually get there...but probably not in my natural life at the rate things are going (incidentally, I’m 49). The role of government, then should be to increase the rate. In the past, this has been done by primarily funding academic research and large government projects (e.g. the G-CPR project). In fact, the ability of information technology to meet Heath Care’s needs must be seriously assessed and incentives should be given to the development of commercial systems that can be implemented across the industry instead of at just one institution.
Finally, the government needs to come to grips with the contradictions of “standards”. Standards are only good if everyone is required to adhere to them. (e.g. DRGs are a standard because HCFA won’t reimburse you unless you use them correctly and there is little, if any consensus over an open group in their development). Open consensus standards take a long time to create...it’s the nature of having consensus driven standards. If this is not serving the country’s needs, then another “less consensus driven” process should be endorsed.
A) Add the most value for improving the quality and efficiency of health care for the nation? Why?
B) Be most important to the business goals or your organization? Why?
C) What is the business case for more rapid standards development and implementation
First of all, use Standards that are accepted and work. The HIS vendors have, for the most part, widely adopted HL7, X12 and DICOM. Where these messaging standards meet a domain’s needs, they should be used and required. In addition, however, the codes for use within these standards need to also be standardized, the processes at least semi-standardized where there is no demonstrated need for process variation, and a process set-up to fairly review and update those areas that reflect emerging areas of knowledge through academic review and periodic publication for mandatory, when applicable, use.
My organization consults to Providers, Payer, Pharmaceutical Companies, and Medical equipment and supply manufacturers. This pretty much covers the Health Care Industry. What’s good for the industry, helps my organization and our clients.
Without more Standards Development and Implementation...we are not going to enable the common and inexpensive electronic exchange of health information.