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Our Uncontrolled Health Care Costs Can Be Traced to Data and Communication Failures (Part 2 of 2)

Posted on April 13, 2016 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://radar.oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

The previous section of this article provided whatever detail I could find on the costs of poor communications and data exchange among health care providers. But in truth, it’s hard to imagine the toll taken by communications failures beyond certain obvious consequences, such as repeated tests and avoidable medical errors. One has to think about how the field operates and what we would be capable of with proper use of data.

As patients move from PCP to specialist, from hospital to rehab facility, and from district to district, their providers need not only discharge summaries but intensive coordination to prevent relapses. Our doctors are great at fixing a diabetic episode or heart-related event. Where we fall down is on getting the patient the continued care she needs, ensuring she obtains and ingests her medication, and encouraging her to make the substantial life-style changes that can prevent reoccurrences. Modern health really is all about collaboration–but doctors are decades behind the times.

Clinicians were largely unprepared to handle the new patients brought to them by the Affordable Care Act. Examining the impact of new enrollees, who “have higher rates of disease and received significantly more medical care,” an industry spokesperson said, “The findings underscore the need for all of us in the health care system, and newly insured consumers, to work together to make sure that people get the right health care service in the right care setting and at the right time…Better communication and coordination is needed so that everyone understands how to avoid unnecessary emergency room visits, make full use of primary care and preventive services and learn how to properly adhere to their medications.” Just where the health providers fall short.

All these failures to communicate may explain the disappointing performance of patient centered medical homes and Accountable Care Organizations. While many factors go into the success or failure of such complex practices, a high rate of failure suggests that they’re not really carrying out the coordinated care they were meant to deliver. Naturally, problems persist in getting data from one vendor’s electronic health record to another.

Urgent care clinics, and other alternative treatment facilities offered in places such as pharmacies, can potentially lower costs, but not if the regular health system fails to integrate them.

Successes in coordinated care show how powerful it can be. Even so simple a practice as showing medical records to patients can improve care, but most clinicians still deny patients access to their data.

One care practice drastically lowered ER admissions through a notably low-tech policy–refering their patients to a clinic for follow-up care. This is only the beginning of what we could achieve. If modern communications were in place, hospitals would be linked so that a CDC warning could go to all of them instantly. And if clinicians and their record systems were set up to handle patient-generated data, they could discover a lot more about the patients and monitor behavior change.

How are the hospitals and clinics responding to this crisis and the public pressure to shape up? They push back as if it was not their problem. They claim they are moving toward better information sharing and teamwork, but never get there.

One of their favorite gambits is to ask the government to reward them for achieving interoperability 90 days out of the year. They make this request with no groveling, no tears of shame, no admission that they have failed in their responsibility to meet reasonable goals set seven years ago. If I delivered my projects only 25% of the time, I’d have trouble justifying myself to my employer, especially if I received my compensation plan seven years ago. Could the medical industry imagine that it owes us a modicum of effort?

Robert Schultz, a writer and entrepreneur in health care, says, “Underlying the broken communications model is a lack of empathy for the ultimate person affected–the patient. Health care is one of the few industries where the user is not necessarily the party paying for the product or service. Electronic health records and health information exchanges are designed around the insurance companies, accountable care organizations, or providers, instead of around understanding the challenges and obstacles that patients face on a daily basis. (There are so many!) The innovators who understand the role of the patient in this new accountable care climate will be winners. Those who suffer from the burden of legacy will continue to see the same problems and will become eclipsed by other organizations who can sustain patient engagement and prove value within accountable care contracts.”

Alternative factors

Of course, after such a provocative accusation, I should consider the other contributors that are often blamed for increasing health care costs.

An aging population

Older people have more chronic diseases, a trend that is straining health care systems from Cuba to Japan. This demographic reality makes intelligent data use even more important: remote monitoring for chronic conditions, graceful care transitions, and patient coordination.

The rising cost of drugs

Dramatically increasing drug prices are certainly straining our payment systems. Doctors who took research seriously could be pushing back against patient requests for drugs that work more often in TV ads than in real life. Doctors could look at holistic pain treatments such as yoga and biofeedback, instead of launching the worst opiate addiction crisis America has ever had.

Government bureaucracy

This seems to be a condition of life we need to deal with, like death and taxes. True, the Centers for Medicare & Medicaid Services (CMS) keeps adding requirements for data to report. But much of it could be automated if clinical settings adopted modern programming practices. Furthermore, this data appears to be a burden only because it isn’t exploited. Most of it is quite useful, and it just takes agile organizations to query it.

Intermediaries

Reflecting the Byzantine complexity of our payment systems, a huge number of middlemen–pharmacy benefits managers, medical billing clearinghouses, even the insurers themselves–enter the system, each taking its cut of the profits. Single-payer insurance has long been touted as a solution, but I’d rather push for better and cheaper treatments than attack the politically entrenched payment system.

Under-funded public health

Poverty, pollution, stress, and other external factors have huge impacts on health. This problem isn’t about clinicians, of course, it’s about all of us. But clinicians could be doing more to document these and intervene to improve them.

Clinicians like to point to barriers in their way of adopting information-based reforms, and tell us to tolerate the pace of change. But like the rising seas of climate change, the bite of health care costs will not tolerate complacency. The hard part is that merely wagging fingers and imposing goals–the ONC’s primary interventions–will not produce change. I think that reform will happen in pockets throughout the industry–such as the self-insured employers covered in a recent article–and eventually force incumbents to evolve or die.

The precision medicine initiative, and numerous databases being built up around the country with public health data, may contribute to a breakthrough by showing us the true quality of different types of care, and helping us reward clinicians fairly for treating patients of varying needs and risk. The FHIR standard may bring electronic health records in line. Analytics, currently a luxury available only to major health conglomerates, will become more commoditized and reach other providers.

But clinicians also have to do their part, and start acting like the future is here now. Those who make a priority of data sharing and communication will set themselves up for success long-term.

Our Uncontrolled Health Care Costs Can Be Traced to Data and Communication Failures (Part 1 of 2)

Posted on April 12, 2016 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://radar.oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

A host of scapegoats, ranging from the Affordable Care Act to unscrupulous pharmaceutical companies, have been blamed for the rise in health care costs that are destroying our financial well-being, our social fabric, and our political balance. In this article I suggest a more appropriate target: the inability of health care providers to collaborate and share information. To some extent, our health care crisis is an IT problem–but with organizational and cultural roots.

It’s well known that large numbers of patients have difficulty with costs, and that employees’ share of the burden is rising. We’re going to have to update the famous Rodney Dangerfield joke:

My doctor said, “You’re going to be sick.” I said I wanted a second opinion. He answered, “OK, you’re going to be poor too.”

Most of us know about the insidious role of health care costs in holding down wages, in the fight by Wisconsin Governor Scott Walker over pensions that tore the country apart, in crippling small businesses, and in narrowing our choice of health care providers. Not all realize, though, that the crisis is leaching through the health care industry as well, causing hospitals to fail, insurers to push costs onto subscribers and abandon the exchanges where low-income people get their insurance, co-ops to close, and governments to throw people off of subsidized care, threatening the very universal coverage that the ACA aimed to achieve.

Lessons from a ground-breaking book by T.R. Reid, The Healing of America, suggests that we’re undergoing a painful transition that every country has traversed to achieve a rational health care system. Like us, other countries started by committing themselves to universal health care access. This then puts on the pressure to control costs, as well as the opportunities for coordination and economies of scale that eventually institute those controls. Solutions will take time, but we need to be smart about where to focus our efforts.

Before even the ACA, the 2009 HITECH act established goals of data exchange and coordinated patient care. But seven years later, doctors still lag in:

  • Coordinating with other providers treating the patients.

  • Sending information that providers need to adequately treat the patients.

  • Basing treatment decisions on evidence from research.

  • Providing patients with their own health care data.

We’ll look next at the reports behind these claims, and at the effects of the problems.

Why doctors don’t work together effectively

A recent report released by the ONC, and covered by me in a recent article, revealed the poor state of data sharing, after decades of Health Information Exchanges and four years of Meaningful Use. Health IT observers expect interoperability to continue being a challenge, even as changes in technology, regulations, and consumer action push providers to do it.

If merely exchanging documents is so hard–and often unachieved–patient-focused, coordinated care is clearly impossible. Integrating behavioral care to address chronic conditions will remain a fantasy.

Evidence-based medicine is also more of an aspiration than a reality. Research is not always trustworthy, but we must have more respect for the science than hospitals were found to have in a recent GAO report. They fail to collect data either on the problems leading to errors or on the efficacy of solutions. There are incentive programs from payers, but no one knows whether they help. Doctors are still ordering far too many unnecessary tests.

Many companies in the health analytics space offer services that can bring more certainty to the practice of medicine, and I often cover them in these postings. Although increasingly cited as a priority, analytical services are still adopted by only a fraction of health care providers.

Patients across the country are suffering from disrupted care as insurers narrow their networks. It may be fair to force patients to seek less expensive providers–but not when all their records get lost during the transition. This is all too likely in the current non-interoperable environment. Of course, redundant testing and treatment errors caused by ignorance could erase the gains of going to low-cost providers.

Some have bravely tallied up the costs of waste and lack of care coordination in health care. Some causes, such as fraud and price manipulation, are not attributable to the health IT failures I describe. But an enormous chunk of costs directly implicate communications and data handling problems, including administrative overhead. The next section of this article will explore what this means in day-to-day health care.

Research Shows that Problems with Health Information Exchange Resist Cures (Part 2 of 2)

Posted on March 23, 2016 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://radar.oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

The previous section of this paper introduced problems found in HIE by two reports: one from the Office of the National Coordinator and another from experts at the Oregon Health & Science University. Tracing the causes of these problems is necessarily somewhat speculative, but the research helps to confirm impressions I have built up over the years.

The ONC noted that developing HIE is very resource intensive, and not yet sustainable. (p. 6) I attribute these problems to the persistence of the old-fashioned, heavyweight model of bureaucratic, geographically limited organizations hooking together clinicians. (If you go to another state, better carry your medical records with you.) Evidence of their continued drag on the field appeared in the report:

Grantees found providers did not want to login to “yet another system” to access data, for example; if information was not easily accessible, providers were not willing to divert time and attention from patients. Similarly, if the system was not user friendly and easy to navigate, or if it did not effectively integrate data into existing patient records, providers abandoned attempts to obtain data through the system. (pp. 76-77)

The Oregon researchers in the AHRQ webinar also confirmed that logging in tended to be a hassle.

Hidden costs further jacked up the burden of participation (p. 72). But even though HIEs already suck up unsustainable amounts of money for little benefit, “Informants noted that it will take many years and significantly more funding and resources to fully establish HIE.” (p. 62) “The paradox of HIE activities is that they need participants but will struggle for participants until the activities demonstrate value. More evidence and examples of HIE producing value are needed to motivate continued stakeholder commitment and investment.” (p. 65)

The adoption of the Direct protocol apparently hasn’t fixed these ongoing problems; hopefully FHIR will. The ONC hopes that, “Open standards, interfaces, and protocols may help, as well as payment structures rewarding HIE.” (p. 7) Use of Direct did increase exchange (p. 56), and directory services are also important (pp. 59-60). But “Direct is used mostly for ADT notifications and similar transitional documents.” (p. 35)

One odd complaint was, “While requirements to meet Direct standards were useful for some, those standards detracted attention from the development of query-based exchange, which would have been more useful.” (p. 77) I consider this observation to be a red herring, because Direct is simply a protocol, and the choice to use it for “push” versus “pull” exchanges is a matter of policy.

But even with better protocols, we’ll still need to fix the mismatch of the data being exchanged: “…the majority of products and provider processes do not support LOINC and SNOMED CT. Instead, providers tended to use local codes, and the process of mapping these local codes to LOINC and SNOMED CT codes was beyond the capacity of most providers and their IT departments.” (p. 77) This shows that the move to FHIR won’t necessarily improve semantic interoperability, unless FHIR requires the use of standard codes.

Trust among providers remains a problem (p. 69) as does data quality (pp. 70-71). But some informants put attitude about all: “Grantees questioned whether HIE developers and HIE participants are truly ready for interoperability.” (p. 71)

It’s bad enough that core health care providers–hospitals and clinics–make little use of HIE. But a wide range of other institutions who desperately need HIE have even less of it. “Providers not eligible for MU incentives consistently lag in HIE connectivity. These setting include behavioral health, substance abuse, long-term care, home health, public health, school-based settings, corrections departments, and emergency medical services.” (p. 75) The AHRQ webinar found very limited use of HIE for facilities outside the Meaningful Use mandate, such as nursing homes (Long Term and Post Acute Care, or LTPAC). Health information exchange was used 10% to 40% of the time in those settings.

The ONC report includes numerous recommendations for continuing the growth of health information exchange. Most of these are tweaks to bureaucratic institutions responsible for promoting HIE. These are accompanied by the usual exhortations to pay for value and improve interoperability.

But six years into the implementation of HITECH–and after the huge success of its initial goal of installing electronic records, which should have served as the basis for HIE–one gets the impression that the current industries are not able to take to the dance floor together. First, ways of collecting and sharing data are based on a 1980s model of health care. And even by that standard, none of the players in the space–vendors, clinicians, and HIE organizations–are thinking systematically.

Research Shows that Problems with Health Information Exchange Resist Cures (Part 1 of 2)

Posted on March 22, 2016 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://radar.oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

Given that Office of the National Coordinator for Health Information Technology (ONC) received 564 million dollars in the 2009 HITECH act to promote health information exchange, one has to give them credit for carrying out a thorough evaluation of progress in that area. The results? You don’t want to know.

There are certainly glass-full as well as glass-empty indications in the 98-page report that the ONC just released. But I feel that failure dominated. Basically, there has been a lot of relative growth in the use of HIE, but the starting point was so low that huge swaths of the industry remain untouched by HIE.

Furthermore, usage is enormously skewed:

In Q2 2012, for example, three states (Indiana, Colorado, and New York) accounted for over 85 percent of total directed transactions; in Q4 2013, five states (Michigan, Colorado, Indiana, New York, Michigan, and Vermont) accounted for over 85 percent of the total. Similarly, in Q2 a single state (Indiana) accounted for over 65 percent of total directed transactions; in Q4 2013, four states (California, Indiana, Texas, and New York) accounted for over 65 percent of the total. (p. 42)

This is a pretty empty glass, with the glass-full aspect being that if some states managed to achieve large numbers of participation, we should be able to do it everywhere. But we haven’t done it yet.

Why health information exchange is crucial

As readers know, health costs are eating up more and more of our income (in the US as well as elsewhere, thanks to aging populations and increasing chronic disease). Furthermore, any attempt to stem the problem requires coordinated care and long-term thinking. But the news in these areas has been disappointing as well. For instance:

  • Patient centered medical homes (PCMH) are not leading to better outcomes. One reason may be the limited use of health information exchange, because the success of treating a person in his own habitat depends on careful coordination.

  • Accountable Care Organizations are losing money and failing to attract new participants. A cynical series of articles explores their disappointing results. I suspect that two problems account for this: first, they have not made good use of health information exchange, and second, risk sharing is minimal and not extensive enough to cause a thoroughgoing change to long-term care.

  • Insurers are suffering too, because they have signed up enormous numbers of sick patients under the Affordable Care Act. The superficial adoption of fee-for-value and the failure of clinicians to achieve improvements in long-term outcomes are bankrupting the payers and pushing costs more and more onto ordinary consumers.

With these dire thoughts in mind, let’s turn to HIE.

HIE challenges and results

The rest of this article summarizes the information I find most salient in the ONC report, along with some research presented in a recent webinar by the Agency for Healthcare Research and Quality (AHRQ) on this timely topic. (The webinar itself hasn’t been put online yet.)

The ONC report covers the years 2011-2014, so possibly something momentous has happened over the past year to change the pattern. But I suspect that substantial progress will have to wait for widespread implementation of FHIR, which is too new to appear in the report.

You can read the report and parse the statistics until you get a headache, but I will cite just one more passage about the rate of HIE adoption in order to draw a broad conclusion.

As of 2015, the desire for actionable data, focus on MU 2 priorities, and exchange related to delivery system reform is in evidence. Care summary exchange rates facilitated through HIOs are high—for example, care record summaries (89%); discharge summaries (78%); and ambulatory clinical summaries (67%). Exchange rates are also high for test results (89%), ADT alerts (69%), and inpatient medication lists (68%). (p. 34)

What I find notable in the previous quote is that all the things where HIE use improved were things that clinicians have always done anyway. There is nothing new about sending out discharge summaries or reporting test results. (Nobody would take a test if the results weren’t reported–although I found it amusing to receive an email message recently from my PCP telling me to log into their portal to see results, and to find nothing on the portal but “See notes.” The notes, you might have guessed, were not on the portal.)

One hopes that using HIE instead of faxes and phone calls will lower costs and lead to faster action on urgent conditions. But a true leap in care will happen only when HIE is used for close team coordination and patient reporting–things that don’t happen routinely now. One sentence in the report hints at this: “Providers exchanged information, but they did not necessarily use it to support clinical decision-making.” (p. 77) One wonders what good the exchange is.

In the AHRQ webinar, experts from the Oregon Health & Science University reported results of a large literature review, including:

  • HIE reduces the use lab and radiology tests, as well emergency department use. This should lead to improved outcomes as well as lower costs, although the literature couldn’t confirm that.

  • Disappointingly, there was little evidence that hospital admissions were reduced, or that medication adherence improved.

  • Two studies claimed that HIE was “associated with improved quality of care” (a very vague endorsement).

In the next section of this article, I’ll return to the ONC report for some clues as to the reasons HIE isn’t working well.

Will New Group Steal Thunder From CommonWell Health Alliance?

Posted on January 26, 2016 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Back in March 0f 2013, six health IT vendors came together to announce the launch of the CommonWell Health Alliance. The group, which included Cerner, McKesson, Allscripts, athenahealth, Greenway Medical Technologies and RelayHealth, said they were forming the not-for-profit organization to foster national health data interoperability. (Being a cynical type, I immediately put it in a mental file tagged “The Group Epic Refused To Join,” but maybe that wasn’t fair since it looks like the other EHR vendors might have left Epic out on purpose.)

Looked at from some perspectives, the initiative has been a success. Over the past couple of years or so, CommonWell developed service specifications for interoperability and deployed a national network for health data sharing. The group has also attracted nearly three dozen HIT companies as members, with capabilities extending well beyond EMRs.

And according to recently-appointed executive director Jitin Asnaani, CommonWell is poised to have more than 5,000 provider sites using its services across the U.S. That will include more than 1,200 of Cerner’s provider sites. Also, Greenway Health and McKesson provider sites should be able to share health data with other CommonWell participants.

While all of this sounds promising, it’s not as though we’ve seen a great leap in interoperability for most providers. This is probably why new interoperability-focused initiatives have emerged. Just last week, five major HIT players announced that they would be the first to implement the Carequality Interoperability Framework.

The five vendors include, notably, Epic, along with athenahealth, eClinicalWorks, NextGen Healthcare and Surescripts. While the Carequality team might not be couching things this way, to me it seems likely that it intends to roll on past (if not over) the CommonWell effort.

Carequality is an initiative of The Sequoia Project, a DC-area non-profit. While it shares CommonWell’s general mission in fostering nationwide health information exchange, that’s where its similarities to CommonWell appear to end:

* Unlike CommonWell, which is almost entirely vendor-focused, Sequoia’s members also include the AMA, Kaiser Permanente, Minute Clinic, Walgreens and Surescripts.

* The Carequality Interoperability Framework includes not only technical specifications for achieving interoperability, but also legal and governance documents helping implementers set up data sharing in legally-appropriate ways between themselves and patients.

* The Framework is designed to allow providers, payers and other health organizations to integrate pre-existing connectivity efforts such as previously-implemented HIEs.

I don’t know whether the Carequality effort is complimentary to CommonWell or an attempt to eclipse it. It’s hard for me to tell whether the presence of a vendor on both membership lists (athenahealth) is an attempt to learn from both sides or a preparation for jumping ship. In other words, I’m not sure whether this is a “game changer,” as one health IT trade pub put it, or just more buzz around interoperability.

But if I were a betting woman, I’d stake hard, cold dollars that Carequality is destined to pick up the torch CommonWell lit. That being said, I do hope the two cooperate or even merge, as I’m sure the very smart people associated with these efforts can learn from each other. If they fight for mindshare, it’d be a major waste of time and talent.

Idiosyncratic Recommendations Based on Widespread Principles: the Health IT Policy Committee Report

Posted on December 21, 2015 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://radar.oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

Congress received an odd document last week from an advisory committee on Health IT. It takes an unexpectedly new–and demandingly detailed–approach to the perennial problem of health record interoperability. However, if one analyzes the authors’ reasoning, it turns out to be based on unstated principles that are widely accepted in health care:

  1. The market is broken, and the government must intervene either through incentives or through requirements.

  2. The intervention should be based on operational or clinical goals, not dictating the adoption of specific technologies.

  3. Policy-makers should pick off low-hanging fruit through goals that produce potentially large benefits with relative ease.

Read more..

Significant Articles in the Health IT Community in 2015

Posted on December 15, 2015 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://radar.oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

Have you kept current with changes in device connectivity, Meaningful Use, analytics in healthcare, and other health IT topics during 2015? Here are some of the articles I find significant that came out over the past year.

The year kicked off with an ominous poll about Stage 2 Meaningful Use, with implications that came to a head later with the release of Stage 3 requirements. Out of 1800 physicians polled around the beginning of the year, more than half were throwing in the towel–they were not even going to try to qualify for Stage 2 payments. Negotiations over Stage 3 of Meaningful Use were intense and fierce. A January 2015 letter from medical associations to ONC asked for more certainty around testing and certification, and mentioned the need for better data exchange (which the health field likes to call interoperability) in the C-CDA, the most popular document exchange format.

A number of expert panels asked ONC to cut back on some requirements, including public health measures and patient view-download-transmit. One major industry group asked for a delay of Stage 3 till 2019, essentially tolerating a lack of communication among EHRs. The final rules, absurdly described as a simplification, backed down on nothing from patient data access to quality measure reporting. Beth Israel CIO John Halamka–who has shuttled back and forth between his Massachusetts home and Washington, DC to advise ONC on how to achieve health IT reform–took aim at Meaningful Use and several other federal initiatives.

Another harbinger of emerging issues in health IT came in January with a speech about privacy risks in connected devices by the head of the Federal Trade Commission (not an organization we hear from often in the health IT space). The FTC is concerned about the security of recent trends in what industry analysts like to call the Internet of Things, and medical devices rank high in these risks. The speech was a lead-up to a major report issued by the FTC on protecting devices in the Internet of Things. Articles in WIRED and Bloomberg described serious security flaws. In August, John Halamka wrote own warning about medical devices, which have not yet started taking security really seriously. Smart watches are just as vulnerable as other devices.

Because so much medical innovation is happening in fast-moving software, and low-budget developers are hankering for quick and cheap ways to release their applications, in February, the FDA started to chip away at its bureaucratic gamut by releasing guidelines releasing developers from FDA regulation medical apps without impacts on treatment and apps used just to transfer data or do similarly non-transformative operations. They also released a rule for unique IDs on medical devices, a long-overdue measure that helps hospitals and researchers integrate devices into monitoring systems. Without clear and unambiguous IDs, one cannot trace which safety problems are associated with which devices. Other forms of automation may also now become possible. In September, the FDA announced a public advisory committee on devices.

Another FDA decision with a potential long-range impact was allowing 23andMe to market its genetic testing to consumers.

The Department of Health and Human Services has taken on exceedingly ambitious goals during 2015. In addition to the daunting Stage 3 of Meaningful Use, they announced a substantial increase in the use of fee-for-value, although they would still leave half of providers on the old system of doling out individual payments for individual procedures. In December, National Coordinator Karen DeSalvo announced that Health Information Exchanges (which limit themselves only to a small geographic area, or sometimes one state) would be able to exchange data throughout the country within one year. Observers immediately pointed out that the state of interoperability is not ready for this transition (and they could well have added the need for better analytics as well). HHS’s five-year plan includes the use of patient-generated and non-clinical data.

The poor state of interoperability was highlighted in an article about fees charged by EHR vendors just for setting up a connection and for each data transfer.

In the perennial search for why doctors are not exchanging patient information, attention has turned to rumors of deliberate information blocking. It’s a difficult accusation to pin down. Is information blocked by health care providers or by vendors? Does charging a fee, refusing to support a particular form of information exchange, or using a unique data format constitute information blocking? On the positive side, unnecessary imaging procedures can be reduced through information exchange.

Accountable Care Organizations are also having trouble, both because they are information-poor and because the CMS version of fee-for-value is too timid, along with other financial blows and perhaps an inability to retain patients. An August article analyzed the positives and negatives in a CMS announcement. On a large scale, fee-for-value may work. But a key component of improvement in chronic conditions is behavioral health which EHRs are also unsuited for.

Pricing and consumer choice have become a major battleground in the current health insurance business. The steep rise in health insurance deductibles and copays has been justified (somewhat retroactively) by claiming that patients should have more responsibility to control health care costs. But the reality of health care shopping points in the other direction. A report card on state price transparency laws found the situation “bleak.” Another article shows that efforts to list prices are hampered by interoperability and other problems. One personal account of a billing disaster shows the state of price transparency today, and may be dangerous to read because it could trigger traumatic memories of your own interactions with health providers and insurers. Narrow and confusing insurance networks as well as fragmented delivery of services hamper doctor shopping. You may go to a doctor who your insurance plan assures you is in their network, only to be charged outrageous out-of-network costs. Tools are often out of date overly simplistic.

In regard to the quality ratings that are supposed to allow intelligent choices to patients, A study found that four hospital rating sites have very different ratings for the same hospitals. The criteria used to rate them is inconsistent. Quality measures provided by government databases are marred by incorrect data. The American Medical Association, always disturbed by public ratings of doctors for obvious reasons, recently complained of incorrect numbers from the Centers for Medicare & Medicaid Services. In July, the ProPublica site offered a search service called the Surgeon Scorecard. One article summarized the many positive and negative reactions. The New England Journal of Medicine has called ratings of surgeons unreliable.

2015 was the year of the intensely watched Department of Defense upgrade to its health care system. One long article offered an in-depth examination of DoD options and their implications for the evolution of health care. Another article promoted the advantages of open-source VistA, an argument that was not persuasive enough for the DoD. Still, openness was one of the criteria sought by the DoD.

The remote delivery of information, monitoring, and treatment (which goes by the quaint term “telemedicine”) has been the subject of much discussion. Those concerned with this development can follow the links in a summary article to see the various positions of major industry players. One advocate of patient empowerment interviewed doctors to find that, contrary to common fears, they can offer email access to patients without becoming overwhelmed. In fact, they think it leads to better outcomes. (However, it still isn’t reimbursed.)

Laws permitting reimbursement for telemedicine continued to spread among the states. But a major battle shaped up around a ruling in Texas that doctors have a pre-existing face-to-face meeting with any patient whom they want to treat remotely. The spread of telemedicine depends also on reform of state licensing laws to permit practices across state lines.

Much wailing and tears welled up over the required transition from ICD-9 to ICD-10. The AMA, with some good arguments, suggested just waiting for ICD-11. But the transition cost much less than anticipated, making ICD-10 much less of a hot button, although it may be harmful to diagnosis.

Formal studies of EHR strengths and weaknesses are rare, so I’ll mention this survey finding that EHRs aid with public health but are ungainly for the sophisticated uses required for long-term, accountable patient care. Meanwhile, half of hospitals surveyed are unhappy with their EHRs’ usability and functionality and doctors are increasingly frustrated with EHRs. Nurses complained about technologies’s time demands and the eternal lack of interoperability. A HIMSS survey turned up somewhat more postive feelings.

EHRs are also expensive enough to hurt hospital balance sheets and force them to forgo other important expenditures.

Electronic health records also took a hit from ONC’s Sentinel Events program. To err, it seems, is not only human but now computer-aided. A Sentinel Event Alert indicated that more errors in health IT products should be reported, claiming that many go unreported because patient harm was avoided. The FDA started checking self-reported problems on PatientsLikeMe for adverse drug events.

The ONC reported gains in patient ability to view, download, and transmit their health information online, but found patient portals still limited. Although one article praised patient portals by Epic, Allscripts, and NextGen, an overview of studies found that patient portals are disappointing, partly because elderly patients have trouble with them. A literature review highlighted where patient portals fall short. In contrast, giving patients full access to doctors’ notes increases compliance and reduces errors. HHS’s Office of Civil Rights released rules underlining patients’ rights to access their data.

While we’re wallowing in downers, review a study questioning the value of patient-centered medical homes.

Reuters published a warning about employee wellness programs, which are nowhere near as fair or accurate as they claim to be. They are turning into just another expression of unequal power between employer and employee, with tendencies to punish sick people.

An interesting article questioned the industry narrative about the medical device tax in the Affordable Care Act, saying that the industry is expanding robustly in the face of the tax. However, this tax is still a hot political issue.

Does anyone remember that Republican congressmen published an alternative health care reform plan to replace the ACA? An analysis finds both good and bad points in its approach to mandates, malpractice, and insurance coverage.

Early reports on use of Apple’s open ResearchKit suggested problems with selection bias and diversity.

An in-depth look at the use of devices to enhance mental activity examined where they might be useful or harmful.

A major genetic data mining effort by pharma companies and Britain’s National Health Service was announced. The FDA announced a site called precisionFDA for sharing resources related to genetic testing. A recent site invites people to upload health and fitness data to support research.

As data becomes more liquid and is collected by more entities, patient privacy suffers. An analysis of web sites turned up shocking practices in , even at supposedly reputable sites like WebMD. Lax security in health care networks was addressed in a Forbes article.

Of minor interest to health IT workers, but eagerly awaited by doctors, was Congress’s “doc fix” to Medicare’s sustainable growth rate formula. The bill did contain additional clauses that were called significant by a number of observers, including former National Coordinator Farzad Mostashari no less, for opening up new initiatives in interoperability, telehealth, patient monitoring, and especially fee-for-value.

Connected health took a step forward when CMS issued reimbursement guidelines for patient monitoring in the community.

A wonky but important dispute concerned whether self-insured employers should be required to report public health measures, because public health by definition needs to draw information from as wide a population as possible.

Data breaches always make lurid news, sometimes under surprising circumstances, and not always caused by health care providers. The 2015 security news was dominated by a massive breach at the Anthem health insurer.

Along with great fanfare in Scientific American for “precision medicine,” another Scientific American article covered its privacy risks.

A blog posting promoted early and intensive interactions with end users during app design.

A study found that HIT implementations hamper clinicians, but could not identify the reasons.

Natural language processing was praised for its potential for simplifying data entry, and to discover useful side effects and treatment issues.

CVS’s refusal to stock tobacco products was called “a major sea-change for public health” and part of a general trend of pharmacies toward whole care of the patient.

A long interview with FHIR leader Grahame Grieve described the progress of the project, and its the need for clinicians to take data exchange seriously. A quiet milestone was reached in October with a a production version from Cerner.

Given the frequent invocation of Uber (even more than the Cheesecake Factory) as a model for health IT innovation, it’s worth seeing the reasons that model is inapplicable.

A number of hot new sensors and devices were announced, including a tiny sensor from Intel, a device from Google to measure blood sugar and another for multiple vital signs, enhancements to Microsoft products, a temperature monitor for babies, a headset for detecting epilepsy, cheap cameras from New Zealand and MIT for doing retinal scans, a smart phone app for recognizing respiratory illnesses, a smart-phone connected device for detecting brain injuries and one for detecting cancer, a sleep-tracking ring, bed sensors, ultrasound-guided needle placement, a device for detecting pneumonia, and a pill that can track heartbeats.

The medical field isn’t making extensive use yet of data collection and analysis–or uses analytics for financial gain rather than patient care–the potential is demonstrated by many isolated success stories, including one from Johns Hopkins study using 25 patient measures to study sepsis and another from an Ontario hospital. In an intriguing peek at our possible future, IBM Watson has started to integrate patient data with its base of clinical research studies.

Frustrated enough with 2015? To end on an upbeat note, envision a future made bright by predictive analytics.

Providers Still Have Hope For HIEs

Posted on July 10, 2015 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Sometimes, interoperability alone doesn’t cut it.  Increasingly, providers are expecting HIEs to go beyond linking up different organizations to delivering “actionable” data, according to a new report from NORC at the University of Chicago. The intriguing follow-on to the researchers’ conclusions is that HIEs aren’t obsolete, though their obsolescence seemed all but certain in the past.

The study, which was written up by Healthcare Informatics, conducted a series of site visits and 37 discussions with providers in Iowa, Mississippi, New Hampshire, Vermont, Utah and Wyoming. The researchers, who conducted their study in early 2014, hoped to understand how providers looked at HIEs generally and their state HIE program specifically. (The research was funded by ONC.)

One major lesson for the health IT types reading this article is that providers want data sharing models to reflect new care realities.  With Meaningful Use requirements and changes in payment models bearing down on providers, and triggering changes in how care is delivered, health IT-enabled data exchange needs to support new models of care.

According to the study, providers are intent on having HIEs deliver admission, discharge, and transfer alerts, interstate data exchange and data services that assist in coordinating care. While I don’t have comprehensive HIE services research to hand, maybe you do, readers. Are HIEs typically meeting these criteria? I doubt it, though I could be wrong.

That being said, providers seem to be willing to pay for HIE services if the vendor can meet their more stringent criteria.  While this may be tough to swallow for existing HIE technology sellers, it’s good news for the HIE model generally, as getting providers to pay for any form of community data exchange has been somewhat difficult historically.

Some of the biggest challenges in managing HIE connectivity identified by the study include getting good support from both HIE and EMR vendors, as well as a lack of internal staff qualified to manage data exchange, competing priorities and problems managing multiple funding streams. But vendors can work to overcome at least some of these problems.

As I noted previously, hospitals in particular have had many beliefs which have discouraged them from participating in HIEs. As one HIE leader quoted in my previous post noted, many have assumed that HIE connection costs would be in the same range as EMR adoption expenses; they’re been afraid that HIEs would not put strong enough data security in place to meet HIPAA obligations; and they assumed that HIE participation wasn’t that important.

Today, given the growing importance of sophisticated data management has come to the forefront, and most providers know that they need to have the big picture widespread data sharing can provide. Without the comprehensive data set cutting across the patient care environment — something few organizations are integrated enough to develop on their own — they’re unlikely to mount a successful population health management initiative or control costs sufficiently. So it’s interesting to see providers see a future for HIEs.

Patients Can Squawk, But We Have Little To Crow About Open Data

Posted on June 15, 2015 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://radar.oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

One of the biggest disappointments at this year’s Health Datapalooza (which I found disappointing overall) was the continued impasse presented to patients who, bolstered by the best thinking in health care as well as Federal laws and regulations, ask for health data stored about them by doctors and other institutions.

Activists such as Regina Holliday and e-Patient Dave proved years ago that giving patients information and involving them in decisions will save lives. The Society for Participatory Medicine enshrines the principle. But the best witnesses for patient empowerment are the thousands of anonymous patients, spouses, parents, and children quietly trundling folders with their own records through the halls of hospitals, building up more knowledge of their chronic conditions than any professional clinician possesses, and calmly but inflexibly insisting on being equal partners with those who treat them.

There were plenty of high-minded words at the Datapalooza about patient rights to data. It was recognized as a key element of patient empowerment (or “activation,” as the more timid speakers liked to say) as well as an aid to better care. An online petition backed by an impressive array of health reformers is collecting signatures (whom someone will presumably look at) and encourages activists to speak up about this topic on July 4. HHS announced that anyone denied access to data to which the law gives her a right can submit an informal report to noinformationblocking@cms.hhs.gov.

Although occasional mention was made of personal health records (PHRs), most of the constant discussion about interoperability stayed on the safe topic of provider-to-provider data exchange. Keeping data with health care providers leads to all sorts of contorted practices. For instance, patient matching and obtaining consent are some of the most difficult challenges facing health IT in the U.S., all caused by keeping data with providers instead of the patients themselves.

The industry’s slowness to appreciate patient-generated data is also frustrating. Certainly, the health IT field needs to do a lot more to prepare data for use: consumer device manufacturers must assure clinicians of the devices’ accuracy, and researchers need to provide useful analytics that clinicians can plug in to their electronic systems. Still, doctors are demonstrating a disappointing lack of creativity in the face of this revolutionary source of information. It’s all to easy to carp about accuracy (after all, lab tests have limited accuracy as well) or just to state that you don’t know what to do with the data.

I heard about recent progress at the UK’s National Health Service from Brian Ahier, who is the only person I know who can explain the nuances of extensions to FHIR resources while actively using both his laptop and his cell phone at the same time. Ahier heard at a UK-US Bootcamp before the Datapalooza that the NHS has given 97% of its patients access to their records.

But there’s a bit of a caution around that statistic: only one-fifth of the patients have taken advantage of this right. This doesn’t bother me. First of all, one-fifth of the population with access to their personal records would be a dizzying accomplishment for most countries, including the U.S. Second, few people need access to records until some major problem arises, such as the need to see a specialist. They probably feel relieved to know the records will be there when needed.

Another aspect of patient control over data is research. The standard researcher-centered model is seen as increasingly paternalistic, driving patients away. They’re not impressed with being told that some study will benefit people like them–they want to tell researchers what really matters to them as sufferers, and hear more about the study as it goes along. Researchers are frantic to reverse a situation where most studies fail simply because they can’t sign up enough subjects.

The Patient-Centered Outcomes Research Institute (PCORI) is one of the progressive institutions in health care who understand that giving patients more of a say will be increasingly important for signing up patients in the first place, as well doing research of value to them. Its PCORnet combines traditional research databases with databases maintained by patient advocacy groups. Each member network can create its own policies for getting consent, which allows researchers to bend with the needs of their research subjects.

OpenClinica, the open source clinical research platform, just announced the release of an app that may contribute to the goals of taking input from patients and binding them closer to the research endeavor.

Public health officials also recognize the sensibilities of the people they monitor. At a panel on data about low-income people, speakers stressed the importance of collecting data in a respectful way that doesn’t make people feel they’re being spied on or could be punished for their behavior.

Let’s talk a minute about health care costs, if only because doctors and insurers don’t want to. (Some doctors are prohibited by their employers from telling patients how much a recommended procedure will cost, supposedly because they don’t want costs to intrude on what should ideally be a clinical decision. This is changing with the increase in deductibles, but often the doctors don’t even know what the final cost will be after insurance.)

One app so admired by the Datapalooza team that they allowed the company to demonstrate its product on the main stage during keynote time was Sensentia. This product everybody is so impressed with takes in information from health plans to allow patients as well as the staff at health care providers to quickly find the health plan benefits for a procedure. (I recently covered another company doing similar work with insurance and costs.)

Sensentia is a neat product, I am willing to aver. It accepts natural language queries, crunches the data about health plans and insurers, and returns the actual health plan benefits for a treatment. Of course, I know the cost of flying from Boston to San Francisco after six clicks in my browser, even though the calculations that go into offering me a price are at least as complicated as those run by health plans. One may be shocked to hear that that current phone calls to an insurer cost $3-$10. This is the state of health care–it costs more than five bucks on average for a doctor just to find out how much it will cost to offer his own service.

A panel on patient-generated data reported more barriers than successes in getting doctors to work with data from patient devices and reports from everyday life. Another panel about improving quality measures culminated in the moderator admitting that more patients use Yelp than anything else to choose providers–and that it works pretty well for them.

For me that was the conference’s low point, and a moment of despairing cynicism that doesn’t reflect the mood of the conference or the health care field as a whole. Truly, if Yelp could solve our quality problems, we wouldn’t need a Datapalooza or the richness of data analysis it highlights. But I think reformers need more strategies to leap the hurdles we’re facing and implement the vision we all share.

Taking a New Look at the Lamented Personal Health Record: Flow Health’s Debut

Posted on June 8, 2015 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://radar.oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

After the disappointing lack of adoption suffered by Google Health and Microsoft HealthVault, many observers declared personal health records (PHRs) a non-starter, while others predicted that any progress toward personal control over health data would require a radically new approach.

Several new stabs at a PHR are emerging, of which Flow Health shows several promising traits. The company tries to take advantage of–and boost the benefits of–advances in IT standards and payment models. This article is based on a conversation I had with their general counsel, David Harlow, who is widely recognized as the leading legal expert in health IT and health privacy and who consults with companies in those spaces through the Harlow Group.

Because records are collected by doctors, not patients, the chief hurdle any PHR has to overcome is to persuade the health care providers to relinquish sole control over the records they squirrel away in their local EHR silos. Harlow believes the shift to shared risk and coordinated care is creating the incentive for doctors to share. The Center for Medicare & Medicaid Services is promising to greatly increase the role of pay-for-value, and a number of private insurers have promised to do so as well. In short, Flow Health can make headway if the tangible benefit of learning about a patient’s recent hospital discharge or treating chronic conditions while the patient remains at home start to override the doctor’s perception that she can benefit by keeping the patient’s data away from competitors.

The next challenge is technically obtaining the records. This is facilitated first by the widespread move to electronic records (a legacy of Meaningful Use Stage 1) and the partial standardization of these records in the C-CDA. Flow Health recognizes both the C-CDA and Blue Button, as well as using the Direct protocol to obtain records. Harlow says that FHIR will be supported when the standard settles down.

But none of that is enough to offer Flow Health what the doctors and patients really want, which is a unified health record containing all the information given by different providers. Therefore, like other companies trying to broaden access to patient data, Flow Health must deal with the problem that Dr. Eric Topol recently termed the Tower of EMR Babel. They study each format produced by different popular EHRs (each one using the C-CDA in slightly incompatible ways) and convert the data into a harmonized format. This allows Flow Health to then reconcile records when a diagnosis, a medication list, or some other aspect of the patient’s health is represented differently in different records.

What’s next for Flow Health? Harlow said they are preparing an API to let third parties add powerful functionality, such as care coordination and patient access from any app of their choice. Flow Health is already working closely with payers and providers to address workflow challenges, thus accelerating the aggregation of patient health record data for access and use by clinicians and patients.

A relative of mine could have used something like Flow Health recently when her eye doctor referred her to the prestigious Lahey Clinic in the Boston area. First of all, the test that led to the referral had to be repeated at the Lahey Clinic, because the eye doctor did not forward test results. Nor did anyone provide a medication list, so the Lahey Clinic printed out a five-year old medication list that happened to hang around from a visit long ago and asked her to manually update it. There was also confusion about what her insurer would cover, but that’s a different matter. All this took place in 2015, in the country’s leading region for medical care.

It seems inevitable that–as Flow Health hopes–patients will come to demand access to their medical records. A slew of interesting experiments will proliferate, like Flow Health and the rather different vision of Medyear to treat health information like a social network feed. Patient-generated data, such as the output from fitness devices and home sensors, will put yet more pressure on health care providers to take the patient seriously as a source of information. And I’ll continue to follow developments.