Here at Health 2.0 there is definitely an air of transformation. Several initiatives that I had been following have come to fruition, or at least to critical mass, among them implementation of EMRs and patient communities. MedHelp now has over 12 million visitors a month, while millions of women annually visit the women’s social health site EmpowHER.com

On the electronic medical records side,  physicians have finally begun to implement EMRs in large numbers, because they are now subsidized by ARRA, the stimulus bill (you remember, the one that didn’t work?) to do so. In order to receive $50,000 to deploy an EMR, a physician need only buy one and demonstrate its “meaningful use” in his practice. For this year, to qualify for the Medicaid meaningful use incentive, all you had to do was purchase the software and go live in your practice. In the future, there will be other, more important qualifiers, such as the health outcomes of your patients. But for this year, just buy the product and begin to use it.

As a result, companies like Practice Fusion, which always made its software free, and is a (private) cloud-based platform have begun to grow by leaps and bounds. Founded in 2005, Practice Fusion grew by 400% in 2009 with the passage of ARRA now has 100,000 users and 21,000,000 patient records online. Next year, it is projected to have  100,000,000 records. Its iPhone app will launch soon, and its iPad app is being designed by one of the country’s top designers, who will speak at Practice Fusion’s user conference in November.

As part of an “exclusive” interview  with Practice Fusion’s founder and CEO, Ryan Howard, in which we took a pedicab ride around downtown San Francisco, I found out that within the next few years, users of EMRs like Practice Fusion will be able to choose physicians based on whether they have EMRs and allow the patient to have access to his or her data. After five years of waiting for the market to catch up with his innovation, Ryan has found himself sitting pretty, with open data ready for the new wave.

[ Aside: I also found out that in the early days of the company, Ryan actually took an insurance settlement check for an automobile accident and used it to make payroll instead of having his torn rotator cuff fixed. Yes, he's a hard core entrepreneur]

However, if you are a patient of the VA, of Medicare, or of any other insurer that is part of the Blue Button initiative, you can get your data today, by logging into VA.gov or Medicare.gov and registering online. Once you prove your identity, you will be given an opportunity to use the Blue Button  to download your data as a text file, or view it as a .pdf . You can save the data to your hard drive or send it to a PHR, such as Health Vault.

A few years ago, my partners in AHITA.org ( a non-profit organized to help providers implement EHRs)  and I implemented an electronic health record in a physician practice. Along the way, we evaluated every major product and discussed with the physicians in the practice what they needed and how to examine their workflows to automate.  It was very effortful, took almost a year, and cost the physician practice about $50,000 in consulting fees.  At the end of the engagement, the AHITA partners decided in all good conscience that all the products sucked and wouldn’t help a small practice; we kind of drifted away from the idea of electronic health records. Our physician partner, who had written his own EHR, gave up in disgust because he couldn’t get anyone to buy it.

Now, Obama’s administration has given incentives that mandate EHRs. 2010 looks like it is going to be the year. And hopefully, many of the products have improved in their ease-of-use and financing programs during the past couple of years. There’s a lot of behavior change around implementing new technologies, and even practices that already own EHR technology need to learn to use it properly to qualify for the meaningful use incentives the government is offering. For most practices, this will mean an increased focus on workflows around ordering, e-prescribing, and clinical decision support and some attention to improving them, not just automating disfunction.

As far as I can discern from listening to the Allscripts webinar I just heard, many of the incentives revolve around seeing more Medicare and Medicaid patients.  All those physicians who were going to give up Medicare patients will be re-thinking that, because to qualify for the stimulus money they have to prove that 44% of their volume is Medicare, or 30% is Medicaid. And this is calculated by individual physician, not by practice.

For a physician, the Medicare part of the program starts this year. But this year you only have to prove that you used electronic records for 90 days during the year, and that at least 50% of your patient encounters have to be at a practice using a certified EHR. That goes up with every passing year.

Another interesting incentive: the physician’s payment will be based on multiplying his or her allowable charges  by 75%, so seeing a Medicare patient and using an EHR should make the patient (me) worth 75% more to the physician who sees me, especially if he delivers professional services, and doesn’t just send me for an MRI or to a lab. The incentive doesn’t count  fees for surgicenters or technical components of a doctor visit. This will be Medicare Part B services. (A physician aiming to collect $18k in 2011 has to submit allowable charges of $24k to Medicare and she will get paid $24k+$18k).

Physicians have to choose whether they want to participate in the Medicare part of the incentive program, or the Medicaid part. For a busy primary care practice, I bet Medicaid patients begin to look more attractive.

Now, away from the money and on to the part that benefits the patient:

Your doctor will now have to use five decision-support alerts in her software, and will have to give you electronic access to your records within 48 hours of your request. The incentives encourage the patient to become part of the conversation, and the doctor to communicate with the patient electronically. The government wants people to use personal health records, and for the physician to communicate with those PHRs, and that is going to happen FAST.

Here’s what the EHRs these physicians adopt will be required to do for the physician to get the subsidy:

• Electronically select, sort, retrieve, and output a list of patients and patients’ clinical information, based on user-defined demographic data, medication list, and specific conditions.
• Calculate and electronically display quality measure results as specified by CMS or states.
• Electronically submit calculated clinical quality measures
• Electronically generate a patient reminder list for preventive or follow-up care according to patient preferences based on demographic data, specific conditions, and/or medication list.
• Implement automated, electronic clinical decision support rules (in addition to drug-drug and drug-allergy contraindication checking) according to specialty or clinical priorities that use demographic data, specific patient diagnoses, conditions, diagnostic test results and/or patient medication list.
• Automatically and electronically generate and indicate real-time, alerts and care suggestions based upon clinical decision support rules and evidence grade.
• Automatically and electronically track, record, and generate reports on the number of alerts responded to by a user.
• Electronically record and display patient records and connect with other providers
• Patient information: electronic copy upon request in 48 hours80%
• Patient access to electronic information (i.e. lab results) within 96 hours of availability10%
• Clinical summary of each patients’ insurance eligibility, and submit insurance eligibility queries to public or private insurers

All the major products do this in one way or another. This doesn’t make them easier to deploy or train staff on, or use. Or make the change management any easier (that’s the part I do).

However, this sounds very promising for both the patient and the physician. And it’s not part of health care reform legislation, it was part of the stimulus, so we know it’s going to happen.

Makes me remember when electronic claims processing came into widespread use — which was not until Medicare mandated sending them electronically in order for physicians to get paid.  You’d be surprised how fast paper claims disappeared:-)

Now that Obama has told people that health IT is on his radar screen for public investment, all the interest groups are lining up.  Below are some excerpts from a blog post by the head of the Commission on Health Information Technology,

a nonprofit group that certifies  electronic health records for standards, functionality and interoperability. For a while now, health record products have been applying for certification by his group. Plus, he’s a former physician. He’s not uninformed.  But I can’t really agree with him.

“… even a 1% improvement in the efficiency of our $2.2 trillion healthcare spend would put us in positive payback territory… Most doctors know they need EHRs and many will respond to an economic push right now.  And the industry supplying those EHRs is a competitive, diverse marketplace that will respond to growing demand with increased capital investment and job growth.”

I disagree that most doctors know they need EHRs. I’ve been working with small practices trying help them decide on deployment for years, and the word in the physician community, at least in Arizona, is that most of the deployments do not save time or costs as they are supposed to.  This is partially because the products are complex and require a great deal of training as they are built now. The worst are the industry leaders in use by many hospitals. The doctors are trying to wait it out until they can retire, except for the younger ones who grew up with IT and demand it. This creates enormous conflict in any practice of more than a single doc: each provider has a different theory and a different need and a different favorite.

To make it more complex, the turnover in medical support personnel, front office and back office, is often frequent, so the training on these complicated products is ongoing and expensive. Support, services and training are the model by which some of these software companies increase their revenues.

“Outright grants may be appropriate for providers in rural and underserved areas, and for safety-net clinics, but in other environments financial incentives should be structured as a series of incremental rewards for progressive achievements.  In the private sector, the Bridges to Excellence program sets an excellent example, while the recently launched Medicare EHR Demo provides a public sector prototype.  These programs offer initial incentive payments for purchasing appropriate technology – a certified EHR — then a second round of money when successfully implemented.  Beyond that, bonuses are paid only as the provider demonstrates improvements in quality or efficiency.  Healthcare payment reform and healthcare IT — twins separated at birth – must grow up and mature together to achieve their full potential.”

I am about to see if my  ownproviders are part of the Arizona Medicare EHR demo so I can sign up. But the people who see Medicare patients, already squeezed by lower Medicare payments, may have difficulty finding the time to implement software while seeing the huge volumes of patients they must now see to keep their offices open.
“…some of the stimulus funds should be used to develop the skilled workforce needed.  It may be possible to redeploy IT personnel from other industries to lay broadband infrastructure for healthcare, but we’ll also need to boost health IT training programs.  And doctors and nurses being asked to change their habits are best motivated by one of their own – a clinician champion.  There are plenty of clinicians who have successfully led these projects, and we can’t afford to have their experience locked up within their own organizations — let’s find a way to put them on a health IT inspirational speaking circuit.”

Speaking circuit? We’ve had those for a while, but the doctors are too busy to show up!

Here’s the only part I think has any hope.  Shift from the doctors (the supply side) to the demand side. Otherwise EHRs are a band-aid.

“You’ve also wisely recognized the need to redirect our health efforts toward prevention, helping people make better choices early in life, and eventually reducing the burden of expensive interventions near the end.  To do this, we need to empower citizens with health knowledge, allowing them to make better health choices and to become more discriminating healthcare consumers.  Personal Health Records (PHRs) will emerge as a platform for this new information flow.  The organization I lead is also preparing to certify these PHRs, to ensure they are secure, private, and can exchange information with EHR systems in doctors’ offices and hospitals.  Projects in this field are a promising area for government investment.”

This part I would like. Many citizens want their records in their hands, and if the central repositories (insurers, pharmacies, hospitals, Medicare/Medicaid) could be “forced” (incented) to dump their data into a PHR, we could help solve this problem. I have a PHR, but I can’t populate it very easily, and since part of it consists of scanned pieces of paper, I can’t search it or see trends. I look for someone like Microsoft or Google to help with this; they are already in the space with products I’ve tried.

“…our  current model is amenable to improvement with an assist from better information.  With better data on prices charged and quality of care delivered, we can reform payment to reward clinicians for the quality or their work, instead of just for the quantity.  With EHRs that easily intercommunicate, we can reward better teamwork among providers to re-integrate care despite our fragmented healthcare business model.  And with empowered health consumers and an online connection that extends beyond the occasional visit to the doctor, we can motivate healthy lifestyles and prevention, eventually reversing the growing burden of chronic diseases.”

Amen, brother. Bring on Health.2.0! It’s already out there in hundreds of online patient communities trading information. That’s where the inspirational speaking tour should begin — with the patients, not the doctors.