In 1990, when I got my first health care job
driving ambulances, not a soul in the New Orleans EMS department had a
cellphone. Not even the head of the service. The mayor, his chief of staff and
the police chief each had one. That was about it.
These
phones weighed like 15 pounds and were hardwired to a car battery. And we
ambulance drivers documented our care on “run sheets” found on metal clipboards
but, since so few people bothered to read them, we also wrote key vital signs
and other metrics on a three-inch-wide piece of white tape smacked across the
patient’s abdomen.
Today,
everyone in New Orleans — and everywhere else — has a cellphone. These
cellphones have the computing power to find, and add to, and direct everything
that anyone would need to know about a patient anywhere in the world… but they
don’t do it! Today’s “do-everything” cellphones are the size of your wallet,
yet most ambulance crew run sheets are still paper, found on metal clipboards.
And most good patient data is still found on those three-inch-wide pieces of
tape.
Why?
I’ll give you one good reason and one bad one.
A
countless number of companies and technologies and ideas were harmed — and, in
fact, blown up completely — between the days of the brick Motorola cellphone
and the iPhone of today. Remember “DSL” companies that connected houses to the
internet over copper wire? Remember “booster antennae”? Remember when we all
thought the “flip phone” was the shizzle?
There
are many corpses scattered in the wake of the Internet and cellphone
renaissance that has occurred over the past 20 years and we are all fine with
that. The young engineers and designers that were part of exploding companies
simply took their backpacks and mini-fridges and went to the next cool company.
When the company worked out, the options for these young engineers and designers
were worth millions. When it didn’t work out, they moved on.
But
there’s a big difference when it comes to health care. If each of these
companies had been dealing in critical patient information in an EMR and lives were at stake,
this would have been a dangerous game. The innovation would have been faster
but the collateral damage would probably have been too much for our social
values.
OK, now
here is the bad reason:
The
market for exchanging information in health care, specifically for sending
referrals, is, in many cases, not legal. I’m not kidding. A few years after we
nationalized health care coverage for seniors (Medicare) and for those in need
(Medicaid) in 1965, we also made it illegal for the sender of a patient to be
given anything of value by the receiver of that patient.
There
was a good reason for it as we were afraid of kickbacks driving up federally
funded care. Well, federally funded care has gone up quite a lot since it was
originally funded, but no supply chain emerged.
Cellphone
carriers can pay retailers who hook up folks to their network, but specialists
can’t pay primary care doctors for the effort required to send clean electronic
clinical info over to them that would improve care and reduce duplication.
If they
could, there would be a lot more than, like, six Wired readers using their
engineering talents in health care. (Hi! Please come work at athenahealth.)
Instead, the only information systems that people pay for are those that work
within their own controlled environments. There are legacy, non-cloud software
systems that are only useful for exchanging information within the institution
that owns that particular IT system. Weird, right?
As a
result, in the last three years, we have hospitals that bought an EMRunder the HITECH Act (and Meaningful Use) that have also bought the practices of the
doctors that use them! We have gone from some 22 percent of docs employed by
hospitals in 2008 to about 44 percent employed by them today. Making people
work for you in order to exchange information with them is not exactly New Age.
And
most of those doctor acquisitions will fall apart in the next three years. You
heard it here first.
The
good news is that, even despite these obstacles, the obvious benefits of cloud
computing, especially through electronic medical records, are
driving health care into the 21st century. We at athenahealth are growing like
crazy and we serve all our clients on one single instance of our web-native
application. We are also being asked by our clients to move information in and
out of legacy systems that don’t communicate well.
We have
even gotten the federal government — the Office of the Inspector General in the
Department of Health and Human Services, to be exact — to bless a small ($1)
interchange fee as “NOT a kickback” in order to attract more entrepreneurial
energy into the efficient exchange of clean health information.
All of
this makes me feel like heady times are ahead in health care. Even though we
are watched by a nervous, panicky government that doesn’t quite get the deets,
enough good seems to be getting done for Uncle Sam to continue letting us move
about the cabin. And the government is getting behind the cloud — or, at the
very least, not getting in the way of it.
So,
people of Wired, come to health care! The water is, well, a little chilly, but
it’s getting warmer all the time. In fact, I’d say spring really is here!
JONATHAN
BUSH
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