Feeding the Dinosaurs

American Healthcare Mandates are Bankrupting Providers to Invest in Soon-Extinct Health Information Technologies

As scholars, researchers, or innovators, we cannot assume that major US healthcare legislation, such as the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2015, is altruistic or benevolent, and will or should continue on a forward trajectory from its historical path. It is appropriate that we be skeptical and objectively examine this and its premise.

The HITECH Act was the result of over 10 years of high-level and persistent lobbying efforts by a trade group, the Healthcare Information and Management Systems Society (HIMSS), whose 350 corporate members profited by billions of dollars from its eventual passage. (O'Harrow, 2009) HIMSS’s then board Chairman admitted to overseeing the organization writing then forwarding to the administration most of its research, materials, language, and financial models for adoption and codification by Congress. Instrumental in processing and explaining that information within the administration was David Blumenthal, who now leads the Commonwealth Fund, a political activist group that, at times, masquerades as an objective public health research foundation. (O'Harrow, 2009) Moreover, the Congressional Budget Office (CBO) independently reviewed the industry-group’s return-on-investment assumptions, adopted by the administration, and found them “overly optimistic.” It found that the alleged financial return of $77.8 billion from health information exchanges was, in truth and fact, more like $17 billion and that would be over 10 years. (O'Harrow, 2009) In the end, approximately $36.5 billion was dedicated to the health information exchange initiative, notwithstanding the CBO estimate that it would take 10 years to get back half of that amount, a 400% difference than the number alleged by the trade group that profited. (O'Harrow, 2009)

In March 2016, the Office of the National Coordinator (ONC) for Health Information Technology contracted one of the largest universities in President Obama’s home town and district, which was also his former employer, to conduct an evaluation. Their report focuses not on whether the HITECH Act was an industry coup to secure $36.5 billion for themselves from the government via an unsupportable business case, but is based on the premise that it was legitimate legislation, should and must be continued and what issues need to be addressed to possibly make that feasible. (Prashila Dullabh, 2016)

Setting aside the apparent corruption that brought about the HITECH Act, and its biased evaluation by the University of Chicago, if the health information exchanges are to have survivability, there is at least one existential risk to be addressed. Namely, the vast majority of health information officers (74%) concede their concerns about the ability to continue without federal subsidies. Less than 25% have the means to cover operating costs and losses. Similarly, 81% those receiving federal grant subsidies said they could continue. Therefore, the evidence suggests the system is independently unsustainable. (Prashila Dullabh, 2016)

The crux of the HITECH Act’s goal was to create methods and a standard by which providers could exchange patient information securely. Technologically, a simple comma-separated-variable (CSV) data standard via free publicly available public-encryption keys, and associated training, may well have accomplished this basic goal for single digit millions of dollars, not tens of billions of dollars.

My best guess is that the function of exchanging health information will actually increase; however, it won't be via the health information exchanges inspired by the HITECH Act, as they are currently known, because they are unable to financially unsustainable independently and neither the federal government nor state governments will want to keep feeding them cash.

Moreover, my prediction is that electronic health records (EHRs), as we know them, will also go away and are probably already well past their prime; they will be a 10-year blip on the RADAR of technology history because they are being superseded by the evolution and adoption of other technologies. Because of the US government's mandate via the "Affordable Care Act," (ironic name given premiums have gone up 20-80% and will go up another 20-25% next year, which will be announced after the election if President Obama can help it), people became obsessed about EHRs; however, few if any are forward looking. They are old technology, mostly relational databases and customer relationship management (CRM) systems from the 1990s. In another five to seven years, it will be HIT professionals great regret that they wasted so much time on the subject of EHRs and how to get them to talk to each other.

Several mega trends are underway that will shift the landscape of HIT: (a) the Internet of Things (IoT); (b) artificial intelligence agents; (c) Big Data as a Service (BDaas); (d) predictive analytics, and, (e) blockchain. The IoT will mean a massive number of devices – as many as 40-50 billion – monitoring information flows that are fed into centralized sources, much of it in unstructured data, where artificial intelligence agents and machine learning will continuously analyze (especially Bayesian network analysis, because it's causal, and cluster analysis) to detect and report actionable intelligence. Neural networking will match the genomic variants of tumors to humans and comparative effectiveness research (CER) will predict which treatment paths are best for each human and, for example, cancer type (Rx&You is actually just starting a pilot with MD Anderson to start doing this). And, Blockchain can quantify and deliver value directly between payers and patients (patient pay-for-performance) to reward the healthy and price the risk of the sick.

None of these capabilities are remotely possible with any current generation of EHR because they aren't architected to allow for it. They would have to completely redesign, then redevelop and redeploy globally, their ability to receive massive quantities of data streaming in real-time from millions of devices, combine unstructured and structured data, have autonomous statistical agents and neural networking running trillions of permutations, then sell and license that information to new clients -- because neither providers nor patients will be (nor can they now) afford it (with the exception of wealthy academic research centers and high net-worth patients).

EHRs, EMRs, HIEs, etc. are already being eclipsed and within 5-10 years, they will all no longer exist at all and be a complete write-off to the poor providers that were compelled to invest many millions of dollars into them. Moreover, providers will be so financially bankrupt from responding to government mandates (at least in the US), that they won't be able to afford these next 5-15 years of technology solutions. Only payers (insurers and national health services) and pharmaceutical companies will be able to afford them and they will mandate them, in one form or another, to providers and patients.

Works Cited

O'Harrow, R. (2009, May 16). The Machinery Behind Health-Care Reform. Washington Post, pp. http://www.washingtonpost.com/wp-dyn/content/article/2009/05/15/AR2009051503667.html?hpid=topnews.

Prashila Dullabh, S. P. (2016). EVALUATION OF THE STATE HIE COOPERATIVE AGREEMENT PROGRAM. Chicago: University of Chicago.

Posted in Articles on Dec 11, 2016