Tuesday, May 26, 2015

The Triple Aimers have missed the mark

This is one of those columns that will risk the respect and friendship of some of my closest colleagues in the health care world.  In addition to disagreeing with me, they may argue that I am giving aid and ammunition to "the enemy," where the enemy might be viewed as those forces in the health care world who really don't want things to change. But as you shall see, I will assert that it is those very colleagues who--by focusing on an overly simplistic ideological approach to health care policy--are inadvertently giving succor to that same group by providing political cover for nefarious behavior.

I refer to many of the most prominent advocates of the Triple Aim.

As set forth in this article and elsewhere, the Triple Aim is described as follows:

Work to improve site-specific care for individuals should expand and thrive. In our view, however, the United States will not achieve high-value health care unless improvement initiatives pursue a broader system of linked goals. In the aggregate, we call those goals the “Triple Aim”: improving the individual experience of care; improving the health of populations; and reducing the per capita costs of care for populations.

At first blush, who can argue with this set of desiderata?  The three components seem ineluctable.

But policy-making is not so simple as setting forth seemingly self-evident or self-fulfilling goals.  Policy-making must take place in the cauldron of competing private and public interests. The transmogrification of goals into policies, statutes, regulation, and corporate and individual action can be ugly and can result in unintended consequences.  It is on this point that I argue that the Triple Aim has been hijacked.

It has been hijacked by powerful political and economic forces--often represented by the nation's hospitals in general and by academic medical centers in particular--but also aided and abetted by federal action.

The clearest representation of the Triple Aim, baked into federal legislation and supported by many health care advocates, is the creation of Accountable Care Organizations (ACOs.)  The idea is that a group of health care institutions and practices in a given geographic area will join forces as an ACO to provide management of care across the continuum of care. The argument goes further, that by shifting from a fee for service rate-making formula to one based more on an annual per capita (risk-adjusted) budget, the ACO should have an interest in the health of the population--resulting in an increase in wellness programs, preventative care, early intervention, and a decline in more expensive hospitalization and procedures.

An interesting policy hypothesis, but what happens when policy turns to practice?  First, we see that the dominant player in many an ACO is the community's academic medical center (AMC) or tertiary hospital. It is not the local multi-specialty practice that has the long-term relationship with a person or family, and which might shop among the region's hospitals for the best care patterns and cost efficiency. No, the area's largest hospital is the one that sets up the ACO in most places and controls its governance and cash flow.

As a matter of corporate structure, a general hospital is often an exemplar of an over-capitalized, inflexible organization with an excessive amount of overhead.  As Clayton Christensen has noted:

The traditional general hospital is not a viable business model. . . . [T]he agglomeration of many  business lines and a desire to serve all kinds of patients results in a very high overhead burden rate -- roughly $9 for every $1 spend on direct patient care.

In light of this corporate structure, many hospitals have best been defined as "cost centers in search of revenue streams." As I have noted:

It's not that the doctors and nurses are any less caring or dedicated, but rather that the leaders of these centers have become calcified with regard to their social mission.  They focus instead on expanding market share, growing margins, and attracting philanthropists to contribute to unnecessary and flamboyant edifices.  They have no real interest in reducing costs, but rather in obtaining and securing revenue streams to cover ever-increasing costs.  Most importantly, they neglect the harm they cause to patients in their facilities, preferring to assert that they deliver high quality care without being willing to be transparent with regard to actual clinical outcomes.

I hesitate to give examples, for fear that they will be considered simply as anecdotes.  But the trends they demonstrate are more pervasive than anecdotal.  Plus, it is important that we look at the some of the organizations often cited as among the best in the country.  Places like Mayo Clinic, investing $180 million in a proton beam facility when there are similar facilities within easy traveling distance for those very few families who can benefit clinically from them. Places like North Shore-Long Island Jewish, belying its stated strategic objectives ("to realize cost efficiencies and ensure patient safety through adherence to best practices") by providing space, support, and publicity for a prominent doctor who affirmatively advocates overuse of diagnostic tools.  Places like the University of Illinois-Chicago, the University of California, and dozens of others who gladly accept "walking around money" for themselves and their surgeons from a medical equipment supplier to invest in market-share-growing robotic surgery.

It would be one thing if the tertiary hospitals and AMCs just engaged in revenue-generating activities.  But using the "population health" rubric of the ACO, they seek to consolidate market power by acquiring other facilities and practices in their geographic area.  And those same hospitals often attempt to foreclose consumer choice by purchasing electronic medical records systems that are not interoperable outside of their network and forcing that choice on their newly acquired clinical partners. Regular readers know that my favorite local example is Partners Healthcare System, but others have documented the same pattern in New York and elsewhere.  The goal is simple, to have leverage over local insurers to drive rates up.

In addition, the hospitals, the equipment manufacturers, and the investment counselors use their political clout to obtain favorable ratemaking treatment from the federal government for expensive new technologies, either to get paid directly from CMS or to allow excess payments from consumers.

Here's my point in going through all this background: We hear little or nothing from the prominent Triple Aim advocates about this tremendous use of political and economic power, power that is limiting customer choice and raising costs.  Instead they focus on Triple Aim "fixes," mainly in terms of insurance plan design and reimbursement penalties that are supposed to support their population health objectives.

But do those fixes work?  What about the adverse impacts on low income families when insurers and employers push high deductible health plans (ostensibly to get consumers more engaged in health care spending) because overall costs are rising?  What about poorly constructed penalties, like the one on readmissions, that have an adverse impact on safety net hospitals?  The comment I most often get on the latter matter is, "Well, it's not a perfect measure, in the grand scheme of things, but it has moved hospitals to focus on the discharge process in a far more meaningful way, and that's making a difference."

Is that really the best the Triple Aim advocates can do?  While billions are being extracted from insurers by growing monopolies, while billions more are being extracted from all of us by complicity between hospitals and equipment manufacturers, while low income families are forgoing care because they can't afford the deductible, we relish a single digit percent improvement in readmissions that has the consequence of hurting facilities carrying for the poor?

And where is the outrage when an entire industry arises around unsupported wellness programs, leading employers to engage in expensive and coercive practices with employees?

Look, there's nothing wrong with the Triple Aim objectives.  What's wrong is that its most prominent advocates--some of the most influential health care experts in the country--have focused so heavily on that ideological approach to health care policy that they have absented themselves from the real battles over power, money, customer choice, and cost.  They are losing ground every day.  While they glance elsewhere, the Triple Aim is being turned on its head: The individual experience of care will degrade; the health of populations will decline; and the per capita costs of care for populations will rise.


nonlocal MD said...

This may be your best post yet, and graphically illustrates the profound gap between vision and implementation. Send it to the New York Times and the Wall St. Journal, although it may not be dumbed down enough for the public.......

Unknown said...

Whilst I am an Australian I watch the U.S. Health system closely & it seems most of your objections ultimately refer to the loss of smaller 'independent' fee for service 'multi-specialty' practices with growing consolidation cloaked in so-called laudable Triple Aims to provide enough care but not more than needed, to the people who need it not just those asking for it, for the most efficient effective cost.
This consolidation which has occurred throughout Medicine throughout the World has more to do with the preferences & work-life balance of newer generations of Health care providers. Your concerns about a Wellness industry seem almost archaic, one would hope wellness was what you have spent your career aiming for.

Michael Millenson said...

Paul, this column puzzles me. You set up a straw man -- the Triple Aim -- that you yourself demolish at the end of the column.

Let's be clear: you and I both agree that it is not the aims, themselves, which are causing consolidation in the health care industry.

If it's not the ends, is it the means? Again, there are legitimate arguments to be made that the ACO payment mechanism needs adjustment. But, again, I don't think you would argue that we should have a cottage industry with unrestricted fee-for-service reimbursement.

What does that leave us with? It tells us that in health care, as elsewhere, long-overdue transformational change presents opportunities that dominant economic players can take advantage of to increase their dominance. The consolidation in cable and in online search doesn't tell us that the "aim" of the Internet was bad. Or dominance by Epic and Cerner means paper records should have been maintained.

You've been a wonderful, thoughtful voice against health care industry power. But just because the idea for the Triple Aim came from the Boston zip code and some of the greatest consolidation and, dare I say, arrogance, also comes from that zip code, does not mean that the Triple Aim's aims were a mistake (as you acknowledge), that making it a national policy was a mistake or that ACOs are a mistake. It means that dominant players in any industry use a time of change to increase dominance.


Paul Levy said...

The main point, Michael, is that those who advocated the new world order are missing in action when it comes to pointing out the way it has been hijacked. As you note, "It means that dominant players in any industry use a time of change to increase dominance," and can do so with impunity because the advocates remain purist in their view and unengaged in advocating for protections from those business interests.

Paul Levy said...


I'm all for wellness, but not for the fraudulent programs that have sprung up across the US.

The consolidation in the US health care market has little or nothing to do with clinician work-life balance preferences.

nonlocal MD said...

I guess the deeper question is, Michael, do we want health care to be an 'industry' like cable or online search, or aviation? We have acceded as it has slid into just another commodity, but other countries have different objectives for their population health.

johnemcdonough said...

As always, I appreciate Paul's splash of cold water on the often excessively self congratulatory impulses of those of us -- myself included -- who cheer on health system transformation. It's necessary and not a pleasant chore -- and I congratulate Paul for his continuous dedication to the task.

I have several other reactions:

Regarding the Triple Aim, I ask myself, what existed before it? Prior to its emergence, when we asked where is the health system going and what is its best path forward, there was no coherent or widely recognized answer beyond professional accountability and autonomy. I am really astonished by how far and wide the Triple Aim has traveled so quickly -- much like the way Don Berwick's creation of "continuous quality improvement" moved with such rapidity in the late 1980s and early 90s. I see it not just across the US but in nations all around the globe -- outside the of the US context -- and in helpful and compelling ways.

Had there been no Triple Aim, would the Affordable Care Act have been materially different? I don't think so. "Accountable Care" was a concept that pre-dated the Triple Aim, as were so many other ACA provisions. So I think it's too heavy a burden to blame the TA for the ACA -- though I think it's absolutely true that the TA encapsulated the essential spirit and essence of the ACA's positive vision for health system transformation. That includes -- moving away from the fee for service culture, engaging providers to think and act beyond their walls, embracing population health, putting patients in the center, and taking responsibility for costs.

These are all necessary and good aims for where we need to go. That these have been captured and distorted in unhelpful ways by the biggest players is part of the way of the world works whether we like it or not. I think it's too high and heavy a load to put the blame for this on the TA -- so many of these actions would be happening anyway.

At the same time, last comment, I think Paul is totally on target in chastising those of us who can comfortably engage in too much "happy talk" about system transformation and not hold the players in the system to account and task for bad behavior. We need more truth telling and honesty as the change process continues and accelerates. That's why I appreciate Paul's commentary and continuing role in the community.

Paul Hattis said...

I too appreciate Paul's thoughtful commentary; though I see it not as an indictment of the 'triple aim' (TA) concept; rather, a fair critique of the trajectory of its implementation to date.

(BTW John McDonough is correct in saying that the TA concept is not new to the ACA era. Go back and read the Community Care Network (CCN) concept being talked about at AHA in the 1990s during the era of the Clinton health care reform effort. For that matter, go back and read late 20s and 1930s writings of Michael Davis and the vision tied to the Committee for the Cost of Medical Care (CCMC) and you will find all of the elements of the triple aim there as well....)

Back to the worries about ACOs as the manifestation of the TA concept. I read Paul's blog among other things to highlight these issues which I fear may work to vitiate the value of the TA as supposedly brought to us through ACOs:

1. The primary hospital centric nature of most ACOs as they have evolved to date across the US.

2. Underneath the global payment being received by ACOs, is fee for service payment going out to providers--especially for specialty care. Absent changing this--I worry that the specialists (and hospital) desires to hold on to their FFS payments will greatly attenuate what a supposed TA approach by an ACO will bring in terms of better quality, population health status improvement and lower per capita costs.

I hope it is still possible to get this all on track.

Paul Levy said...

Thanks to you both, who have much more background in the field than I.

With the focus on ACOs, though, let's not overlook the lobbying power that we have seen applied to CMS, with regard to excessive payments for modalities that should properly have limited clinical applications, or that have clinically unsupported applications. And to permitting balance billing for unnecessary ophthalmic procedures for Medicare recipients. It is in this arena--worth billions in excess costs--that I hear very little from health care advocates. (Indeed, it was under the watch of many such advocates in the Administration that these pricing distortions were permitted.) Why is there such a fear or reluctance to call out these incredibly wasteful policies?

Also, why aren't advocates demanding complete interoperability of EHRs so that providers and consumers can have some choice and not be held captive by dominant provider groups?

Anonymous said...

On top of this Paul, you have been pointed out before as the ONLY businessperson in health care to work for this issue. We have it in Virginia, in droves. You should see what I'm getting in writing from the Va. Dept. of Health, who represents the State Medical Board. Even legal stuff, FOIA information, their lawyer will refuse to answer.

Barry Carol said...

To push back against the high costs and high reimbursement rates commanded by dominant hospital systems and their salaried or affiliated doctors, we need price transparency. If the patient receives a prescription for imaging, for example, and is sent to the local hospital to get it, it would be helpful if it could be quickly determined that there are far less expensive facilities nearby that can do the test with equally good equipment and equally capable technicians.

If an outpatient surgical procedure that can be scheduled in advance is required, price transparency would allow patients to learn about possibly significant price differences among the local hospitals and ambulatory surgical centers. Information about risk-adjusted outcomes, readmission rates, infection rates and the like would be helpful here.

In theory, if the dominant local hospital system commands far higher reimbursement rates than other providers in the area, it should be possible for less expensive centers to enter the market to provide services like imaging and outpatient surgical procedures as long as they are not precluded from entering the market by CON laws.

With respect to interoperable electronic records, I agree that they’re desirable but I don’t think they’re critical. If I need to go to an ER and I can’t communicate, I now have the following information on my iPhone: allergies, drug list, current diseases and conditions, surgical history including the year of the procedure and the hospital it was performed at, where my advance directive is located, my blood type and whether or not I’m an organ donor. If other records are needed, they can be faxed over as long as someone knows who to call for them but the need is probably not urgent.

What insurers need to effectively need to fight back against dominant hospital systems is countervailing power. This means not just price transparency for patients and referring doctors but also the ability to contract with some hospitals within a system but not others including the ability to decline to contract with an academic medical center in a system like PHS that has more than one.

Paul Levy said...

What perfect timing. In my email today is an invitation for a webinar that starts this way:

'One of the goals of the IHI Leadership Alliance is to develop a set of “radical redesign” principles for health care that all organizations can use to deliver on the full promise of the Triple Aim. Examples include “Make it easy” (i.e., continually reduce waste and all activities for patients, families, and clinicians that don’t add value); and “Move knowledge, not people” (i.e., use all helpful capacities of the digital age).'

Such nice thoughts and no doubt useful and should be suported, but the gains are swamped by the cost and power factors I discuss in my post. No way can these things achieve "the full promise of the Triple Aim."

"The conversation will be led by Don Berwick, IHI President Emeritus and Senior Fellow; Elliott Fisher, Director of the Dartmouth Institute for Health Policy and Clinical Practice; and Jenn Verma, Senior Director of the Canadian Foundation for Healthcare Improvement."

Maybe someone can ask them the questions and where they've been on these issues.

Bob said...

This is a great post.

Note that the progenitor of ACO's was Dartmouth, which has always viewed health as centered on a community hospital, from the first studies of Jack Wennberg. That is their view of the structure of medical care, so the encrustation starts from their view, and follows in their solution, the ACO.

Also note that the ACO idea is purely utilization based, not price based. And it is completely internal administration based, not competition based. And it says nothing about centers of excellence, and primary care choosing among alternatives for the patients' welfare, nor empowering primary care; rather, it is enslaving primary care, and is wedded to the employment, corporate model.

Unknown said...

Dr. Levy,

Whilst I agree with all of your broad points regarding the malignant influence of money, and market consolidation cloaked within the ACO mission; I wouldn't place blame for this at the feet of advocates of the Triple Aim. As you know, the creator of the framework fights against market consolidation, for a restructuring of the reimbursement incentives, and ensuring choice in the marketplace.


The perversion of the Triple Aim can be seen in the approach many ACOs are using to capture market share, squeeze out the providers that have the community experience and isolating the holdouts by adopting closed EHR solutions to force patients to stay in network. I was very encouraged you mentioned interoperability, as I see this as one of the most practical and obvious signs that the interests of an ACO is not truly focused around wellness, rather market capture. I'd like to hear your thoughts on how to approach conversations around creating true incentive for the Cerners and Epics of the world to start caring about patient wellness and create truly interoperable solutions, it seems as though they're doing everything in their power to stem the sharing of information; is this CMS's job?

Great read, and interesting perspective!

Austin Dobson

Anonymous said...

Those interested in EHR interoperability might want to read up on the Argonaut Project. John Halamka, an old colleague of Pauls is an important contributor.

This is from his blog.


Opening paragraph.

"Yesterday, a group of private sector stakeholders including athenahealth, Beth Israel Deaconess Medical Center, Cerner, Epic, Intermountain Health, Mayo Clinic, McKesson, MEDITECH, Partners Healthcare System, SMART at Boston Children’s Hospital Informatics Program, and The Advisory Board Company met with HL7 and FHIR leadership to accelerate query/response interoperability under the auspices of ANSI-certified HL7 standards development organization processes."

There is work being done on interoperability! How well it will work, will be yours to judge.


Paul Levy said...

That was in December. It took until last month for Epic to cease charging its customers to send and receive data from other systems, charges that were quite high.

Modern Healthcare story in October:

"Epic Systems' August decision to retain a Washington lobbyist was widely seen as a sign that the leading electronic health-record system vendor is feeling political heat based on the perceived lack of interoperability between its EHR systems and other systems.

At a House Energy and Commerce Committee hearing in July, Epic was singled out for criticism by U.S. Rep. Phil Gingrey (R-Ga.), a physician, who cited a RAND Corp. report asserting that Epic's systems were “closed records.” Gingrey argued that the federal program providing incentive payments for healthcare providers to install EHRs was intended to promote interoperability. “Is the government getting its money's worth?” he asked. “It may be time for the committee to take a closer look at the practices of vendor companies in this space, given the possibility that fraud may be perpetrated on the American taxpayer.”"

Final, in April:

"And now comes Epic Systems Corp....with an announcement that it is dropping the fees it has been charging customers for data transfers between Epic customers and non-Epic customers through a module formerly called Care Elsewhere.

Previously, Epic customers sending clinical messages to a health information exchange were charged 20 cents each, while inbound messages from a non-Epic user cost $2.35 for that patient for a year...."

This story demonstrates the power of public pressure on bad actors, especially when there is federal money involved.

It's also interesting to note that, in this case, the pressure did not come from Triple Aim public policy advocates. It came from competing vendors and health systems that were getting locked out of communications with Epic customers.

On Twitter said...

Interplay on Twitter:

Bob Wachter ‏@Bob_Wachter

Gutsy indictmnt of #TripleAim @Paulflevy http://bit.ly/1KxBW06 Agree w/ concrns re consolidatn, but system is imprvng (by #s). Better idea?

My reply:

@Bob_Wachter Better idea: Have more advocates stand up and vocally oppose the parts that don't work, for starts. On sidelines now.

Paul Levy said...


First of all, that op-ed was too little and too late. The issue had been festering for years.

As far as "how to approach conversations around creating true incentive for the Cerners and Epics of the world to start caring about patient wellness and create truly interoperable solutions." This isn't about "conversations." It's about using the fact that these companies get tens of millions in federal dollars for EHRs, and there should be the kind of requirements you suggest as part and parcel to receiving that money.

Also, please remember that some health care systems were quite happy, strategically, to not have interoperabilility. I recall a presentation made by Partners several years ago to investors in NYC about how that lack of interoperablity gave them assurance of continued revenue growth.

In 2012, they said:

“The game’s going to be won in the future off the flow of information,” said Partners' chief financial officer.... Partners officials believe the new information system, which is expected to cost between $600 million to $700 million, will lead to more coordinated patient care and have a life cycle of at least 10 years. http://runningahospital.blogspot.com/2012/05/writing-off-public-interest.html

Pat Mastors said...

Paul, your pointed challenge, incisive writing and moral clarity in this post amount to an eye-opening and sobering challenge to advocates seeking a more affordable, functional and satisfying (for patients and families) health care system. If you could personally orchestrate and execute the ideal response to what you describe as gaming of the TA -- with a pass from its biggest proponents-- and devise attendant strategy, (i.e. write the script), what would that look like? how could GoPVI.org best raise the volume, profile and urgency of this stuff?

MightyCaseyMedia said...

The money shot for me: "the real battles over power, money, customer choice, and cost" are indeed still happening far, far away from the point of care, and compromising the patient's experience, the community's health, and the ability to control spiraling costs. Of the three legs of the Triple Aim stool, the cost piece is the biggest barrier to its implementation, IMO.

Can you think of any US industry that would willingly transform itself outta $1T+ in revenue per year?

That's the ultimate economic outcome of the Triple Aim, and I can hear and feel the resistance of the medical-industrial complex to ending their arms race toward "market dominance" via daVinci systems, proton beam facilities, soaring marble lobbies, and equally soaring temples full of hospital beds ... when what we really need is hundreds (thousands?) of small clinics across the landscape helping people get or stay healthy via great primary care, not tertiary hospital resurrections.

Payers and big health systems, EHR vendors, policy wonks all negotiate over the patient's supine form (and the heads of most clinicians, to be fair) to determine how to divide up the $3T+/year their arms race serves up.

Do we have a prayer of Triple Aim in this landscape? I dunno, but I'm fighting a ground war with my patient-side band of guerilla compatriots to see if we can drive some revolution from the grassroots. 'Cause the folks in suits ain't moving fast enough toward change.

karielynn said...

The ACO in my opinion was created to address provider desires not to be shut out of the Medicare managed care market. Outside of New England and Northern California, managed care is king. The sad part is that ACOs are moving so slowly that Medicare Advantage will surely destroy any chance the providers have in the government market. In California, Medicare Advantage is approaching 60%. The way it works is big, publicly traded payers contact with huge physician groups - i.e., Healthcare Partners is over 4k physicians owned by Davita (which grabs a billion dollars already from Medicare patients). Over the years, CMS has been overpaying Medicare Advantage plans to push people this route while it underpays on Medicare fee for service and pursues fraud actions against providers but never Medicare Advantage. Further, pool arrangements between plans, physician groups and hospitals always are unfavorable to the providers. ACOs are doomed to start late, be underfunded and unable to compete against Medicare Advantage. It's a shame because cutting out the middleman makes sense but the wide - scale purchase of physician practices by plans and publicly traded companies probably won't be undone this time (like the 90's). The hospitals will be the odd men out. This was happening in spite of and way before anything in Washington. Wall Street is the driving factor and hospitals are not those kind of money makers.

DZA said...

Matters little who you annoy with this adept analysis; matters more who you influence. Himmelstein and Wollhandler rang bell ages ago and nothing changed, except for the worse. Rome is burning...

Tim McClain said...

I will begin by confessing of never running a hospital or a hospital system. My experience has been with the Department of Veterans Affairs (VA) health system and the Department of Defense (DoD) Military Health System, from both the agency side and as a contracted vendor of administrative and direct healthcare provider services. The Triple Aim is familiar to the federal government because the Quadruple Aim in the DoD healthcare system is the Triple Aim in Paul’s article with the addition of “Readiness” (defined as “enabling a medically ready force, a ready medical force, and resiliency of all MHS personnel”) as the fourth aim. The Quadruple Aim was introduced in 2010 by Admiral Christine Hunter. See: https://facilities.health.mil/home/wp-content/uploads/MHSQuadAim_copied.png. Many of the comments in the article and in the Comments section on the Triple Aim apply equally to the Military Healthcare System.

I was particularly interested in Pauls’ comment in response to comments by John McDonough and Paul Hattis. Mr. Levy wrote: “Also, why aren't advocates demanding complete interoperability of EHRs so that providers and consumers can have some choice and not be held captive by dominant provider groups?” Later comments addressed the large EHR companies, the Argonaut Project, and recent efforts regarding information exchange, costs and interoperability.

All of this background is relevant to the readers of Paul’s article because DoD is about to award an estimated $11 Billion contract to a single vendor for a new EHR. Only three companies remain in the running for the contract award, Epic, Cerner and Allscripts. The contract will be awarded by the end of this fiscal year. One of the large EHR companies is about to get much larger without enforceable guarantees of significant new technology and improvements in interoperability. Once the federal government implements the new system in DoD, it is not a stretch to conclude that the system will be mandated as the standard for federally-funded healthcare including Medicare and its providers, Medicare Advantage, TRICARE, VA and many community providers. Is the current DoD RFP structured to deliver on that awesome responsibility? Most civilian hospital and provider groups should be very interested in the answer to that question since it may have far reaching consequences in the medical community.

In my opinion DoD is seeking to acquire a current EHR to replace its AHLTA system rather than a future-state EHR that will still be technologically relevant in 2035.

Paul Levy said...

Thank you. This seems like an important moment to pause and rethink at DoD.

Adrian Gropper said...

Thank you, Paul for this important write-up.

Can you find a way to post it as a Comment on the CMS Next Generation ACO solicitation? http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-03-10.html

e-Patient Dave said...

As I said in a private email, much of this is over my head. But this much isn't: we're all screwed if these issues aren't policed (by government, the biggest payer and the one with regulatory control) to truly serve the patients for whom the whole freaking industry exists.

Somehow I missed that Epic dropped its heinous fees for Play Nicely With Others. The mere fact that they (reportedly) hired a lobbyist to resist this would make me say, out loud for the first time: "Damn you, Epic. This is not about you. Stop impeding the flow of my mother's data, my daughter's data, everyone's data. STOP IT! Take CARE of PATIENTS!"

Five years ago I gave a speech at the annual meeting of AHRQ IT grantees and contractors. The slides are here. Slide 10 said:

Foundation Principles - Ethical:
Save lives first. Then compete.

This is not funny.

Robert Nelson said...


Excellent. Too much content to comment on, but just to say your analysis is spot on.

Thank you,
Robert Nelson,MD