The Hope of E-Health Initiatives
David J. Brailer, M.D. & Ph.D.
10/7/2008

(Kerry Weems introduction of Dr. Brailer)
Now, I want to introduce you to a former colleague of mine, Dr. David Brailer, who currently is the chairman of Health Evolution Partners in San Francisco. It was my privilege to work with David when he became the nation’s first national coordinator for Health Information Technology, a position that was created by executive order in 2004. That office of National Coordinator is the hub of health IT efforts at the federal level, and David deserves much of the credit for the wide recognition of its value in healthcare today. David is here because of his preeminence in the health IT field but many do not know him as a clinician and as a former professor at the Wharton School of Business. While practicing at the Hospital at the University of Pennsylvania in the 80s and the 90s, he specialized in care for people with HIV. David has said that while he was at Penn, he was witness to the revolution in HIV treatment, the protease inhibitors. He compared the lives saved with protease inhibitors to the lives saved with introduction of antibiotics. The patient’s with HIV almost always died before the advent of these miracle drugs. Once protease inhibitors became available, patients survived for many more years. So, now you are saying that is great. So, what does that have to do with health IT? According to David … quite a lot. First, his work with HIV patients was a profound lesson in the power of integrated, coordinated healthcare, which electronic exchange of information makes possible. The HIV team was comprised not only of the doctor, the nurse, the pharmacist, but also a social worker, who it turns out was a lawyer, so a terrible time for discrimination. Second, it taught him the doors that can be opened when a patient is fully engaged in their care. Doctors who work with HIV at Penn were routinely confronted by smart, well armed patients who brought in reams of information from the internet search and who often knew more about breakthroughs in their treatment because they were connected to other networks of people engaged with HIV on the web. David says this was the best model of consumer-driven healthcare. This is what health information technology makes possible. It is what David has lived through and what he has practiced and what we are here to advance. So, it is my privilege to introduce to you, Dr. David Brailer.

Thank you, Kerry. I have spoken after Kerry many times and I have gotten very used to lowering the microphone from him. Many of you do know Kerry as a strong advocate for health information technology, but I would bet none of you know the extent of his commitment and contributions the way I do and the reason is because I have not told the following story ever. Kerry and I have a very longstanding agreement to never reveal our methods to others, but I am going to break the rule because I want you to know something about this guy. Some of you might know that in 2004, when I was in my sixth month as the National Coordinator, Congress, in its infinite wisdom, saw fit to cut my budget to zero. Some of you may further know that the president in a very unusual act reapportioned federal funds to restore the funding for my office. What you don’t know is that the person who navigated me through the bureaucracy, who weaponized me to make it to the other end was Kerry. So here we have a 6 month neophyte federal servant all cost entrepreneur turned policy maker working with a 20-year or better in the federal end fighting and we made it through that process. And I just want you to know Kerry, we probably would not be here today if you had not done the things you have done. Thank you very much. And I hope I did not just get you fired.

I did learn a lot from Kerry but I learned a lot from people in Washington other than him. One teacher was a very well-known aging statesman politician who for some reason saw fit to help me along in my stumbling ways. I met with this person occasionally and he taught me the art of policy craft as it is done in Washington and in my second meeting, he leaned over to me and looked over his shoulder and in a whispered voice said, “You want to know the secret of lasting success in Washington?” Of course I said yes. So, I leaned over and he looked over his shoulder again to check for eavesdroppers and slowly said “create acronyms… they will outlive you!” So, I went immediately to work and created RHIO, NHIN, CCHIT, HITSP, HISPC, HIE and of course ONCHIT, which we later mercifully shortened to ONC lest it be confused for the division of the bureau waste management.

Each of us is here today because we feel an urgent need to reshape healthcare, could be a physician who is caught between the way we pay for care and what our patients want, could be a consumer who really wants to know what treatments work and who does them well and cannot get answers to questions, an innovator who invests in the lifesaving therapy just to watch it trickle into practice, and an employer who faces relentless cost growth in healthcare at a time when their business’s survival is in question. A policy maker who knows that a health threat could come at anytime and is trying to be prepared. Now the root of each one of these dilemmas is in need for information, valid, timely, detailed, specific, nonproprietary clinical information and along with that the tools that collect and analyze and communicate that information. We can’t ask Americans to take more control for their own healthcare if we do not give them information about their own health status. We can’t expect clinicians to prescribe safe and cost effective drugs without giving them information about formularies, interactions, and low cost alternatives at the time they prescribe. We have no hope of creating integrated care delivery or medical homes in the United States without information tools that help clinicians collaborate as if they were working side by side. And, we cannot bring market efficiencies to healthcare without information about what truly works and what things really cost. And this is why when you step back to the very root, why it is that our transition to health information technology in the United States has gained so much both in the industry and across the entirety of society. Because of this we are now 5 years into the big step forward of health information technology in the United States. This was kicked off by the president’s executive order that Kerry mentioned in 2004, but it built upon more than 30 years of research, pilot testing, programs, evaluation, teaching, discovery, pioneering and entrepreneurialism. After all of this time in this investment, the components that we need to bring healthcare into the digital era, to introduce the era of digital medicine, are now in place. CCHIT certification is a virtual necessity in the ambulatory EHR market. I predict a very short period of time between now and the day when a product cannot be sold in the market without that seal of approval. Certification for inpatient tools is underway as well. A much more complicated legacy-filled environment that is going to be able to bring this kind of trust in market growth to hospitals as it has done to ambulatory care. Usable information standards are being deployed. The secretary described earlier today that more than 110 standards that people will accept by the time he leaves office. This is the first time not only that we have clarity on standards but that we have real teeth behind the standards so they actually mean something, and not exercises on paper. I give them a long legacy life of information systems standards will take a long time to diffuse into practice but I can tell you the process is underway. It is becoming very real in the workrooms, and skunk rooms, and development rooms of vendor shops not only around the United States but around the world. RHIOs and health information exchanges are continuing to drive staff and evolve and they are becoming strong platforms to the diffusion of technologies whether it is electronic prescribing, electronic records, data sharing, surveillance, personal health records, telemedicine or other activities. Given the criteria describe the Rhode Island Health Institute’s activities. It is one of many that continue to thrive across the United States today. Some of you may not know that the NHIN continues to turn information sharing into a reality. Last month, the functions it supports, document query, document retrieval, authorization frame works and consumer preference profiles were implemented in four federal agencies. This is an enormously complicated undertaking not only within the federal government but across our health care. But the architecture that the NHIN brings gives us a framework that allows us to have true modularity of not just information but of the functions and tools that sit upon them. There are many people that worked tremendously hard to get us to this point and a lot of them are in the room today. But what happened is because of this work, and we are beginning to see results. We are beginning to see the payoff that comes from these efforts in place. For example, in hospital settings, the electronic record is the norm. Now, it does not mean that every hospital has it today. It means that you cannot be running a hospital today or be a board member of a hospital today without having an electronic plan underway. If you do not have it in place, funded or bought or very well along in doing that, your bond underwriters are asking you tough questions, your liability insurers are asking you tough questions, state agencies are asking you tough questions, your customers and doctors are asking questions. This is moving to the point where it is a standard of care in our hospitals.

The physician transition to electronic records is also underway in a very different way. Today large physician groups have high rates of electronic record adoption. Small physician groups continue to have very, very low levels of adoption, but despite those low levels today, the majority of physicians in large and small groups say that they do plan to adopt an electronic record at some point in time. They know that it is inevitable. They know that this is something that healthcare is moving towards. They know that there is only a matter of time between now and when they must be part of this. There are significant marked anomalies in the physician electronic record environment. It is still very expensive. Not all the tools are ready for that very low cost environment, but this is something that is moving and this is why electronic records rely upon the presence of the E-prescribing, because E-prescribing to many doctors in small groups is the on ramp to move into the digital era. It is smaller, it is less challenging, it is less disruptive, it has more direct value to them, so they are able to move forward with this as a pathway towards full electronic capabilities and superimposed on all this insider baseball of healthcare is that the American public continues to have significant awareness of and resonance with the need for electronic records. They understand the difference between an emergency room that has some of their records and those they do not, whether the doctor is putting information into a computer when they talk to them or not, if they are handed a written prescription or not, if they have access to a personal health record or not. Consumers are continuing to talk to their health plans and legislators and physicians and online search engines and others about their need for more information and for more personalized information. So, this quick summary and I have left out many things that are happening in this industry, shows that the last 5 years have seen tremendous and sustained progress. Their predictions that this effort would fail have been proven wrong. The fear that the hype cycle would take it way up and bring it way down have not been born out. The progress is authentic, it is widespread and I think it is irreversible. But I think what is important about this is not only what is being done, it is how it is being done. Each of these steps is a living exercise in public/private collaboration. The market is driving change, but the government is standing by it as a convener, witnessed today, as a boundary setter and as a co-participant and certainly when needed, as a regulator. This experiment, this method of change, I think provides our nation with a very useful set of tools beyond health IT as we look at other health reform issues and say how do we get there from here. Now despite this progress, it is clear we have to confront some very important open issues. I will name three. First, I do not think we have a pathway that is clear, that allows us to accelerate adoption of electronic records in small physician practices. Many of these practices are in rural or suburban areas, some are left in urban areas. But these practices often lack the basic tools, information technology capabilities, broadband connections, staff who are able to support things other than patient care activities etc., etc.

Now, we have the electronic prescribing incentive that we talked about today and there are many other things to help smaller physician offices alone. Twenty one states have now fostered EHR adoption programs. There are 50 safe harbor programs that are available to physicians from 115 hospitals and there is nearly a billion dollars of incentives on top of the E-prescribing money to help physicians adopt the electronic records. But this total amount of money is still very small compared to the overall transition cost for physicians and it does not address the skill and the work capabilities of getting there. Now, clearly our reimbursement policies in the United States penalize the output of information technology, which is high quality care. We face though a barrier that is even bigger than license fees, which is the overall cost of putting these tools in place. We have not attacked this yet in a way that we have a clear answer. Everything helps, but we have more work to do here. Secondly, our national paradigm for privacy and portability is inadequate if not obsolete. We’ve outgrown the regulatory scheme to protect self information. HIPAA was designed for paper records, not for streaming, living, functioning digital information. Another acronym, the health information security and privacy collaboration has detailed many of the shortcomings of HIPAA. These are well known and I just want to talk about two. One is the blind spot in HIPAA coverage. Let me call your attention to a recent New England Journal of Medicine article on online health management services. This could be the Google Health, the Microsoft HealthVault, and many others. Since these are not healthcare entities or contractors to healthcare entities, these online services are not regulated by HIPAA. They have immense freedom to use your information as they see fit. I am not saying that they are doing anything wrong today, my point though is that progress continues and we never anticipated new life forms in the health information space that are not connected to a doctor or a health planner or lab or a pharmacy, or who are contracting with them. So this blind spot shows us many ways that the scheme that we had in the past treats differentials in the future they do not create uniform protection. Also into a large to be more importantly, HIPAA sidesteps perhaps the most important problem that we face, which is who controls your health information. The so called HIPAA triad functionally prevents consumers from being in control of their health information. The triad means three things, consumers cannot require that there information be sent from one holder to another, can only require that it goes to the consumer, and they cannot have it sent on the time table they want, I mean if it is in clinical time, days, minutes or hours, it does not have to be done, relying on the good role of the holder to do that, and it cannot necessarily have it sent in a useful format, a fax may not be good enough and so this hobbles the ability of a consumer to have a truly affordable set of information. HIPAA has become a very large barrier to digital medicine and I expect that we will spend a lot of time in the future confronting the issues of how do we revamp it to bring it into the digital age. And finally we face a backward looking licensing structure in the United States. One of the most promising benefits of digital medicine is the ability to separate the participants in care in time and space. You do not have to be within a few feet of your patient to render good care. We have seen what an especially radiologist can do to help a small hospital by reading complex brain MRIs from afar. We have seen how dermatologists, psychiatrists, and other clinicians have helped people around the world by using telemedicine. Our medical standards, professional liability and licensing roles do rely upon a 3 feet rule. Essentially, if the patient is not 3 feet from the doctor it is not a good care. Because of this, we cannot make the best specialist available to our population. We cannot think about shifting primary care into the home or notions like hospitalization at home. We cannot think about consumers shopping around or if they have to get on a plane to see the clinician. In 1989, almost 20 years ago, the Federation of State Medical Boards proposed a uniform licensing regulation and nothing has happened since. It is time for state medical boards to produce a uniform, standardized interstate licensing capability and if not we need to explore it at the federal level, how do we actually bring this about. I could go on with challenges healthcare is an industry filled with people confronting challenges, but I want to come back to the important message here, which is that digital medicine is perhaps the most powerful force for good in healthcare today. I simply cannot think of anything else that can help us address the simultaneous goals of improving quality, improving accountability, improving transparency, and using our money wisely. There are many more things that we need to do and many challenges, but it is clear that some day we will be able to see these born out. Some day health reform will become the top thing on the American public’s agenda. I do not know what the catalyst would be and I also do not think we can move health reform forward without this being a top priority to the public, but I do know that when health reform comes center stage, one of the most important tools we will rely on to make it happen is digital medicine. It is a foundational asset to build health cares future upon. We have seen tremendous urgency in digital medicine in the last 5 years. I continue to be astonished by the energy and the enthusiasm and the capabilities. It has been across facets of healthcare, across the political spectrum, across generations, and across geographics. But the people who are most likely to stand up and make this happen when we are called upon are the people in this room. It is up to each of you to keep the momentum moving, it is up to each of you to keep this in front of new leaders who come to Washington, and it is up to each of you to make sure that this is kept in the shortlist as we confront other big problems. If all work hard together, saw some of you for 30 years, I saw a couple of you today, several of you for 5 years and I am sure several of you this is your first time, but I commend all of you for your commitment and work and I want to stand up and challenge you to do more, do it faster, do it harder, and to do not give up. Thank you so much for your time today.