Along with the implementation of CMS’s hospital price transparency rules in 2021 came a market opportunity for savvy health tech startups able to not only aggregate the massive amount of data coming in from providers and payers, but to actually make it usable for shopping healthcare services or large-scale market analysis for those without a computer engineering degree or background in healthcare economics. Turquoise Health is one of those startups, but what makes the Andreessen Horowitz-backed biz a stand-out from the pack is the extra SAS platform of services it’s building on top of those analytics and compliance products that will, ultimately, offer payers and providers a way to use all that pricing data to better negotiate their contracts with one another. Turquoise Health’s CEO Chris Severn explains the business model and how he plans to ‘platform out’ price transparency to a next-gen rev cycle state that gets us to the holy grail of “upfront, ubiquitous pricing in healthcare.”

A new report by economist Jon Gabel and his colleagues at NORC, a research center affiliated with the University of Chicago, looked at the use of transparency tools in an employer health plan. The analysis found the use of price transparency tools to be spotty. For instance, 75 percent of households either did not log into the transparency tool or did so only one time in the 18-month period of study. Fifteen percent did so twice; but only 1 percent logged in 6 times or more. The authors concluded:

It could very well be that we are asking too much of a single tool, no matter how well-designed. Consumer information for other goods and services on price and quality are seldom dependent upon information gained mainly, if not solely, through a digital tool. Rather, information on relative value is spread far and wide through advertising and other kinds of promotion using conventional, digital, and social media communication channels.

An earlier Harvard study on transparency tools, published in JAMA, found patients do not tend to use the tools to comparison shop for lower prices (in fact, spending rose slightly). An NBER study concluded that when transparency tools do lower spending, it is because consumers used to tools to identify prices and use the information to decide whether they can afford the service and skip it if they cannot.

The transparency tool in the current study also emailed “Ways to Save” suggestions on how consumers could reduce medical spending. The authors made an important observation:

It is also possible that the message on the “Ways to Save” e-mail turned off many households. While the emails did highlight opportunities to save a specific amount of money, a vast majority of the savings were for the employer and a much smaller amount of savings applied to the employee. It is possible that many employees viewed the transparency initiative as simply a means for the employer to save money.

That is a very good point. Encouraging workers to reduce unnecessary spending is all about creating the appropriate incentives. Before they will take the time to comparison shop, consumers must benefit from their efforts. They must also become accustomed to comparison shopping. In this analysis, the firm studied had a deductible for individuals of $1,400 and $2800 for a family of four. The out-of-pocket limit was $2,800 per individual and $4,800 per family. The employer provided an additional $400 in health care benefits per year in the form of a health reimbursement arrangement (HRA) deposit. It would be interesting to tease out who was shopping and why. A healthy, single person with a $400 HRA and only a $1,400 deductible is not likely to worry about the cost of a physician visit. The most they can be out before their health coverage begins to pay significant benefits is $1000 ($1,400 – $400). Moreover, they may not need a service that is easily shopped. An MRI is a commodity procedure whose price could be compared. But a physician visit or a routine blood test ordered during a physician visit is unlikely to be shopped.

I have shopped for blood tests, MRIs, CT scans and cheaper drug prices on many occasions. But, then again, my deductible is $5,000 and I’m a health economist with years of experience.

Another thing I noticed about the study was one of the cost-saving features was selecting a provider. Although I might choose a provider partly based on cost if I have advanced knowledge, I’m less likely to change providers once I have one unless I am likely to save significant amounts. California-based Castlight Health discovered convincing patients to change their behaviors when selecting providers was more difficult than they anticipated.

One impediment to comparison shopping for health care is that many consumers are not regular consumers of health care. They may see their doctor once a year, take a generic drug, or occasionally be referred to a specialist. Many do not need enough regular services sufficient to learn the process. Maybe that is a good thing. If 20 percent of patients consume 80 percent of all health care dollars, maybe it makes sense to concentrate efforts on the 20 percent.

I wonder if the results would be different if performed today on people with a health plan coupled with a $5,000 deductible? Would it be any different using a “high touch” transparency tool? How about if consumers had a patient-centered medical home, where the doctor collaborate with their patient to seek out cost-effective medical care? It’s been my experience that patients are quite willing to save $1,000 on an MRI or switch to generic drugs with nominal copays when they can save a buck.

Devon Herrick is a fellow at the National Center For Public Analysis.

Source: Jon Gabel et al., “Price Transparency Tool Attracts Users But Does Not Lead to Use of Lower-Priced Services,” Changes in Health Care Financing & Organization, Issue Brief, September 2016. Available at: http://www.hcfo.org/files/hcfo/2016GabelPriceTransparencyToolBrief.final.pdf

On a recent shift in the Emergency Department, a resident boasted to me that she had convinced a patient to have an MRI done after discharge, rather than in the hospital. She was proud of this achievement because MRIs cost much more in the hospital than they do elsewhere – sometimes thousands of dollars more. To advocates of “cost-conscious care,” a new movement in medical education that aims to instill in young doctors a sense of responsibility for the financial consequences of their decisions, this story seems to belong in the ‘win’ column.

But this story also raises troubling questions: Why wasn’t the resident more concerned about how the hospital’s charging practices were leading her to delay care for her patient? What about the prolonged anxiety the patient would suffer? What about the extra day of work she would have to miss? And most importantly, why does an MRI cost thousands of dollars more in the hospital than it does across the street?

Like many doctors, she had fallen into the ‘transparency trap.’ This phenomenon is an unintended consequence of price transparency efforts that have come in response to patients and doctors being kept in the dark for decades about the prices of common services. Unfortunately, as the CEO of one large hospital put it, “the vast majority of [prices] have no relation to anything, and certainly not to cost.” In fact, studies have shown that in a functional market, MRIs would cost somewhere around $250, and we wouldn’t be nearly as concerned about doing too many of them.

When we forget how arbitrary today’s prices are, and start anchoring our medical decisions to the prices we see, we risk reflexively ordering fewer ‘expensive tests’ for patients who would otherwise get them. We start believing that MRIs really are that expensive, rather than recognizing that they just seem so expensive because of the dysfunction of the health care market. That’s the transparency trap.

To be sure, price transparency is mostly a good thing – it helps patients avoid sticker shock, and may give providers a reason to make their prices competitive. Without question, doctors also have a responsibility to reduce wasteful spending and to consider the “financial side effects” of care, especially when patients bear much of the cost directly.

But not every MRI is unnecessary or wasteful. And patients shouldn’t be penalized for the dysfunction of the health care system. Instead, doctors should focus on advocating for an end to price gouging in health care. At the very least, we need to change the questions we ask, and alongside “cost-conscious care,” we need to teach medical students and residents to take today’s prices with a hefty grain of salt.

As more and more hospitals agree to make their prices publicly available, we risk more doctors falling into the ‘transparency trap.’ When we see that a hospital charges some sky-high amount for a test, let’s not just think: “Wow, that’s an expensive test! I should order less of those,” — but start asking: “How on earth do we let them get away with charging so much?”

The electronic health record (EHR) is now used by the majority of physicians during every patient encounter. The EHR has become the most important tool in our “black bag” and precisely for that reason, the EHR must be highly accurate and free of bias. As our most heavily utilized tool, the EHR must also be flexible and highly optimized so as to ensure it does not adversely impact the delivery of healthcare. Unfortunately, numerous surveys have found widespread physician dissatisfaction with EHR design.

The fact that EHR programming code is shielded from objective scrutiny by independent evaluators increases the risk that the EHR will contain errors and bias which could adversely impact our patient’s health, hinder our ability to deliver healthcare, “warp” the design of the healthcare system and drain financial resources from our patients and society.

EHR “errors” are well documented in the literature and are referred to as “e-iatrogenesis” or “technology induced” errors. “Bias” in EHR programming code is not discussed in the literature.

EHR errors and bias can be divided into the following categories:

.1: There are programming errors which crash the EHR and brings the patient encounter and/or the healthcare system to an abrupt halt. (1)

2: There are random programming errors which have resulted in:

1. erroneous information being presented to the physician
2. data that was electronically “filed” into the wrong patient chart
3. failure of the EHR to detect important Rx dosing errors, Rx-Rx interactions and Rx-Dx interactions
4. incessant “red flag” warnings that force providers to turn-off all warning messages
5. confusing “pick lists” which have led to clinical errors (2,3,4)

3: There may be unintentional programming bias, which presents information as a “fact,” when a more nuanced presentation would be more accurate. (e.g. A treatment recommendation which fails to mention that there is no data to support the recommendation for elderly patients.)

4: There may be programming code whose sole purpose is to enhance an EHR vendor’s fiduciary interests. (e.g. A pharmaceutical or medical device company pays an EHR vendor to prioritize their product on the treatment recommendations list.)

5: There are programming decisions that create EHR “work-flow” characteristics which impedes a physician’s ability to take care of their patient. (e.g. The need to click a “box” when the data is present in another section of the EHR or an EHR company refuses to improve the functionality of a feature for bureaucratic reasons.)

6: There are EHR design decisions which lead to the exclusion of a “feature” for corporate strategic reasons. (e.g. The decision to exclude an interoperability module as a means of generating additional revenue or to protect market share.)

7: There are unintentional design errors of omission when a feature is not included in an EHR because of the vendor’s lack of imagination or their failure to understand the needs of a healthcare provider. (e.g. An EHR may lack the ability to: display/sort only the patient’s “abnormal” lab results, readily create a list of all uncontrolled diabetic patients or print an envelope addressed to the patient.)

Without a doubt, the proprietary nature of EHR programming code has the potential to adversely impact healthcare. (5)

At its most fundamental level, the practice of medicine is predicated on the rational application of scientific principles which have been vetted using a transparent evaluative process. This process has served the public interest well. The proprietary nature of commercial EHRs has shielded them from the same level of scientific scrutiny which we mandate from new pharmaceuticals and medical devices. Currently, we wait for someone to report an EHR error before the error is fixed. In the clinical realm, this would be tantamount to waiting for a patient to have their first episode of angina before we initiate a statin. Rationally, we proactively measure our patient’s lipid profile and intervene before their first clinical event. In the same vein, we should demand full transparency of EHR programming code and proactively evaluate the code as a means to reduce EHR errors and bias.

The need for code transparency was recently highlighted by a Politico investigative report which found that the contracts of six large EHRs all contained a “gag clause” which prohibited the users from publicly disclosing errors in their EHR.(6) I also know from personal experience that EHR users have been dissuaded from publicly disclosing errors in their EHR and some EHR companies contractually proscribe users from publishing screen shots from the EHR without vendor permission.

The adverse consequences of proprietary source code has lately become a topic of public discussion when it was discovered that Volkswagen had used proprietary software to altered the emission control systems of their vehicles so as to fool regulators into believing that their diesel engine were compliant with national emission control standards, when in fact Volkswagen vehicles were emitting far larger amounts of nitrogen oxide than was allowed by law. (7) Had Volkswagen’s software code been “published information” this deception would have been detected a long time ago and tons of pollution would not have been added to our atmosphere.

An objective assessment of healths related apps, which are built using proprietary source code, have found serious flaws that have resulted in the dispensing of incorrect medical information and a disregard for patient privacy. The editorialists who had review 3 such studies concluded that “most people would be surprised at the low standards of apps … and disappointed that the safeguards they rely upon … such as truth in advertising, professional practice standards, or clinical testing of medical products, appear to be absent.” (8)

In 2015, the Institute for Medicine had recommended that the Federal Government should mandate that health IT vendors should be required to “…routinely submit their products for independent evaluation.”(9) In my opinion, it would be a mistake to assign this responsibility to the Federal Government as it tends to be overly bureaucratic, secretive, inflexible and prone to external fiduciary interests.

Clearly, increased EHR transparency needs to be imposed on the EHR industry and this needs to be done in a way which is fully transparent to the public.

While others have voiced concerns about EHR errors and/or encouraged increased EHR transparency, none have proposed a mechanism to increased transparency. (10,11, 12)

I believe we can improve EHRs, without disrupting the EHR market or incurring Federal or private expense, if all EHR programming code was published to the web as a PDF or as a text file and accessible to be read by anybody. I would call this type of source code “published information.” “Published information” is not the same as “open source” software, as the latter gives the user the ability to modify the source code. While there will be some technical or logistic issues if the EHR industry published their source code, none of the impediments are unsurmountable.

As a means of pressuring the EHR industry to publish their source code, medical schools, training programs and medical societies should begin to teach their trainees and members that physicians have a professional obligation to prioritize the use of “evidence based” EHRs and should favor EHRs which have “published” their programming code, in the same way physicians are taught to favor “evidence based” treatment options. Concurrently, these organizations should begin to educate our politicians on this subject.

Large businesses, commercial insurers and the Federal Government should attach financial incentives to encourage the use of EHRs whose programming code is “published information” much in the same vein as some of these entities now ascribe financial incentives/disincentives arising from the use of “Certified” EHRs and  achieving “Meaningful Use” and “PQRS” mandates.

Undoubtedly, EHR vendors will argue that forcing them to publish programming code was tantamount to requiring that they reveal “trade secrets.” As a programmer with more than 2 decades of programming experience accumulated during the creation of a Stage I ONC Certified EHR, I can categorically state that the “trade secret” argument is derived from a misunderstanding of the coding process. If I learn about a feature that is in another EHR which I think will be useful in my EHR, I will add it using de-novo programming. Similarly, when Steve Jobs saw Xerox’s “mouse,” his software engineers did not need to see the coding which supported Xerox’s “mouse” in order for them to incorporate the mouse into Apple’s operating system. (13)

The EHR industry has benefited immensely from the Federal Government’s $30+ billion investment and have a responsibility to ensure that their EHRs meet the needs of our society. This could be efficiently and inexpensively accomplished if they made their EHR programming code “published information.” After the EHR programming code is “published information,” and the academic, medical and technical communities have scrutinized the code, we can expect to see fewer EHR errors and bias. This will help ensure that EHRs evolve into the accurate, flexible and highly optimize tools which we need to delivery low cost and high quality healthcare.

1. Boston Children’s EHR down for days, Bernie Monegain, Healthcare IT News. 3/27/2015http://www.bostonglobe.com/metro/2015/03/25/boston-children-emerges-from-day-shutdown-electronic-medical-records/Q6sE7hRM4CxFeMEDYWP8IK/story.html
2. Review of Reported Clinical Information System Adverse Events in US Food and Drug Administration Databases. Myers RB, Jones SL, Sittig DF. Appl Clin Inform. 2011;2(1):63-74.
3. A red-flag-based approach to risk management of EHR-related safety concerns.  Sittig DF, Singh H. J Healthc Risk Manag. 2013;33(2):21-6
4. A clinical case of electronic health record drug alert fatigue: consequences for patient outcome. Carspecken CW(1), Sharek PJ, Longhurst C, Pageler NM. Pediatrics. 2013 Jun;131(6):e1970-3.
5. Engineering the electronic health record for safety: a multi-level video-based approach to diagnosing and preventing technology-induced error arising from usability problems. Borycki EM(1), Kushniruk AW, Kuwata S, Kannry J. Stud Health Technol Inform. 2011;166:197-205
6. Doctors barred from discussing safety glitches in U.S.-funded software, Tahir, D, Politico, 9/11/2015, http://www.politico.com/story/2015/09/doctors-barred-from-discussing-safety-glitches-in-us-funded-software-213553)
7. VW Is Said to Cheat on Diesel Emissions; U.S. to Order Big Recall, New York Times, 9/18/2015,http://www.nytimes.com/2015/09/19/business/volkswagen-is-ordered-to-recall-nearly-500000-vehicles-over-emissions-software.html
8. ‘Trust but verify’ – five approaches to ensure safe medical apps. Paul Wicks and Emil Chiauzzi, BMC Medicine (2015) 13:205
9. Safe use of electronic health records and health information technology systems: trust but verify. Denham CR, Classen DC, Swenson SJ, Henderson MJ, Zeltner T, Bates DW. J Patient Saf. 2013 Dec;9(4):177-89
10. Improving Diagnosis in Health Care, Institute for Medicine. Sept 2015 https://iom.nationalacademies.org/~/media/Files/Report%20Files/2015/Improving-Diagnosis/Diagnosis_Recommendations.pdf
11. Electronic Health Records and National Patient-Safety Goals. Dean F. Sittig, Ph.D.,  Hardeep Singh, M.D., M.P.H. NEJM 2012:367;19
12. Report of the AMIA EHR 2020 Task Force on the Status and Future Direction of EHRs. Payne TH, et al. J Am Med Inform Assoc 2015;0:1–11
13. Triumph Of The Nerds Part 3, Great Artists Steal, PBS, 1996, https://archive.org/details/PBS.Triumph.of.the.Nerds.3of3Hayward Zwerling, MD practices at the Lowell Diabetes and Endocrine Center and is Vice Chair of the Committee for Information Technology of the Massachusetts Medical Society. This proposal does not reflect the views of the Massachusetts Medical Society.

As President Obama’s healthcare reform unfolds in the last years of his administration, critics and supporters alike are looking for objective data. Meaningful Use is a funding program designed to create health IT systems that, when used in combination, are capable of reporting objective data about the healthcare system as a whole. But the program is floundering. The digital systems created by Meaningful Use are mostly incompatible, and it is unclear whether they will be able to provide the needed insights to evaluate Obamacare.

Recent data releases from HHS, however, have made it possible to objectively evaluate the overall performance of Meaningful Use itself. In turn we can better evaluate whether the Meaningful Use program is providing the needed structure to Obamacare. This article seeks to make the current state of the Meaningful Use program clear. Subsequent articles will consider what the newly released data implies about Meaningful Use specifically, and about Obamacare generally.

A short history of the problem

Historically, the US medical system has been a type of “sickcare”, rather than “healthcare”. It has been reactive – treating the ailment instead of preventing it. Doctors and hospitals have typically been rewarded by volume of procedures, rather than quality of patient outcomes. Instead of patients receiving preemptive care and monitoring early on, they often receive life-impacting procedures and prescriptions later, when their health has visibly declined.

The costs of treating or surviving a condition or injury can consume a person’s time, energy, and financial resources. What’s more, a patient’s safety under a provider’s care is not assured, as preventable medical errors in the US are commonplace – causing 400,000 deaths each year, or the equivalent of two 747s crashing each day.

We know that other national healthcare systems cost less, are subject to fewer errors, and take less of a toll on the patient.  In the US, patients must also voyage through the chaos surrounding their treatment – dealing with rejected insurance claims, record-keeping, confusing follow-ups, and frequent medical errors. These tasks can be complicated and subtle enough to confuse and dishearten the patients involved. Add to that the disturbing frequency of bankruptcy due to medical expenses, and we have a fairly accurate picture of the healthcare system that Obamacare intended to fix.

The nervous system of healthcare reform

The HITECH Act was part of President Obama’s Reinvestment and Recovery Act of 2009. It requires the government to standardize health IT and gives bonus payments to Medicare and Medicaid providers who use that technology well. The funding and regulations surrounding these payments were dubbed “Meaningful Use”.

Most people think that Obamacare is just the Affordable Care Act (ACA). But the first chapter of Obamacare was the HITECH act, which was passed as part of the stimulus package at the beginning of Obama’s first term. This act funded Health IT reform in the United States, and among other things subsidized providers to install software to create and maintain electronic healthcare records for all of their patients.

It is not possible to understand whether Obamacare is successful without using data from these Health IT systems. It is not possible to ask “Is Obamacare working” without Health IT, so a more useful question is “Is Health IT reform working”. The funding for Health IT systems has been less controversial than the contents of the ACA, because Health IT reform has been a rare area of agreement in the United States political system. Both parties have been cheerleaders of improved Health IT technology.

Obama was not the first President to consider or improve the state of health IT in the United States. President Clinton enacted The Health Insurance Portability and Accountability Act (HIPAA), which included safeguards for personal health information. The specific goal for nationwide adoption of electronic medical records (EMRs) was announced by President George W Bush, who also created the Office of the National Coordinator for Health Information Technology (ONC) under Health and Human Services (HHS).

If Obama’s healthcare reform were a ship, Meaningful Use would be both its compass and its rudder. It measures the healthcare system, but can also change health reform’s direction as needed. At least, that is how the program is supposed to work.

Reason for structure

The key component of health IT is the EHR (electronic healthcare record), which stores and shares patient information in a format that is machine and human-readable. This is the record that the doctor or hospital typically maintains about patients.

Before the Meaningful Use program, there was almost no agreement on what an EHR was and how it should be used. It was clear that many people were selling “Health IT snake oil” before the Meaningful Use regulations were in place and expected the HITECH funding to be a source of income. There was also a debate about whether we should call these digital systems Electronic Medical Records (EMRs) or Electronic Health Records (EHRs).

Eventually, the term EHR was defined as a digital health IT systems capable of appropriately moving healthcare data between providers. This concept, shortened to the single word “Interoperability”, would the highest goal of digital health technology. Meaningful Use is designed from the ground up to reject the siloing and data hoarding that had been so pervasive with health IT deployments in the past. If digital health systems remain incapable of exchanging data, then Meaningful Use was a failure.

The policy makers behind the Meaningful Use program had to ensure that the funding would actually serve to improve the care of patients. The term “Meaningful Use” highlights precisely what the Obama administration was most concerned to avoid, “meaningless use”.

For instance, the traditional paper and fax system is still preferred by many doctors. They could buy whatever EHR ended up meeting government standards, receive a payment, but never actually use the EHR they purchased. While the EHR collected virtual dust, the EHR vendor would still get paid (indirectly) by the government.

Even a physician using 90% of their EHR functions could be unaware of, or ambivalent toward some feature the government believes crucial for care quality improvement.

Issues such as these encouraged the creation of detailed and challenging objectives for providers and EHRs. EHR vendors had to meet strict standards for their products. In turn, healthcare providers had to prove that they used those EHRs extensively. While some aspects of Meaningful Use are optional, there is a core list of features that are required of every provider receiving Meaningful Use payments.

Meaningful Use basics

Health and Human Services (HHS) is responsible for implementing most of Obamacare. For the HITECH Meaningful Use program, two HHS sub-agencies were delegated to split the work: ONC and CMS.

The Office of the National Coordinator for Health IT (ONC) was designated as regulator of the standards and testing for an EHR to become certified EHR technology (CHERT). Of course healthcare providers were free to purchase any health IT solutions they liked, but only by using CEHRT would they receive a subsidy from the government for their purchase. CEHRT software was designed to give a provider everything they need to attest in either the Medicare or Medicaid EHR Incentive Program.

Centers for Medicare and Medicaid (CMS), is charged with creating objectives for providers, and measuring their performance in the Medicare attestation process (state agencies assess for the Medicaid program). Objectives vary for eligible professionals and hospitals, and include things like drug allergy checks, recording vitals, and electronic prescribing.

Both the requirements for EHR Vendors and the requirements for healthcare providers were initially grouped into three stages, which increased in health IT complexity, clinical integration, and quality metrics. As the stages got harder and more time passed, the incentive funds would wane and eventually turn into negative adjustments on regular Medicare payments.

Responses to Meaningful Use

Since the beginning of the program, CMS and ONC have been criticized by both vendors and providers in their execution of this program. Vendor associations like Healthcare Information and Management Systems Society (HIMSS), and provider organizations like the American Medical Association (AMA), have been united in their protest of various requirements, almost invariably wanting to lower the Meaningful Use bar. Almost no feedback coming from vendor and provider groups requested that CMS or ONC make Meaningful Use more stringent. Of course, such associations do not represent all providers and vendors, some of whom have requested higher standards for Meaningful Use.

ONC and CMS had to weigh this kind of feedback with the responses from patients, providers, and others with front line EHR experience – those who wanted strong assurances that new digital systems would not fail them in the way that previous generations of Health IT systems had.

Even as the HITECH was being authored, regulators recognized that there would be components of the healthcare industry that would want to progress quickly and achieve the most difficult goals for Health IT, and there would be others that would prefer a more minimalist approach.

The HITECH Act specifically instructs CMS and ONC to make Meaningful Use more challenging over time, and since HITECH was passed the government has already spent $28 billion on health IT reform. During the entire Meaningful Use program ONC and CMS have been under fire from all sides, but with very different messages: “Make Meaningful Use easier”, but also “Make more progress”. In order to determine what to do, CMS and ONC must assess vast amounts of qualitative data as well as subjective industry and public feedback.

Meaningful Use Stages and CHERT Editions

As we seek to evaluate whether or not HHS has been successful pacing Meaningful Use and balancing the interests of the parties impacted by digital health technology, we will need to get specific about requirements for how certified EHRs (CEHRT) and Meaningful Use line up. Essentially, we need to precisely parse what the doctors and hospitals were supposed to do, and what the EHR vendor community was supposed to accomplish.

The first two stages of Meaningful Use have been defined, and the third (and final) is currently undergoing rulemaking. Generally a “stage” refers to a different pile of funding and a substantial increase in complexity of the requirements.

The Definition of Meaningful Use is what determines the objectives in each of the three stages. The definition dictates what providers must accomplish, and it is intended to pair with a particular generation of CEHRT. CMS has regularly changed the Definition to adapt to the needs and requests of providers, vendors, and patients. These alterations result in different “versions” of the each Meaningful Use stage, labeled by the definition year. So the next version of Stage 1 will be “Stage 1- 2015 Meaningful Use Definition”. There are also Stage 1- 2011, 2013, and 2014 Definitions.

Even with its history of changes, Stage 1 adoption is considered by many to be a success. By 2014, two-thirds of all eligible providers had attested to it. Stage 2, however, had a rough start last year. This was partially due to implementation problems with 2014 Edition CHERTs.

Editions of CEHRTs were intended to progress whenever a new Meaningful Use stage began (2011 CHERT Edition at Stage 1’s start in 2011, and 2014 CEHRT Edition at Stage 2’s start in 2014). As the new technology became available, the older EHR technology was meant to fade out. A flexibility rule last year let certain providers who had problems using 2014 CHERT to regress to a Stage 1 attestation, though they were scheduled to be in Stage 2. These providers were also able to attest to the older, 2013 Definition of Stage 1.

Untangling the various stages of Meaningful Use standards is non-trivial, we have released infographics detailing how the program has changed for Eligible Providers and Eligible Hospitals.

Stage 2 and VDT

CEHRT challenges aside, many providers have told CMS that the current Stage 2, with its increased percentage thresholds and new objectives, is too difficult to achieve.  In response to the large volume of such opinions, CMS proposed a rule this April that would drastically change Meaningful Use for 2015-2017. It includes removing redundant and “topped out” measures, switching to one set of mandatory measures (instead of the current core and menu structure), and modifying patient engagement measures.

A cursory inspection of the proposed rule’s public comments indicates overall support from providers, and a backlash from patients. Controversy surrounds the proposal to lower the threshold for patients to view, download, or transmit their information from 5% to a single patient, and to switch the electronic messaging objective from a percentage-based measure to a yes/no for capability.

Thousands of responses were submitted by patients and organizations as part of an organized effort led by patient-advocate leaders. They stated that relaxing the objectives denies patients access their own data, and would prevent them from properly managing their own care.

Providers frequently argued that their patients are elderly or low-income and do not necessarily have a computer, know how to use email, or want to communicate digitally. They believe that the effort required to meet the objective takes away time needed to properly care for the patient.

The Meaningful Use standards that required specific interactions with patients, as well as communication with other providers, caused frustration for providers. They protested that EHR vendors blocked efforts to exchange healthcare data, and that their Meaningful Use funds might not be delivered because third parties were not willing to exchange data.

Subsequent articles, coming soon, will explore in more detail the issues surrounding Stage 2 and VDT, as well as the impact of grandfathering of Meaningful Use funding.

Exchanging healthcare information

From a policy perspective, implementing digital healthcare records nationwide, but failing to ensure that they actually exchange healthcare information, is a little like climbing Mt Everest but failing to make the summit. Simply put, it’s expensive, painful and pointless. This fact did not go unnoticed by Congress, which requested in the 2015 Omnibus Appropriations bill, that ONC use its regulatory power to enforce interoperability. Specifically:

ONC should use its authority to certify only those products that clearly meet current meaningful use program standards and that do not block health information exchange. ONC should take steps to decertify products that proactively block the sharing of information because those practices frustrate congressional intent, devalue taxpayer investments in CEHRT, and make CEHRT less valuable and more burdensome for eligible hospitals and eligible providers to use.

ONC found that healthcare providers and health IT vendors used methods such as charging unreasonable fees for information exchange, creating “non-standard” IT that made exchange difficult, or using policies that restricted individuals from accessing or transferring their data.

It is clear that at least some actors are hampering the efforts of healthcare information exchange. But even health IT backed by vendors with good intentions can still cause serious problems. EHR-born errors have started a new era of patient-safety concerns. Doctors and nurses must be cautious when entering or reading data, and vigilant as they integrate health IT in their already complicated and detailed workflow. Some doctors believe that the government is dangerously rushing EHR deployment, making them choose between protecting their patients or achieving Meaningful Use.

Up until very recently it was not possible to evaluate how CMS and ONC were collectively performing in their management of the Meaningful Use program. But newly public data submitted by providers and hospitals under the Meaningful Use program can be used to evaluate doctors. Subsequent articles will reveal how different vendors influence the performance of providers on the various clinical tasks set before them by Meaningful Use. By using provider performance to score EHR vendors, we will gain insights into how the Health IT marketplace has reacted to the Obamacare incentives, and how effective Health IT will be at measuring the overall performance of an Obamacare-based health system going forward.

Twenty years ago this month, the Boston Globe disclosed that health columnist Betsy Lehman, a 39-year-old mother of two, had been killed by a drug overdose during treatment for breast cancer at Dana-Farber Cancer Center. In laying out a grim trail of preventable mistakes at a renowned institution, the Globe prompted local soul searching and a new focus on patient safety nationally.

Although I didn’t know Betsy personally, we were about the same age, had two kids about the same ages and were in the same profession. (I, too, was a health care journalist.) That’s why I was particularly disappointed by a recent conference celebrating the reopening of the Betsy Lehman Center for Patient Safety and Medical Error Reduction. It was heavy on statistics and poll results; e.g., one in four Massachusetts adults say they’ve seen an error in their own care or the care of someone close to them.

What the meeting lacked was urgency, the kind of poking and prodding of established interests that journalists are good at. In that spirit, let me suggest two demands the Lehman Center should make on behalf of patients. First, every hospital should publicly release timely, comparable and usable safety information. Second, every hospital should publicly commit to a “no preventable errors” goal and a strategy to reach it.

These two actions would save lives ­– locally, and also elsewhere as the prestigious local medical community sets a national example for others to follow.

Preventable hospital errors kill as many as 400,000 people annually. Harvard’s Dr. Lucian Leape famously contrasted the secrecy of hospital errors’ with the public nature of plane crashes. Unfortunately, accessible, consumer-friendly information about safety at individual hospitals is still elusive. Dana-Farber’s website, for example, discusses its commitment to safety — which has been extraordinary — but the hospital nonetheless prefers to tell rather than show.

The list of quality measures uses technical language, provides no benchmarks and mostly has information dating back to 2013. (The federal HospitalCompare site similarly has long delays in posting data and isn’t easy to use, and state data isn’t much better.) Some other local hospitals are more forthcoming, but many resemble old-time burlesque dancers, seemingly revealing all while actually showing not much of interest.

There’s a better model. Louisville-based Norton Healthcare discloses a long list of safety and quality indicators and uses color-coding to show how those numbers relate to a desired goal. There are state and national comparisons and clear rules. Among them: “We do not decide what to make public based on how it makes us look,” and “We give equal prominence to good and bad results.” Norton has been doing this for 10 years.

The state-run Lehman Center should challenge Massachusetts hospitals to meet that candid standard by this time next year. Hospitals should also post information when they know it’s valid, rather than waiting for the feds. Every patient should be able to get the kind of information Betsy Lehman might have put in her column.

Transparency works best when it fuels accountability. Although “first, do no harm” is a professional ideal, few hospitals have adopted “zero preventable harm” as an explicit goal. Most settle for voluntary industry efforts with carefully calibrated harm reductions and multi-year timetables.

Why this is so is unclear, but one barrier is concern over the “business case” for patient safety; i.e. does improving safety help the bottom line. Though the public rarely sees this discussion, one recent medical journal article presented the return on investment (ROI) from preventing bloodstream infections in kids with cancer! The article emphasized the “low cost of implementation” and “high value” of “prevention efforts in this population.”

Doctors don’t promise to “first, do no unprofitable harm.” The Lehman Center should challenge every hospital to make zero preventable harm an explicit goal and have a plan in place to achieve it.

The two life-saving actions I’ve proposed require nothing more than a sustained commitment to ensuring that every patient receives care as safe as you’d want for your father or your child. I still remember the haunting letter Betsy Lehman’s mother sent to a patient safety conference some 15 years ago. Mildred Lehman wrote:

May I appeal to you to pause for a moment, if you will, in your important task. For in the wings outside your busy meeting rooms may be heard the murmurings of patients gone now due to fatal medical error, or harmed by a medical system they trusted. They are the ones absent…Among them is my young, brilliant daughter.

Patient safety must be utmost and constant, both ingrained into the system you seek to strengthen, and into caring hearts.

Surely, full transparency and working towards zero preventable harm are where caring hearts seeking true system change must start.

Michael Millenson is an author, journalist and a principal at Health Quality Advisors. 

You’d get something like this:

HAT TIP: Jeanne Pinder. WHHY Philadelphia. Learn more about Pinder and her project here.

I think it’s fair to say Jonathan Gruber will not be offered the role of Pinocchio. Although intelligence agencies, in search of the truth serum, might have an interest in the ingredients of what he drinks.

Please put away the pitchforks. Gruber deserves credit for honesty and bipartisanship. Plus a complete rejection of Disneyland economics. If you’re looking for transparency, the other face of honesty, Gruber is ground zero.

‘Stupidity’, though, was an unfortunate choice of noun. And inaccurate. Gruber should have said ‘rational ignorance’ or ‘boundless optimism in technocracy,’ which describes most voters in any democracy.

‘Rational ignorance’ sounds smart. The cognoscenti know what you’re trying to get at. And the rationally ignorant, well they’re rationally ignorant. The term means something we do all the time: that is we can’t be bothered to seek information whether something is factually correct or not. It’s an information heuristic (mental short cut).

Imagine the information overload if we were presented itemized bills for everything we consumed in a restaurant. We’d know the costs of transporting that fine rack of lamb to the city, of its slaughter, of cleaning the abattoir after the slaughter. But to what avail is this information?

Unless you’re a payer hunting for pseudofraud, granularity is a nuisance. So that to avoid long term anhedonia from figuring CBO’s myriad calculations from magical Keynesian models we watch the Kardashians instead.

When you’re rationally ignorant you can be duped. Or rationally duped. But here is the key point: we choose what we allow ourselves to be duped about. No one can fool us twice without our consent.

I love a certain technology: MRI of the heart. It pays my electricity bills. Show me a study that shows this technology is beneficial and I’ll gloss over the methodology. Show me a study that casts an aspersion on its efficacy and I’ll become a pit bull terrier of methodology and conclude: a) the study was underpowered for the effect size and b) more research is needed.

My rational ignorance is not equal. There is a value component to it. I am rationally ignorant about statements that are egosyntonic with my utopia.

To those who believe that ACA will somehow cut costs whilst expanding coverage and access you can’t say ‘if you believe that you’ll believe anything.’ Because they won’t believe anything. They’re not stupid. They’re rationally ignorant.

People who couldn’t see the indifference between a mandate and a tax, and many still couldn’t see it when Justice Roberts pointed the obvious, aren’t so gullible that you can sell snake oil. They’re rationally ignorant.

People who marched against the ACA with that priceless placard ‘Government, hands off my Medicare,’ aren’t script writers for Monty Python. They’re rationally ignorant.

The problem isn’t that we’re rationally ignorant. The problem is how selective and predictable our rational ignorance has become. The problem is the ease with which we can access echo chambers which endorse this selectivity. The problem is the moral certitude with which we deny our rational ignorance.

Gruber, on the other hand, knows his biases, acknowledges them, and says ‘yes the ends justify the means.’ This is intellectual honesty 101. You may not like his means but how can you not muster a tincture of admiration for this man AND claim a desire for transparency?

Rational ignorance, I suppose.

Crowdsourcing is engaging a lot of news organizations today. While some journalists are nervous about crowdsourcing — “Yikes, we’d rather talk than listen, and what if they tell us something we don’t want to hear? Or something that we know isn’t true?” — we here at clearhealthcosts.com love crowdsourcing. We find, as journalists, that our communities are smart, energized, truthful and engaged, and happy to join hands in thinking, reporting and helping us make something that’s bigger than the sum of its parts. We learn great things by listening, so … now we’re going to to an experiment crowdsourcing coverage for our blog.

Our current project crowdsourcing health care prices in California, with KQED public radio in San Francisco and KPCC/Southern California public radio in Los Angeles, has been a great success, as was our previous project with WNYC public radio, and we’re looking forward to launching similar projects with other partners.

Our community members have a lot to say. Some of what they say about health care prices we knew (people are upset, and they feel like they’re paying too much, and they have a hard time understanding their bills) — but some of what they say is totally radical: They’re out there negotiating over prices regularly. They’re putting away their insurance cards, choosing to pay cash and saving hundreds and hundreds of dollars.

They want to show us their bills. They want to talk about it.

1. Almost overnight, we have seen an explosion in the number of doctors contacting us to offer support of pricing transparency. Our theory: most docs got into this profession to help people, and they’re appalled by the epidemic of money medicine, and by the simple fact that their treatment decisions are increasingly governed by money — what the insurance company will pay, what the patient can afford, what’s on the formulary. Yes,  there are some bad apples in the bunch. But that is the exception, not the rule. (Hospital bills, on the other hand, are full of errors and overcharges.)

2. There’s a similar explosion in the number of people who want to  talk about “all on Medicare.” The idea of single-payer is still unpalatable to much of the nation, and the term “single-payer” has itself been tainted in the political discourse. But we are hearing from people on the left and the right and in the middle who are saying variations of this: “All on Medicare” to us means something like “Enough is enough. Single payer is the way to go.”

3. The shocking rise in generic drug prices: what happened, and will the congressional investigation that Bernie Sanders is mounting have any effect? Nearly 70 percent of Americans use some prescription drugs, and the skyrocketing prices affect millions of people. Should we blame it all on Big Pharma? What about pharmacy benefit managers?

4. Mergers and acquisitions in health care hit an all-time high. Lists of providers with office addresses, phone numbers and billing contacts are out of date before they are even printed, let alone posted on the web. Will we wind up with one big hospital health care system, named Blue Partners Aetna Cigna Cedars Mayo Cleveland Optum Sutter HCA Tenet Continuum? And how will that differ from “all on Medicare” or single-payer or whatever you want to call it? Oh, right: Blue Partners Aetna Cigna etc. will be a for-profit, with an eye on Wall Street.

5. People are paying cash for health care, as they increasingly realize that putting away their insurance card is good under certain circumstances. A $4 generic at a big-box store rather than a $15 co-pay for a generic under their insurance plan? A $580 charge for a cash MRI rather than an $1850 charge under their insurance plan because they haven’t met their deductible? We may be seeing the beginning of the end of employer-sponsored high-premium insurance. And wait until the Cadillac tax hits fully in 2018; people are already positioning themselves for that, and it’s looking ugly for those who want to preserve a system in which employees pay no premiums and no co-pays or co-insurance or deductibles.

6. Price transparency is huge. Those who embrace it will be rewarded, and laggards may be punished. You may have a great insurance plan, few health problems and low out of pockets. But you’re an exception, rather than the rule. Listen to our community members:

“Thanks for what you’re doing to make healthcare reasonable and fraud-free!”

“From Rapid City South Dakota. I think your effort to establish a list of prices for various medical procedures is great. ”

“I just want to say that your website is amazing. Please don’t stop because you are helping people everyday, many of whom are struggling to make ends meet while others are just looking for a some transparency in a market where there has traditionally been very little.”

7. Insurance plan design is totally not sexy, but it is  the next big frontier. Narrow networks? What does your plan allow, and what does it prohibit? Can you get the kind of insulin you need under your plan’s formulary, or are you only covered for insulin you’re allergic to? Do you have to travel 300 miles for behavioral health coverage? Did your insurance deny treatment that made your illness, injury or condition worse?

8. Medicaid expansion reduces everybody’s private premiums in states where it’s been embraced. This makes sense, but who thought about it in this way? It will be interesting to see how many more states decide to refuse Medicaid expansion, and how many embrace it.

9. Healthcare.gov will not work perfectly during open enrollment. Neither will the states’ individual exchanges. We will probably hear a lot about this, and we’ll probably have to write about it, but this is a sideshow, and the complaints about failed software should be remarked upon and then ignored. Software doesn’t always work; we happen to know. The administration is trying to fix it, but it’s still complicated.

10. Patient engagement is indeed the blockbuster drug. Yes, it’s hard; yes, it’s often unreimbursed. Yes, it can go awry. But it is the future of medicine: let me introduce you to patients and providers joining hands to make a better future: e-Patient Dave deBronkart, Casey Quinlan, Danny Sands, Leslie Kernisan, Gilles Frydman, the Society for Participatory Medicine, and the people at the heart of the Patient-family Engagement Roadmap, prepared by the American Institutes for Research under a grant from the Gordon and Betty Moore Foundation. Even the Institute of Medicine has weighed in on shared decision-making.

11. I am not planning to write about this, but I add it here for the sake of adding it: The ACA didn’t totally fail. The ACA didn’t totally succeed.

So that’s a start on what we’re thinking about. What do you want us to cover?

Tell us your thoughts, either in the comments, by Twitter @chcosts, or by email to info (at) clearhealthcosts (dot) com.

With such  success in those two projects, we decided to try crowdsourcing our coverage: what health cost topics should we cover? We’re looking back  and looking forward — and we’re coming to you, our community, to help guide us. Here are some subjects we plan to write about.

Our ask for you: Please tell us what surprises you. What you want us to cover?

Let us know, in the comments, by Twitter @chcosts, or by email to info (at) clearhealthcosts (dot) com. Or by snailmail to P.O. Box 8124, Pelham, N.Y. 10803. Or by Pony Express…

Jeremy Hunt, secretary of state for health in Britain, recently toured the Virginia Mason Medical Center in Seattle. He said  the visit was “inspirational” and announced plans to have the British National Health Service (NHS) sign up “heart and soul” to a similar culture of safety and transparency. Hunt wants doctors and nurses in NHS to “say sorry” for mistakes and improve openness among hospitals in disclosing safety events.

I had a similar reaction to my tour of Virginia Mason. The hospital appears impressive—and truly gets impressive results. My nonprofit, the Leapfrog Group, annually takes a cold, hard look at the hospital’s data and named Virginia Mason one of two “top hospitals of the decade” in 2010. Every year, it ranks near the top of our national ratings.

Virginia Mason’s success is rooted in its famous application of the principles of Japanese manufacturing to disrupt how it delivered care, partly at the behest of one of Seattle’s flagship employers, Boeing. There are numerous media stories and a book recounting the culture of innovation Virginia Mason deployed to achieve its great results, so I won’t belabor the point here. But at its essence is Virginia Mason’s unusual approach to transparency. Employees are encouraged to “stop the line” – that is, report when there’s a near miss or error. Just as Toyota assembly workers are encouraged to stop production if they spot an engineering or safety problem, Virginia Mason looks for every opportunity to publicly disclose and closely track performance.

It is not normal for a hospital to clamor for such transparency. Exhibit A: the Leapfrog Hospital Survey, my organization’s free, voluntary national survey that publicly reports performance by hospital on a variety of quality and safety indicators. More than half of U.S. hospitals refuse the invitation of their regional business community to participate in Leapfrog, suggesting that transparency isn’t at the top of their agenda. But for Virginia Mason and an elite group of other hospital systems, not only is the transparency of Leapfrog a welcome feature, but they challenge us to report even more data, faster.

I hope the British health care system takes Virginia Mason’s model and runs with it, but, more than that, I hope the model takes hold here in the U.S. Too many hospitals in the U.S. avoid disclosing their performance instead of welcoming transparency as an opportunity to build trust with the patients in their care. The movement toward transparency has a long way to go. We do not have publicly disclosed accreditation reports, even though those reports are tickets for hospitals to obtain public funding through Medicare. We do not yet know enough about infection rates, sentinel events, medication errors and outcomes including death rates from many common (or uncommon) procedures.

Price transparency is also rare, according to a report by the Catalyst for Payment Reform. The ultimate example of our tendency toward non-disclosure came last week, when USA Today reported that CMS quietly removed from public disclosure the incidence of certain “never” events, like objects left in after surgery. Experts disagree on the merits of how CMS counts these “never” events, and CMS—no doubt influenced by lobbyists—believes that they aren’t fair to hospitals. Yet, in a culture of transparency, CMS would do the opposite: first err on the side of reporting the “never” events, then let the experts refine the measure over time. Indeed, as the Virginia Mason experience demonstrates, the very act of reporting can accelerate improvement and transformation. It’s time for the U.S. to ignite its passion for free speech and lead the world in applying it to health care.