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By Dennis Miller, BHC Senior Writer

At the World Health Care Innovation and Technology Congress (WHIT v5.0) being held Monday through Wednesday next week in Alexandria, Virginia, attendees will hear from some of the nation’s preeminent politicians, policy makers and industry executives on improving health and healthcare through information technology (IT). Among the scheduled speakers are former President Bill Clinton, former Speaker of the House Newt Gingrich, and the subject of today’s Special Feature, the nation’s first National Health Information Technology Coordinator or ‘Health IT Czar,’ David Brailer, M.D.

Dr. Brailer was appointed by President George W. Bush to this newly created position in May, 2004, and served until May, 2006. In that role, he led the effort to help establish uniform, nationwide standards for electronic health records, under an Executive Order mandate to implement widespread deployment of health information technology within 10 years to help realize substantial improvements in safety and efficiency in the nation’s healthcare system. Today, he continues to work toward technological and systemic modernization of healthcare as Chairman of Health Evolution Partners, a company working to drive advancement in healthcare by investing in promising technology.

While known principally on the national stage for his efforts to promote the adoption of electronic health records, Dr. Brailer’s work both before and after his service as Health IT Czar is much broader than that, encompassing no less than a complete re-engineering of the nation’s and world’s healthcare systems. Health Evolution Partners represents the latest manifestation of that ongoing work. “We’re really the healthcare version of a ‘green investor,’” he explains. “A green investor might invest in wind and solar as new forms of energy for our economy. We’re looking for the healthcare version for wind and solar. We’re looking for technologies, services, ideas, mechanisms and strategies that change the quality, efficiency, consumer involvement, transparency, and accountability of the healthcare industry.”

In his Opening Keynote Address to the WHIT v5.0 Congress entitled “The Battle for Health Information Dominance,” Dr. Brailer plans to outline some of the major trends and challenges for healthcare innovation in the coming years. “This is obviously a very important time for healthcare and for change in healthcare,” he says. “And so what I am going to do is really try and separate out some of the things that are big question marks that we don’t know the answer to, such as, ‘How will the health reform debate turn out?’ and ‘Who will be insured and who won’t be?,’ from the things I think are moving on despite that, which is the constant pressure on the industry to contain costs, the issues around servicing better quality, the continuing growth and consumer drive in the industry, and how that really continues to foment and drive change. And what that means for entrepreneurs, for policy makers, and for the person who is running or is in a healthcare system today. It’s a very tumultuous environment and I just want to tease out some of the things that people really need to know to navigate the next year.”

Dr. Brailer sees behavioral healthcare as a particularly target-rich environment for the type of systemic and technological improvements he feels hold enormous potential for enhancing care quality while improving efficiency and reducing costs. “Electronic records — e-prescribing — can alert a doctor to a drug/drug interaction or allergy that could be deleterious to a patient,” he explains. “It could alert them in the future to a drug/genomic interaction that could cause a dose to go higher or lower. There are a lot of significant drug/drug interactions in mental health, particularly interactions between mental health drugs and drugs that are used for more metabolic issues. So I think there’s an example for just improving decision-making — to make sure we don’t make mistakes when we pick a drug or pick a treatment.”

He also sees the potential for telemedicine and remote monitoring to play a key role in shifting behavioral healthcare to less intensive and more condition-appropriate settings. “We have seen a number of tools that help patients communicate with doctors via email, via video, and to find a specialist when we need one. And one of the areas where this has shown the most promise is in treating depression or in other, I would say, ‘lighter,’ mental health issues,” he says. “We’ve seen a number of examples where telemedicine is quite relevant to that and it’s one of the vanguards that’s pushing it forward.

“The other area where I think we see information tools really driving efficiency and driving quality is shifting people out of institutional settings into more home-based settings. And this is done in part by electronic and remote monitoring and in part by allowing a different form of self-management, so people have prompts about what they should be doing and not doing. And again, I think mental health is an example of that.”

Behavioral Health Central will be on hand to cover the WHIT v5.0 conference, and will be bringing you interviews and discussions with some of the major speakers in the days to come. Today, we present a wide-ranging interview with Dr. Brailer, in which he explores the healthcare industry’s many challenges, offers his thoughts on how technological innovation and systemic improvements can address those challenges, and discusses the potential for electronic health records to help spur a revolution in how healthcare is delivered and financed. To listen to our interview, click the audio icon above. The following is a written transcript of our talk:

BHC: Give us a quick overview of what you plan to talk about in your keynote address at the World Healthcare Innovation and Technology Congress.

DB: Well, this is obviously a very important time for healthcare and for change in healthcare. And so what I am going to do, Dennis, is really try and separate out some of the things that are big question marks that we don’t know the answer to, like, “How will the health reform debate turn out?” and, “Who will be insured and who won’t be?” from the things I think are moving on despite that, which is the constant pressure on the industry to contain costs, the issues around servicing better quality, the continuing growth and consumer drive in the industry, and how that really continues to foment and drive change. And what that means for entrepreneurs, what that means for policy makers, and what that means for the person who is running or is in a healthcare system today. It’s a very tumultuous environment and I just want to tease out some of the things that people really need to know to navigate the next year.

BHC: Now I would imagine that the drive toward adopting electronic medical records will be a big part of your talk. Is that correct?

DB: Well, it sure will be, I think I can’t go anyplace anymore without talking about that, Dennis.

BHC: How is the nation’s healthcare system doing so far adopting electronic medical records?

DB: Well, I think we are certainly doing really well. We were very pleased to build the architecture for how the nation’s going forward, and we’re still following it to this day and following it in a way more intensely than we thought would happen. It’s really gotten enormous momentum, but we have a long way to go. Still, the minority of doctors have electronic records. The minority of hospitals have fully complete clinical records and systems that doctors use, and nursing homes and ancillary care centers really have none.

So we have a long way to go, but I think the strategy is laid out, the basic approach is set, we now have funding coming in and I think it’s going to move forward. It’s going to move forward because younger doctors and younger patients have put their foot down and said, “We’re not going to be in a healthcare system that doesn’t have good information and good communications” in the kinds of ways that business get done that they see in every other part of their lives.

So I’m going to talk about that, I’m also going to talk about some of the potential hype that’s going on around this stimulus bill and what it is and is not, and whether or not it alone is going to change, and some of the unintended consequences that come from the stimulus bill.

So I’m going to talk about that but I’m going to put it in a broader perspective of a number of things that are happening in the industry that I think go far beyond that also.

BHC: When it comes to electronic medical records, how does the United States compare to other nations around the globe in the adoption of them?

DB: Well, the U.S. is behind and ahead, depending on your point of view. Many countries in Europe, for example, were far along with this even ten years ago. Doctors had a PC in their office. They had software to use to keep track of their patients. And so, by one measure, they’re well ahead of us in “electronic records.”

On the other hand, if you really look at what those doctors did with those systems and how they used them, they were not really the things that we’re talking about today. They were not used by doctors to order drugs, to really keep track of what was going on with their patients, to help alert them to issues with their patients, to help them communicate with other doctors, or to allow the patient to have access to their information.

This notion that we have today of the electronic record as a continuity of patients across doctors and health systems, as a communication vehicle for professionals to collaborate, as a kind of man and machine working together to be smarter than man alone, is not what Europe or Asia has done.

So I think in that sense we’re ahead. We’ve innovated much more impactful concept of electronic records that’s now starting to filter out into those countries. But I do think the important lesson is we do have a lot to learn from other countries and I think we have a little bit to teach them as well.

I just got back from a week in Europe looking at all the different installations that are underway and what’s working and what’s not. And I would just say that everyone is watching what happens in the United States and recognizes that the United States will set the tone for the globe. And I think what’s at stake with that is whether or not our health IT companies become the global leaders in electronic records. Every IT sector of our economy has become globalized and health IT will as well, and I hope the United States gets it right so our indigenous companies become the leaders all around the world in electronic records.

BHC: Give us a few examples of how electronic health records can improve efficiency and reduce costs in healthcare and particularly, given our audience, in behavioral healthcare.

DB: Sure. I think there are a lot of examples. I’ll just give three examples. First, in terms of how decisions get made. We know, for example, in prescribing, that electronic records — e-prescribing — can alert a doctor to a drug-drug interaction that could be deleterious to a patient, [or] a drug allergy. [It] could alert them in the future to a drug/genomic interaction that could cause a dose to go higher or lower. And it turns out that some of the commonly used drugs in mental health have an enormous array of side effects, as all of the professionals in the industry know. And they’re metabolized in ways in the body that make them quite complicated.

So, there are a lot of significant drug-drug interactions in mental health, particularly interactions between mental health drugs and drugs that are used for more metabolic issues. So I think there’s an example there for just improving decision-making; to make sure we don’t make mistakes when we pick a drug or pick a treatment.

The second area is in communication. We have seen a number of tools that help patients communicate with doctors via email, via video, to find a specialist when we need one, and one of the areas where this has shown the most promise is in treating depression or in other, I would say, ‘lighter,’ mental health issues. Not frank psychosis, but some of the mainstream, more common mental health issues where people need to have continuity and connection to professionals even if they’re in a rural area or if they’re traveling. And we’ve seen a number of examples where telemedicine is quite relevant to that and it’s one of the vanguards that’s pushing it forward.

The other area where I think we see information tools really driving efficiency and driving quality is shifting people out of institutional settings into more home-based settings. And this is done in part by electronic and remote monitoring. This is done in part by allowing a different form of self-management, so people have prompts about what they should be doing and not doing, and again, I think mental health is an example of that.

So health IT in mental health or in other areas of healthcare, itself will not save money and will not change quality. But health IT used in the setting of changing how healthcare’s delivered — how decisions get made, how patients can engage and how communication occurs — can change everything. And that is the real lesson here.

BHC: Were the funds that were provided for health IT and the American Recovery and Reinvestment Act sufficient? Or would you describe them as just a down payment on what we need to do?

DB: Well, we know the nation's conversion to elect electronic records from top to bottom is a hundred-billion dollar effort. Our industry today spends about $25 billion a year, so you would conclude it just takes four years. Most of that — I would say north of 20 billion — is spent on replacing legacy systems, things not on the critical path of getting widespread adoption. So we’re really moving slowly towards that goal of investing into that huge backfill that we need. The stimulus bill, nominally, $34 billion, obviously divided half into penalties, half into incentives, at face value has a huge impact.

But if you take it apart, I think there are a couple of things that are quite clear. You take the seventeen or so billion dollars of incentives that’s spread across several years, so that does increase spending per year, but not doubling or going up by 50 percent. It may increase by about 10 percent. So there’s a little bit of a bump up on an annual basis.

Secondly, it’s not like the government comes along and says to a doctor, “Hey, I’m going to give you $44 thousand,” that that doctor, who might have been already planning to spend say $50 thousand on electronic records will now want to spend $94 thousand. No, they’ll still spend $50 thousand. They’ll spend it out of the government’s pocket rather than out of their own. So I don’t think it necessarily at the level of the doctor translates dollar for dollar into more spending. I think it creates more opportunities for doctors to spend a different way.

And finally, I think we’ve seen time and time again that it’s really hard for the executive branch to follow through on Congress’s intent. And one place [that] that is no more likely than is a complex financial incentive that goes through Medicare to doctors. And I think we will see what the Medicare Rules look like that make doctors able to get access to this money. And if it turns out to be very complicated, burdensome, full of paperwork and potentially full of penalties, doctors won’t do it and you won’t see the effect. If Medicare gets the religion here and makes it easy and straightforward and compelling and in a partnership with doctors, it could have quite an impact.

Finally, I would just say, I don’t think I know of a circumstance where Congress has threatened a penalty against doctors as they do here. There’s a penalty if doctors don’t use electronic records by a certain period of time. I don’t think I’ve ever seen Congress really follow through with that. And the best example is the SGR, which is the formula that calculated doctor reimbursement. So I would be very surprised if that penalty ever gets levied against doctors. And by the way, that is the component that the Congressional Budget Office estimated and had the biggest impact on adoption.

So I think there’s a lot of shoes yet to drop and we will be watching the regulatory process to see if the executive branch is as excited about this opportunity as Congress has been.

BHC: Obviously the private sector has a strong role to play here as well. Describe for us how your company, Health Evolution Partners, is helping to drive the conversion to electronic records.

DB: Well, our mandate is quite a lot larger than that Dennis. As I said, I can’t run from electronic records and I wouldn’t want to, but we do a lot more things than that. We’re really the healthcare version of a “green investor.” A green investor might invest in wind and solar as new forms of energy for our economy, we’re looking for the healthcare version for wind and solar. We’re looking for technologies, services, ideas, mechanisms and strategies that change the quality and the efficiency, the consumer involvement, the transparency, the accountability of the healthcare industry.

Health IT is part of that. We’ve looked at a number of ideas. We’ve invested in an electronic prescribing company called Prematics. We’ve invested in a teleradiology company called Optimal. We’ve invested in another teleradiology company called Foundation. We’ve invested in a laser optics company called Mauna Kea. But there are many, many more.

There are ideas and new devises that are much more able to communicate and to be able to deliver a cost-effective return for patients. There are opportunities in how patients manage their own care under an HSA that are quite transformative for some people and by the way, quite aligned with where we think the movement for broader access is going. There are tools that help the pharmaceutical industry be more accountable in the later phases of their drugs on the market — phase IV — so they can really find and detect errors faster and be able to deal with new side effects or new things that were not discovered in the studies.

So we’re looking really around the globe for ideas that will impact healthcare that have a good proposition behind them and we’re bringing them to the United States. And so we look really at anything from small companies to very big ones and are in constant search for that idea that can change things but is packaged with a kind of savvy, and navigate a very complicated and often very toxic healthcare industry in terms of rejecting new ideas.

BHC: You’ve described what you refer to as three major pain points in the American healthcare system where waste and inefficiency are rampant. Would you give us a quick overview of those major points?

DB: There are two areas where we know the people who purchase healthcare on behalf of the American public — big pension funds, big employers, government agencies, state and federal — they see a couple of things that are really concerning to them.

Number one, the fastest growing line item in healthcare cost today is imaging and it’s being driven by more and more complex imaging and more and more reads and interpretations. It’s not that the prices are going up, everyone gets scanned more. And so that’s an area where there’s an enormous opportunity for efficiencies in terms of reducing duplicate scans, in terms of making sure that the patient gets the appropriate scan, that the patient gets only the scans they need and not lots of extra scans that are just nice to know but not helpful, that the scans are done technically correct so that they don’t have to be done over for performance reasons, etc., etc., etc. It’s an industry filled with low-hanging fruit and I think the radiology community has been working hard to establish appropriateness criteria and more capacities know what’s right or wrong, but it’s not really gotten taken up in the market. So this is an area that we think is really quite promising and quite needed.

Another area is the cost of specialty therapies — of biotherapeutics. We have some of the greatest miracles happening in the drug industry in terms of a drug like a Gleevec or a drug like Lucentis or Avastin that really perform admirably on people. But for all of the good drugs, we have drugs that have marginal benefit and are enormously expensive. And one of the frustrations in the industry is that we figured out through generics and through step therapy and appropriateness and through various usage guidelines and tools to get regular oral drugs used appropriately. The cost of those has barely been going up, but the specialty side has been going up tremendously with very little evidence of gross value add. So this is an area of enormous opportunity and promise.

And I think the third area that’s on everyone’s mind is, “How is it that we can bring the ability to do what some people call ‘shifting left’— to move people out of hospitals into primary care, and primary care into people’s homes? To get people into less intensive sites of care?” And clearly the issue here is when it is [that] state and federal regulators will give up the ghost and simply acknowledge that the care that’s delivered via televideo, telemedicine, and email can be just as good and no more abusive than the care that’s delivered when the doctor’s three feet away from their patient. The industry has shown that this can work. The regulators are a generation behind and so this is an area that I think there’s just enormous promise.

But these are just three out of dozens of areas in an industry that’s just struggling to come into this century in terms of ways of delivering care services.

BHC: Dr. Brailer, just one final question. Obviously you’re probably paying very close attention to what’s going on in Washington, and we’ve now got versions of healthcare reform in the Senate and in the House. From what you’ve seen of those are they on the right track in regards to using technology to improve efficiency and lower the cost?

DB: There’s not an American that does not want to see our care system be more fair and more accessible to people in ways that allow people to get access to the same care across the economic spectrum. And to not have it really be a healthcare system that discriminates on the base of wealth or income. So I think the movements by Congress to try to level the playing field are quite beneficial. I think there’s clearly a lot of debate about the form that those take in terms of the government being a public operator of insurance versus simply a guarantor and I’m not even going to comment on the politics of that, because I do think that that is a political debate, not a policy debate. But I think the general direction is welcome.

I would also say though that Congress had the opportunity, and early in the discussion, Congress talked about, changing healthcare, in terms of changing the incentives that doctors face so they don’t have to choose between doing the right thing for their patients and keeping their practices afloat. And hospitals could have better incentives so that they did not have to choose between their profits or their margins and treating patients the way they think they should be in terms of taking away the artificial barriers between doctors and hospitals so there could be a more collaborative care process as we see in other countries and as we see in integrated delivery systems here, [and] in terms of changing the way the information is used so we can see things like telemedicine, as I mentioned, or more health information exchange.

There was a really incredible once-in-a-generation talk about taking away the regulatory barriers and changing the legacy, obsolete policies, and I think that really held the industry back. And what I hear is thundering silence on those. There’s nothing being talked about. And I’m glad we’re expanding insurance. I have some issues personally with some of the ways that we’re thinking about it, but generally, I think it’s the right direction.

What I’m regretful of is that we no longer are talking about fixing some of the core parts of the industry that were created and have been perverted by obsolete policies. And that is an issue that’s got to be addressed. It’s going to have to be addressed soon. I think that the healthcare reform debate would have been much stronger had we packaged access and efficiency transformation into one policy change. It may be politically too much to bite off, but I think Congress has only done part of the job and there’s a lot more to be done by a future Congress on this.
 

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