Mark Hagland is a nationally recognized health care journalist, public speaker, and author. More information about him and about his work can be found at www.markhagland.org. In the following entry, he shares a few thoughts about the health care reform that is already happening in America.

With all the heat surrounding the national health care reform debate this summer, it would be easy to lose sight of the reality that what is primarily being talked about in Washington right now is health insurance reform (though with some elements of reimbursement reform mixed in).

And while people of good will might disagree on the best approach to address the enormous health insurance problems in our country, some level of consensus is beginning to emerge on what is sometimes referred to as “internal” health system reform—and that’s a good thing.

By “internal” reform, I mean the kinds of operational and incentive-related activities that take place within and around patient care in hospitals, clinics, and integrated health systems. I mean the innovative work being pursued by pioneer organizations across the country with regard to improving patient safety, patient care quality, clinician workflow, operational efficiency, and cost-effectiveness in care delivery.

I’ve described many examples of such work in my writing for health care professional publications, as well as in the two books I’ve written, Paradox and Imperatives in Health Care (which I co-authored with noted health care economist and futurist Jeffrey C. Bauer, Ph.D.), and Transformative Quality: The Emerging Revolution in Health Care Performance. In addition to shorter descriptions of various types of pioneering work in “internal health care reform” mentioned in those two books, I also provided fully 23 case studies of such work between the two volumes, focusing on organizations like Brigham & Women’s Hospital in Boston, Virginia Mason Medical Center in Seattle, Northwestern Memorial Hospital in Chicago, and Geisinger Health System in central Pennsylvania, all organizations that are doing what needs to be done to improve the quality of patient care and make health care more transparent, accountable, and ultimately affordable, for everyone.

My case studies in both books range from the very broad to the more specific. On the very broad side was my case study on the 44-hospital Trinity Health system, based in Novi, Michigan, whose clinician and IT leaders are engaged in a truly massive effort to improve care quality and efficiency, with intensive health care IT support.

Among other things, the Trinity Health folks have been developing evidence-based order sets that they are standardizing across the entire health system, while also developing standardized clinical process workflows across the health system. Just these two elements alone are remarkable (there are many other aspects of the Trinity Health innovation work), and speak to the vast potential across the U.S. health care system for significant internal reform of the health care delivery nationwide.

Meanwhile, at the University of Pittsburgh Medical Center, a 20-hospital health system in Pittsburgh, PA, intrepid physicians have been creating innovations that demonstrate perfectly the kinds of synergies that can result when clinicians, IT professionals, and IT vendors work together to improve the environment around medication ordering, medication management, and overall access to relevant patient information at the point of care. Working with the Pittsburgh, PA-based dbMotion software company, Dr. Bill Fera and his colleagues at UPMC have innovated a kind of semantic interoperability that, since early 2008, has made it possible for physicians at some UPMC hospitals to pull up all of a patient’s medications and other clinical information (also including lab and radiology results) on a single screen, vastly improving physicians’ ability to make the best ordering and diagnostic decisions at the point of care.

Both of these case studies, along with nine others, are described more fully in Transformative Quality (available via my publisher’s website at www.productivitypress.com). What is strongly heartening for me is that organizations like Trinity Health and UPMC are showing the way forward, even as policymakers debate health insurance coverage and other very important health care policy issues in the coming weeks and months.

And, regardless of the final outcome of the comprehensive health care reform debate taking place in Washington right now, a consensus is emerging among all stakeholders that the “internal” reform that organizations like UPMC and Trinity Health are helping to lead is equally vital and important. I, for one, am looking forward to being able to write many, many more articles and book chapters about such innovations going forward. This is the kind of difficult, yet rewarding, work that health care providers face going into the future. In short, when it comes to “internal health care reform,” the future is now.

Dr. Joel Diamond, CMO for Dodge client dbMotion, provides some interesting insight into the world of interoperability on his blog. Utilizing dbMotion technology, the University of Pittsburgh Medical Center (UPMC) recently completed the initial phase of its extensive interoperability initiative. As a practicing physician within the UPMC network, Dr. Diamond provides an interesting perspective on this hot topic.

Woodcock and Associates is a leading consulting organization working in the medical practice operations and revenue cycle management areas. Today Elizabeth W. Woodcock, MBA, FACMPE, CPC, writes on the potential of Medicare cuts in 2010.

With payments to physicians treating Medicare beneficiaries scheduled to plunge by 20.6 percent starting January 1, 2010, and a depressed U.S. economy, you wouldn’t think there could be any good news ahead for physicians. But the Obama administration has offered a ray of hope – and it could turn into a bright beam of light for physicians. Or not.

There are few specifics so far, but in testimony before the House Budget Committee recently Dr. Peter Orzag, head of the White House’s Office of Management and Budget, hinted that the administration may toss out Medicare’s flawed sustainable growth rate (SGR) formula. Orzag added: “We recognize that we need to move toward a system in which doctors face stronger incentives for providing high-quality care rather than simply more care.”

The SGR helps determine annual fee updates to doctors, but its flawed approach – subtracting per capita GDP from spending on physician services – has produced automatic across-the-board cuts for several years running. Congress always reverses the cuts at the last minute, but next January’s scheduled 20.6 percent cut – the biggest yet – might be too costly to overcome.

Tossing out the formula would be welcome news because private insurers tend to mirror Medicare’s movements. Physicians’ bottom lines are further eroded by consumer-directed health care products – a fancy name for putting more financial responsibility on patients. Unfortunately, patients are a physician’s worst payer. Many patients either can’t or won’t pay larger shares of their health care costs. As the ranks of the uninsured grow, the problem grows worse, bringing even larger write offs.

So far, there are more questions than answers: Will Obama actually eliminate the SGR and boost Medicare payments? If so, what will the new fee schedule look like? Will it be another complicated mess like the initial years of the government’s pay-for-performance program, the Physician Quality Reporting Initiative (PQRI)? Will the economy turn around next year and bring patients the money they need to adequately fund health savings accounts and pay their health care bills? Will insurance coverage be expanded to cover the uninsured – and if it is, will the reimbursement be enough for physicians to sustain their busy, but increasingly unprofitable practices?

The biggest question of all is: How much longer will the current system of private-based health care survive amidst the many downward pressures on physician income? Sure, we’ll always have doctors, but will there be enough of them and who will they work for? As the old radio shows used to say, ‘Stay tuned, folks!’

Atlanta-based Elizabeth Woodcock speaks and writes about the medical practice industry. Book her for a speaking event, or purchase one of her programs on DVD here.

Long-time Dodge client Dialog Medical is a provider of automated informed consent technology. Vice President, Marketing Tim Kelly weighs in on how the stimulus is impacting niche vendors:

This question is being asked with increasing frequency and, on the heels of the HIMSS Conference, the answer appears to be, “The same as for EHR vendors.” Hospitals are continuing to embrace the offerings of niche vendors, yet healthcare providers are exhibiting the same recession-influenced caution relative to purchase decisions as they are for any technology vendor. If there is a short-term “silver lining” to the purchase deliberation process it is that niche vendors don’t have the added worry of having to prove that their products will ultimately be deemed “certified technology.” Thus, for the balance of 2009, the impact of the EHR/stimulus push may be negligible, however, that will change quickly…

Inherent to the question above is the more pointed query, “Once the regulations are written and there is a clearer definition of exactly what it will take to get CMS reimbursement under the HITECH Act, how will niche vendors get any attention from hospitals that are not ‘meaningful users’ of EHRs?” That answer will depend on whether the niche vendor inserts itself into the ‘stimulus fray’ or retrenches and focuses its attention only on the Stage 4 EMR Adopters (assuming, of course, that “Stage 4” becomes the ‘Mendoza Line’ for Medicare incentive payments).

The intrepid niche vendors that embrace the EHR stimulus push will adopt at least two central strategies specific to helping hospitals meet the requirements set forth in the HITECH Act:

1. Implementation of our product will drive clinician usage of the EHR.
2. Integration of your EHR with our product is essential to demonstrating that your EHR meets the “qualified” definition.

Niche vendors tend to offer narrowly defined products that increase hospital efficiency and meet a well-defined need. Consider a recent analysis published in The New England Journal of Medicine, electronic laboratory reports are fully implemented in 77% of U.S. hospitals while electronic physicians’ notes are fully implemented in only 12%. Forward-thinking niche vendors will leverage the ‘pull through’ benefits offered by their respective products. Winning strategies will focus on how niche solutions enhance the value of the EHR and increase clinician adoption of technology in general.

The HITECH Act defines a qualified EHR as having the capacity “to exchange electronic health information with, and integrate such information from other sources.” Niche vendors historically are adept at interfacing with various EHRs as a manner of necessity. The integration tenet of the stimulus legislation may even enhance the motivation of EHR vendors in terms of their willingness to collaborate on interfaces. Regardless of whether ‘warmer, gentler’ EHR vendors emerge, niche vendors must communicate the ability of their systems to allow hospitals to demonstrate successful information exchange between the EHR and other sources.

The Chinese adage, “may you live in interesting times,” is quite apropos to niche vendors caught in the turmoil of the EHR/stimulus legislation. Whether that admonition is a curse or a benediction will depend on the degree to which niche vendors position their offering as supporting the requirements set forth by the HITECH Act.