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For The Record Q & A With Jeff Margolis

Jeff Margolis, founder, chairman, and CEO of The TriZetto Group, has long been an advocate of implementing innovative technology to broaden the effectiveness of healthcare. Recently, he spoke with For The Record about his new book, The Information Cure, and the overall direction of HIT.

FTR: What was the motivation for the book?
Margolis: I am increasingly concerned that the discussion surrounding the healthcare crisis is following the same problem-solving methodology we have seen for years. It seems most people working on the healthcare problem only understand a subset of the U.S. healthcare system and why, in total, it works the way it does. The pursuit of a lasting solution must be based on a more meaningful objective than the political expediency of saying “everybody is covered.”

There are many aspects of U.S. healthcare that are absolutely outstanding, and instead of focusing on the what—as in what is wrong—there must be a focus on the how. The how question of solving healthcare must take the best of every sector of the healthcare system and transform it into a cohesive, integrated, affordable, and sustainable system.

We need to step above the normal discourse and put forth ideas that will give people a broader understanding of the problems facing the healthcare system while also providing workable solutions. [Albert] Einstein said that the definition of insanity is doing the same thing over and over again while expecting a different answer. I wrote The Information Cure and documented the vision of integrated healthcare management because the problems we are trying to solve are complex, and we will not create a sustainable, affordable healthcare system by following the same rationale that has plagued the healthcare debate for decades.

FTR: What effect, if any, will stimulus funding have on HIT adoption?
Margolis: Stimulus funding has had both positive and negative effects on healthcare IT adoption. In one sense, it is a move in the right direction to be talking about IT at all. However, stimulus funding has created an environment where any company that has any technology agenda is pushing ahead with its IT solution to get a chunk of the money, with few really thinking about driving a sustainable, integrated approach or the best way to address the specific needs of consumers, providers, and others.
Integrating electronic records into provider organizations is about more than just finding the right software and installing it.

Doctors and hospitals must change their workflow and think about their business and patient care objectives in the context of new reimbursement methods that will increasingly pay for consistently following the best available care guidelines and producing good results. They have to wrestle with the issues of a better records system, improved efficiency, improved patient-physician interactions, and more. They need to decide upon and know their ultimate goal before implementing an IT solution.

EHRs can serve a useful purpose, but without a clear objective at the provider level, the stimulus money has placed the learning process of doctors and hospitals on the backs of American taxpayers. Worse, I fear that in many cases, wasted effort and money will entrench technologies and methods that make it much more difficult to do the right thing later.

Nor can EHRs be developed in isolation. There are many types of records under development, including EHRs, electronic medical records, and PHRs. The healthcare system needs all three types to work more effectively and efficiently. I expect that it is going to take much longer than the president’s goal of five years to get EHRs widely adopted, and longer still to have them work systemwide—in practical health information exchanges—the way many hope.

In the meantime, TriZetto is pushing ahead with a PHR solution that can provide 80% of the benefits people envision for EHRs, and get numerous constituents, including consumers and providers, accustomed to trusting and using electronic records for healthcare. As part of our contribution to healthcare reform, in early 2010, we will enable PHRs for more than 100 million people at no cost to our payer customers for use by the providers and consumers they serve. 

FTR: Are you pleased with the progress thus far behind the attempt to define meaningful use?
Margolis: I am not particularly pleased with the progress behind attempts to define meaningful use because although the overall system should be consumer centric and population based, the thinking process is very centered on clinicians’ use. Although efforts are being made to include population management concepts and care coordination concepts—currently not the domain of most clinical applications—the industry focus is on how to define a “useful” implementation of clinical EHRs to accomplish by 2015 what many health plans can already do today. It is illogical to exclude health plans, other than integrated delivery systems such as Kaiser [Permanente], from the process of being reimbursed because “they are just administrators.”

Meaningful use, in a broader context, is one of the most important levers we have to significantly impact both the cost and quality of healthcare and could help do so much more than digitize clinicians’ environments. However, defining meaningful use has turned into a cat-and-mouse game trying to find a way to profit from the stimulus funding. Just look at the valuations being ascribed. Companies in the healthcare IT industry are creating mechanisms that say if you agree to spend a certain amount of money with us, we will take the responsibility that our products and services qualify for meaningful-use funds. It seems a little like trying to make sure everybody gets a mortgage, whether they can handle it or not.

FTR: Why do you consider a systems approach key to improving healthcare?
Margolis: A systems approach is critical to improving healthcare because it is predicated on defining and reaching a clear objective. In The Information Cure, I address the healthcare dilemma by starting with the objective of deriving more value from every healthcare dollar spent. The book considers the entire system—consumers, providers, payers, suppliers, employers, brokers, everybody in the healthcare supply chain—to understand how the parts work together and can be incented to function in a way that achieves a sustainable, affordable, and effective healthcare system.

You cannot take some rubber, sheet metal, bolts, and screws, throw them into a garage, and expect to build a luxury sports car. The same is true of the healthcare system. A systematic approach is the only way to reach a full understanding of the healthcare marketplace, and understanding the marketplace from a supply-chain perspective is the only way we can make the right changes.

FTR: How should the industry get consumers to buy into the idea of PHRs?
Margolis: First, consumers need a little bit of education. For most Americans, the idea of a health plan having access to and using personal health information may raise concerns. What they may not understand is that health plans already have this information; it just is not organized in a single useful record for their [personal] use or for use by their caregivers. By using the data health plans gather to pay doctors’ medical claims or pharmacy claims, coupled with enrollment questionnaires and health risk assessments, health plans can create robust PHRs that give doctors, pharmacists, and hospitals a true, more complete picture of the patient’s health.

Before this can happen, however, consumers must trust that their information will not be used by health insurers to deny coverage or raise rates. This is where Washington healthcare reform comes in. The health industry must reach an agreement that there will no longer be individual underwriting based on preexisting conditions. If consumers no longer fear their information will be used against their personal interests, we will be able to evolve and revolutionize the use of PHRs.
Providers also are critical in the development and use of PHRs. Physicians understand the value of receiving a complete health history from their patients, saving time during the interview process and more fully understanding their patients’ needs.

When I see my primary care doctor and ask whether he knows what happened to me in the last 60 days, the answer is always no. But if I ask, “Do you want to know what happened to me?”—that I had to go to the emergency room and had some tests, for example—of course he says yes. Payers have the information that such activities took place. We can harness this information to improve healthcare outcomes and patient care. Payer-based PHRs are broadly comprehensive although not as clinically deep as electronic records used in a healthcare delivery environment. PHRs span multiple care settings—doctor’s visits, hospital admissions, pharmacy activity, laboratory tests, imaging tests—to provide a complete and accurate view of a patient’s health status. After all, most Americans, in fact, receive care from multiple providers and facilities.