PROVIDENCE – When Amazon, JPMorgan Chase and Berkshire Hathaway announced on Monday, Jan. 29, that they were planning a new joint venture to tackle “the hungry tapeworm” that is the cost of health care eating away at corporate revenues [and, for everyone else, much of their household income], the resounding shock wave sent the stock markets plummeting.

“Top insurer UnitedHealth fell 3 percent, helping to drive a more than 300-point drop in the Dow,” as CNN reported. “Two other big insurers, Cigna and Anthem, dropped more than 5 percent. Aetna and Humana were each down about 3 percent.”

In addition, the CNN story continued: Drug store giants CVS and Walgreens both declined more than 4 percent. Pharmacy benefits manager Express Scripts plummeted nearly 7 percent.

The clear worry, as the CNN story voiced, was that the new disruptive enterprise being planned by Warren Buffett, Jeff Bezos of Amazon and Jamie Dimon of JPMorgan Chase would upend the profit stream of wealth extraction that has driven the health care delivery system in the U.S. for decades.

Translated, Buffett, Bezos and Dimon were promising to solve the seemingly intractable conundrum of the ever-increasing costs for drugs, health insurance and medical treatment with a new technology platform.

[As one physician told ConvergenceRI, commenting on the move, it was yet another version of the golden rule: those who have the gold make the rules.]

Be afraid, be very afraid, Wall Street
Exactly what the new enterprise will look like and what it will do remains unclear, except in large amorphous terms. The news release accompanying the announcement said that it would be an independent, nonprofit company, “free from profit-making incentives and constraints.”

The initial goal is to create technological solutions to deliver simplified, high quality and transparent health care to their nearly 1 million employees at an economical price, according to reports.

Translated, the three executives seek to transform the very hungry tapeworm that is health care delivery into a mosaic butterfly of corporate savings, although it is unclear whether the ending will be the same happy one as that in the popular Eric Carle children’s story.

Epic storytelling
As fate would have it, Carl Dvorak, president of the Epic Systems Corporation, was giving a lecture on the evening of Jan. 29 as part of the “Healthcare in America” preclinical elective at the Warren Alpert Medical School at Brown University. More than 100 students and faculty attended the talk by Dvorak,

The topic of Dvorak’s talk was “Technology for Accelerating Changes in Health Care,” focused on the role of health IT in shaping the future health care system.

Epic, a privately held firm headquartered in Verona, Wisconsin, is the purveyor of one of the largest electronic health record systems in the world, with a market share of approximately 26 percent for all acute care hospitals in the U.S., according to 2016 data.

Worldwide, Epic is said to have some 190 million patient records flowing through its data systems.

One of the non-transparent costs of the U.S. health care delivery system – or wealth extraction system – depending on your point of view, is the tremendous investments being made in health IT by hospital systems.

Much of that money actually flows from the federal government to support the adaptation of EHRs – what Dvorak described as a major public works project.

“This was our [21st century] version of the Tennessee Valley Authority,” Dvorak said. “They [the government] didn’t care if it worked; it just had to have reasonable expectation that it would work,” in order to help keep the economy afloat in the aftermath of the Great Recession.

Dvorak added, as a kind of meaningful aside: “The puzzle is that when you take government money, it comes with strings attached. The money is temporary, but the strings are permanent.”

The need for health IT to calculate and to analyze the equations of outcomes for accountable care organizations, for Medicare and Medicaid, for meaningful use, is no longer optional, according to Dvorak.

The local equation
In Rhode Island, in the last few years, Lifespan made an “announced” investment of more than $100 million to convert to EPIC, although sources have told ConvergenceRI that Lifespan’s actual investment was much higher, nearly $230 million.

Similarly, Care New England made a major investment of more than $50 million to convert to Epic, focused initially on its outpatient operations. Its potential merger partner, Partners Healthcare in Boston, spent more than $1 billion to convert to Epic.

While the total amount of investment may be known, what has not been transparent is the way that the costs of those investments in health IT have been allocated to be repaid by patients and consumers of the different hospital systems.

Translated, what is the patient share of the costs of those investments? Is there a “surcharge” that goes onto everyone’s bills? Do those costs show up, for instance, on emergency room bills? Or, is it part of the large variance in costs for an MRI? Good questions.

Dvorak asked his audience how much they thought had been spent in the last year on health IT to boost the continued use and adoption of electronic health records. Someone in the audience suggested: “Millions?”

Much, much more, Dvorak answered, laughing; he added that he couldn’t discuss the actual figure because he was bound by non-disclosure agreements.

[In March of 2013, five years ago, the amount being spent by the government on EHR implementation was $1.6 trillion, according to Stephen Soumerai, professor of population medicine at Harvard Medical School. At the time, Soumerai said that the investment was being made without any research evidence to support the claims that changes in delivery, outcomes, quality and cost savings could be achieved through EHR implementation.

Translated, to paraphrase the lyrics of John Prine's song, "Sam Stone," there's a hole in the health system's arm where all the money goes.]

Heroes and villains
Dvorak was an unapologetic and unabashed promoter of the value of health IT as a way to control costs, to improve quality and to increase better outcomes, what could be termed as the triple aim of health IT.

Dvorak welcomed the nomenclature of villain: “Today, I stand in front of you as one of the major villains,” he said proudly, describing the great antipathy that many doctors and nurses have for the enormous time suck that health IT has become on their jobs. [See link below to ConvergenceRI story, “New kind of pain scale: what doctors really think about EHRs”]

Dvorak said he had been with Epic for 30 years, “One of the things that has fascinated me in watching American public health policy in the last 10 years is how, in American health care, we have this huge process of heroes and villains – a unique process to manufacture crises and then try to monetize it.”

To help make his point, Dvorak asked the audience: “Does anyone remember when pain became the fifth [vital sign]?”

Dvorak described the manner in which drug companies had helped to create “the perception” that we had to do something new to reduce pain, to manage pain.

“I get it; pain is painful,” Dvorak said. But for him, the story was about how “traditional pain management got shut down in favor of commercializing this new [approach].”

He wondered out loud if depression would soon become the sixth vital sign, saying that the had lost a niece to depression last summer, she had committed suicide, and she had been taking what Dvorak described as a plethora of pills for anxiety and PTSD.

What struck him as odd as he attempted to sift through what had happened were the warnings given with each of the prescriptions – one that said if you feel any tendencies of suicide, please contact your doctor, and another that said, before stopping this medication, seek medical treatment, because stopping it is more likely to increase suicidal tendencies.

In Dvorak’s view, one of the benefits of platforms such as Epic will be able to “bring more data to bear on these situations, so we don’t have to wait as long.”

Opportunities and threats
To Dvorak, the biggest challenge for clinicians in the future [and no doubt to Epic] will be the way that companies such as Google and Amazon gain access to and then mine patient medical records.

“What will Google and Amazon try and sell your patient?” he asked, rhetorically. “How will Amazon try and influence your patient and their understanding about what they need from a health care perspective?”

Dvorak warned that the health care industry was on the precipice of that happening, where patients’ private medical records will no longer be under the stewardship of the provider and clinician [and perhaps the patient].

Dvorak claimed that Epic had always been a big believer in patients having access to their own data through patient portals. “But the next wave,” he said, “with Google, Amazon and Microsoft able [to gain access to a patient’s health record], it will [make for] an interesting, complicated future.”

Translated, with the explosive growth of wearable devices, health IT is being redefined and rewired, with numerous competitors to the hegemony of Epic. Dvorak spoke about some projects now underway at Epic in collaboration [with both Apple and FitBit, without revealing too many details.

[FitBit and Epic, for instance, sources have told ConvergenceRI, are part of a pilot project with Partners Healthcare in Boston to use wearable devices to tracks cardiac patients as part of an innovation lab project. A similar pilot is being explored at Care New England, according to sources.]

“There’s a revolution in consumer monitoring devices,” Dvorak continued. “The FitBits, the Apple watches. They are not all medical grade, but they are often medically useful. They have their places [in the health IT ecosystem].”

By putting a simple FitBit on folks who have undergone a knee replacement, Dvorak said, you can figure out who’s up and off the couch in one week. “For patients not getting off the couch, we’ll send a nurse into the home because we need to get them up and moving. These little devices are helping us to understand what is happening with patients not under direct supervision.”

To place in context the continuing evolution of digital medical devices, Dvorak brought up the prevalence of pregnancy tests today. “It wasn’t that long ago that rabbits had to die.”

Tracking unnecessary utilization
The holy grail of health IT has been the promise, never yet achieved, that it can reduce fraud, waste and unnecessary utilization, as a way to reduce health care spending.

Dvorak proselytized his continuing faith in the Epic platform to solve the puzzle of unnecessary utilization.

“We have studied 120 million ambulatory progress notes around the world,” Dvorak said. What we found, he continued, “is that in America, progress notes are four times longer than anywhere else in the world.”

Dvorak asked a number of rhetorical questions to bolster his arguments: Does it make physicians happy to write progress notes that are four times longer? Does it make physicians happy to use some other physicians’ progress notes that are four times longer than necessary?

Epic has installed in all of its systems what Dvorak described as a “flight data recorder” that captures the data, along with some 750 benchmarks that run the gamut from clinical outcomes to surgical measures. “What we’ve been able to do over the last five years to change the dynamic of how people think about automation,” he claimed.

The value, Dvorak continued, is that Epic can look across a community of health systems and be able to see which ones seem to do better and have better outcomes, related to process outcomes.

Using computer algorithms that can watch more and more data points, Dvorak said, “We can benefit today from machine learning to help us see the patterns before they are visible to the human eye. We benefit from millions upon millions [of data points] to check to see that things are normal.”

Another embedded technology that Epic is experimenting with is technology that listens in the exam room and records all the conversations of what is said. “Voice recognition technology can parse out [what is being said] by two or three people in an exam room talking,” he said.

A further exploration of digital technology is recording a video of what is going on in the exam room, using a special camera where the people are recorded as stick figures, according to Dvorak.

The high cost of living and dying
Another big future challenge, Dvorak said, was that the opportunities to make a positive difference in a person’s life through medicine are beginning to exceed what the average person can pay, in many cases exceeding what an average person makes in an entire lifetime.

As an example, Dvorak used the case of one of his grandparents, who died in the hospital, where the cost of his last week was significantly higher than the health care costs of all his grandparents for their entire lifetimes.

In the U.S., Dvorak said, “We’re always selling excess capacity; we’re always selling unnecessary care to a person.”

The future policy challenge for the American model of health care, he continued, is this: “We’ve lived for a long time under the premise that if we build it, they will come, that if we build the capacity and market it, the patients will come.”

The policy issue is how best to ration health care, which was a little more acute in the U.S. because of the lack of access and higher pricing than in other nations, according to Dvorak.

The human connection to healing
In the question-and-answer period that follow Dvorak’s talk, Dr. Elizabeth Toll, a pediatrician and internal medicine specialist at Lifespan, challenged some of Dvorak’s emphasis on data in medicine.

“Medicine is also a human undertaking,” she said, expressing her worries about the over-emphasis on data.

Many of the things that help patients – and what draws clinicians into the field of practicing medicine, Toll said, “is the need for human contact, the sense of being with another person and helping them feel better by the simple act of creating a relationship with them.”

Toll said she had bristled a bit when Dvorak talked about the way that new physicians were more adept at using technology and there would be faster rate of adoption once older clinicians retired.

“When we talk about phasing out the old people like me,” Toll continued, “there are some things we know about life. What it means when I tell a patient, I won’t tell anyone about this, this is private. Or, what it means to listen carefully enough [to patients] so that you don’t have to order [unnecessary] tests.”

Toll said the motivation why people become doctors and nurses was still about becoming part of the healing profession.

“I don’t see people coming into medicine and nursing are so much different than ever before. They are people who are drawn to help other people feel better,” she said.