Kalla: Have patience with electronic health records

Madison, Wis. - Ravi Kalla is more than the CEO of a custom software developer. As an executive with offices in Madison and India, he is pretty well plugged in to the happenings of international software, and as a member of Gov. Jim Doyle's eHealth Care Quality and Patient Safety Board, he's looking at the implementation of electronic health records.

For those hoping that a full EHR implementation is just a couple of years away, he has some deflating news: we may still be at least 10 to 15 years away from a full, and fully functional, implementation across multiple settings, including where it's needed most - emergency rooms.

Freeing physicians from handwritten tyranny, he noted, has proven to be a daunting task, especially if paper is replaced by something even more dysfunctional. It's not a simple process to integrate patient medical information, securely and seamlessly, across multiple sites of care, but that is what will have to happen before healthcare professionals and consumers see the full value of EHRs.

In fact, Kalla believes we may see personalized medical treatments, what he called "DNA medicine," before the obstacles to EHRs are overcome. Thanks in part to the cracking the human genome, researchers have found that certain drugs are more effective in people with certain biological attributes.

Slow adoption Kalla, the chief executive of Symphony Corp., noted that only nine percent of the 1- to-4 physician practices and only 15 percent of outpatient facilities have adopted EHR in the five years since the American Institute of Medicine released its landmark study on medical errors. Change is coming, he said, but it will be very gradual because there are few incentives in place for physicians.

"No one can answer the question, "How will physicians benefit from a system change?" he stated. "And that's because most of the cost savings from patient-centric care will come from the provider side."

Before that happens, the culture of medicine has to be changed because physicians view EHRs as a threat to their autonomy. "You need systematic, cultural pathways to make providers do the right things," he noted. "Providers have no incentive to measure quality."

Impetus for change, however slow, could come from the competitive pressure of keeping up with the Jones, and it could be the result of incentives provided by the government sector. Kalla cited pay-for-performance Medicare pilot programs that incent improvements in general care and chronic disease management.

But until there are more incentives for stakeholders, the change will be incremental, in part because doctors aren't the only speed bump. There are interoperability issues between systems, the need to develop a common vocabulary of medical terms, and perhaps other cultural barriers that have yet to emerge.

eHealth

Wisconsin is attempting to be on the vanguard of that change, and perhaps pick up the pace. Earlier this year, Doyle appointed Kalla to the e-Health Care Quality and Patient Safety Board, which has been charged with developing a strategic plan for statewide adoption and exchange of EHRs in five years.

The effort is in the beginning stages, and initial victories would be to implement some kind of electronic system for human resources, order entry, prescriptions, and the exchange of radiological images.

The next debate will be centered on how to share data nationwide. One school of thought is to build a centralized system for data aggregation, but Kalla views that as a "hacker's paradise" because there would be a large number of entities with access to the data. He supports, and is working to develop, a federated model that accommodates only peer-to-peer access and, in his view, is more likely to address Health Insurance Portability and Accountability Act guidelines.

"The technology is there, all the encryptions," he said, "but technology doesn't tell you how to meet security and privacy requirements."

A recent partnership established between Symphony and the Michigan-based CareEvolution seeks to implement a novel clinical information-sharing model in the region within a year. Kalla believes this federated model, which uses a peer-to-peer record locator service and a double-blind data protection mechanism, will avoid the high costs and hacker security pitfalls of both the centralized and decentralized models of information depositories.

Vendor neutral interoperability solutions will be important, he said, because two parties can have the same solution and achieve a seamless transition, but a third party could gum up the works with incompatible software, rendering interoperability impossible.

Given these barriers, Kalla predicted the full adoption of EHRs will come after the first example of genetic-based medical care hits the market. Kalla believes existing management systems could quickly be made obsolete by this trend, which uses personal genetic profiles to identify a patient's predisposition toward various diseases, and to develop disease-management programs.

Cracking the human genome has made personalized medicine possible, and Kalla says this approach has much more momentum than adoption of EHRs. Healthcare providers would be wise to incorporate this possibility in their long-range planning, he advised. "I don't think people are aware of how quickly that change is coming," he said.

Hear a Symphony

The privately run Symphony Corp. was founded in 1997, and now has more than 200 employees globally, including 100 in Madison. Traditionally, it has offered healthcare providers with financial and operational performance tools in areas ranging from payroll to clinical information systems to predictive modeling, and combined that with "matured" implementation methods for it own custom products, and those produced by the likes of Epic Systems and McKesson.

Matured implementation refers to a process where new software is thoroughly tested in the work environment to ensure better predictability for clients, and it is Kalla's intention that Symphony become known for its implementation services.

The company is headquartered in Fitchburg, and has offices in the nation's capital because of its work with the Center for Medicare Services, and in Kalla's native India. It already has extensive relationships with the world's leading companies, including five of the Fortune Global 100, and a number of state government agencies in Wisconsin.

And now Symphony is gradually branching out from its core business of customized software development. It is in hospital settings writing interfaces so that systems can talk to one another, and it has acquired Strategic Health Corp., a cost containment and disease management consulting firm.

"We're completing the circle," Kalla said. "We are more of a one-stop shop."

That shop now is located in the Fitchburg Technology Campus, where Symphony moved in January to take advantage of high-bandwidth connections and video conferencing capabilities, which enable contact with employees at client sites in the United States, the Great Britain, and Spain.

It also precludes some travel in this age of record high energy prices, a trend that Kalla believes will increase the use of video conferencing. "We are trying to avoid travel as much as possible," Kalla stated. "I can't put my finger on the savings, but we think four times before making that [next] trip."

Related stories

• Interview: Dr. William Yasnoff on health records, part 1

• Interview: Dr. William Yasnoff on health records, part 2

• Symphony Corp. moving into Fitchburg Technology Campus

• Symphony Data merges with Atlanta outsourcing company