Tech

Tech

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flying cadeuciiInteroperability in health care is all the rage now. After publishing a ten year interoperability plan, which according to the Federal Trade Commission (FTC) is well positioned to protect us from wanton market competition and heretic innovations, the Office of the National Coordinator for Health Information Technology (ONC) published the obligatory J’accuse report on information blocking, chockfull of vague anecdotal innuendos and not much else. Nowadays, every health care conversation with every expert, every representative, every lobbyist and every stakeholder, is bound to turn to the lamentable lack of interoperability, which is single handedly responsible for killing people, escalating costs of care, physician burnout, poverty, inequality, disparities, and whatever else seems inadequate in our Babylonian health care system.

When you ask the people genuinely upset at this utter lack of interoperability, what exactly they feel is lacking, the answer is invariably that EHRs should be able to talk to each other, and there is no excuse in this 21st iCentury for such massive failure in communications. The whole thing needs to be rebooted, it seems. After pouring tens of billions of dollars into building the infrastructure for interoperability, we are discovering to our dismay that those pesky EHRs are basically antisocial and are totally incapable or unwilling to engage in interoperability. The suggested solutions range from beating the EHRs into submission to just throwing the whole lackluster lot out and starting fresh to the tune of hundreds of billions of dollars more. When it comes to sacred interoperability, money is not an object. It’s about saving lives.

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The secure, appropriate, and efficient sharing of electronic health information is the foundation of an interoperable learning health system—one that uses information and technology to deliver better care, spend health dollars more wisely, and advance the health of everyone.

Today we delivered a new Report to Congress on Health Information Blocking that examines allegations that some health care providers and health IT developers are engaging in “information blocking”—a practice that frustrates this national information sharing goal.

Health information blocking occurs when persons or entities knowingly and unreasonably interfere with the exchange or use of electronic health information. Our report examines the known extent of information blocking, provides criteria for identifying and distinguishing it from other barriers to interoperability, and describes steps the federal government and the private sector can take to deter this conduct.

This report is important and comes at a crucial time in the evolution of our nation’s health IT infrastructure. We recently released the Federal Health IT Strategic Plan 2015 – 2020 and the Draft Shared Nationwide Interoperability Roadmap. These documents describe challenges to achieving an interoperable learning health system and chart a course towards unlocking electronic health information so that it flows where and when it matters most for individual consumers, health care providers, and the public health community.

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Screen Shot 2015-04-06 at 7.20.19 PMNiam Yarhagi’s  THCB piece, Congress Can’t Solve the EHR Interoperability Problem (March 21, 2015) raises excellent points with which I mainly agree.  So why write a responding blog?  Because I don’t agree with his solution.

To review:  Dr. Yarhagi discusses a draft congressional bill that calls for the creation of a “Charter Organization” that “shall consist of one member from each of the standard development organizations accredited by the American National Standards Institute and representatives that include healthcare providers, EHR vendors, and health insurers.”

Four agreements:   I agree with Dr. Yarhagi’s conclusion that the proposed charter organization will not succeed; I agree with his prediction that it won’t be able to develop useful interoperability measures (hint: these are the same vendors that have refused to cooperate for the past 30 years); I agree that the ONC or CMS will not decertify an EHR vendor that has over 50% of all American patients and providers; and I agree that there are some medical providers who intentionally refuse to share patient information (because they think it gives them a competitive advantage over their local rivals).

One disagreement:  But I disagree strongly with Dr. Yarhagi’s faith in the market to ensure that healthcare information technology (HIT) vendors will be obliged to “develop sustainable revenue stream through reasonable exchange fees negotiated with the medical providers.”  That is, he asserts that if there were a real market without federal subsidies and requirements that all healthcare providers buy the HIT,  then providers and the HIT vendors would agree on reasonable fees for exchanging patient records.

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Ryan BecklandThe growth in business cases for new models of healthcare delivery and integration of digital health technology is reaching the point of convergence — creating powerful synergies where there was once only data silos and skepticism.

We have not quite achieved this synergy yet, but opportunities emerging in 2015 will move the industry much closer to the long-awaited initiatives in connected, value-based care.

Individuals are constantly hyper-connected to a variety of technology networks and devices. Wearables will continue to enter the market, but their features and focus will go well beyond fitness. Even the devices entering the market now are more sophisticated than ever before. Some are now equipped with tools like muscle activity tracking, EEG, breath monitoring, and UV light measurement.

It will be fascinating to watch how consumer electronics, wearables, and clinical devices continue to merge and take new forms. Some particularly interesting examples will be in the categories of digital tattoos, implantable devices, and smart lenses.

As the adoption of wearables continues to grow, we will continue to see more value placed on accessing digital health data by healthcare and wellness organizations. This will be especially important as healthcare shifts towards value-based models of care. The need to gain access to the actionable data on connected devices will only grow as innovation creates more complex technologies in the market.

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flying cadeuciiWhile the electronic medical record (EMR) has advantages, it also has introduced liability risks. EMRs can lead to lawsuits or result in a weak defense by casting the physician in an unfavorable light.

EMRs can increase malpractice risk in documentation of clinical findings—copying and pasting previously entered information can perpetuate any prior mistakes or fail to document a changing clinical situation.1 In a study by The Doctors Company of 97 EMR-related closed claims from 2007 to 2014, 13 percent of cases involved prepopulating/copy-and-paste as a contributing factor.2 Copy-and-paste is a necessary evil to save time during documentation of daily notes, but whatever is pasted must also be edited to reflect the current situation. Too often the note makes reference to something that happened “yesterday.”

Checkboxes, particularly those that prepopulate, can be a physician’s nemesis. EMRs have been presented in court that show, through checkboxes, daily breast exams on comatose patients in the ICU, detailed daily neurological exams done by cardiologists, and a complete review of systems done by multiple treating physicians on comatose patients. Questioning in court as to how long it takes to do a review of systems and a physical examination, the patient load of the physician for that day, and how many hours the physician was at work cast doubt on the truthfulness of the testifying physician. A time analysis showed there was no way the physician could have accomplished all that was charted that day, leading to the loss of credibility of that physician in court.

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Mark Cuban has been actively commenting in Saurabh Jha’s THCB post about him. We thought this comment was worthy of being a standalone post (and he agreed)–Matthew Holt

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The tech sector will leave people better off at a lower cost. Moore’s law will have its day. But we are 5 years off from minimal impact. 10 years off from Marginal Impact.

In 20 years we will all look back and think 2015 was a barbaric year of discovery.

To give perspective. We pioneered the Streaming Industry TWENTY YEARS AGO. And now we are finally seeing streaming becoming mainstream as a technology but it still cant scale to handle mega live events.

HealthTech will continue to move forward quickly with lots of small wins. It will slow down when there is an inevitable recession in the next 20 years, then jump again afterwards.

In 30 years our kids/grandkids will ask if its true that there were drugstores where we all bought the same medications , no personalization at all, and there were warnings that the buyer may be the one unlucky schmuck that dies from what used to be called over the counter medication.

We will have to admit that while unfortunate it was true. Which is why “one dose fits all ” medications were outlawed in 2040 :)

By then hopefully we will have a far better grasp on this math equation we call our bodies.

Of course it will be long before then that we make decisions based on optimizing health rather than trying to reduce risk.

The biggest challenge will be training health care professionals.

Medicine today seems to be in that 1980s phase that tech went through where no one got fired for hiring IBM. So IBM got lots of business because it was the safe choice rather than the best choice.

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thcbEpic Systems, the market leader in electronic health record software (EHR), recently made a quiet but potentially transformative announcement that may finally shake the healthcare industry out of its technological doldrums.

Epic said it is prepared to support the creation of a more open interoperability platform for integration with other diversified healthcare applications. This will attract substantial investment to create software that operates, hopefully seamlessly, within the Epic EHR infrastructure.  Expect Epic’s competitors to follow suit, eventually opening up the marketplace of installed EHRs to third-party software developers and the efficiencies of modern, post-EHR technology ecosystem.

Epic’s critics have often denounced the company for selling a mostly closed technology, dampening hopes for the creation of an ecosystem of best-of-breed applications that work together with the EHR to automate much of the care delivery infrastructure beyond patient intake and billing.  The value of such an infrastructure is extremely compelling and so the company is under enormous pressure from its customers to become more open.

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Joseph KvedarCriteria for Stage 3 of meaningful use of EHRs were released recently and there is lots of controversy, as would have been predicted. One set of recommendations that is raising eyebrows is around patient engagement.

The recommendations include three measures of engagement, and providers would have to report on all three of them, but successfully meet thresholds on two.

Following on the Stage 2 measure of getting patients to view, download, and transmit their personal health data, the Office of the National Coordinator (ONC) has proposed an increase from five to 25 percent.

The second measure requires that more than 35 percent of all patients seen by the provider or discharged from the hospital receive a secure message using the electronic health record’s (EHR) electronic messaging function or in response to a secure message sent by the patient (or the patient’s authorized representative).

The third measure calls for more than 15 percent of patients to contribute patient-generated health data or data from a non-clinical setting, to the EHR.

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flying cadeuciiCurrently, when healthcare data moves in this country it does it using fax machines and patient sneaker-nets. Automated digital interoperability is still in its earliest stages, mostly it has a history of being actively resisted by both the EHR vendors and large healthcare providers. We, as an industry, should be doing better, and our failure to do so is felt everyday by patients across the country.

The ONC-defined difference between EHRs and EMRs is that EHRs are interoperable. Yet, as I have said before, we have spent almost a billions of dollars and generally gotten EMRs instead of EHRs.

Comments were due Apr 3 for the ONC Interoperability Roadmap for 2015-2020. This was specifically separated out from the overall ONC Health IT Strategic Plan for which comments have closed.

Both of these plans ignore the lessons in execution from the previous strategic plan for health IT from ONC. The current Interoperability Roadmap mentions the “NwHIN” (Nationwide Health Information Network) for instance, and only covers what it accomplished, which are mostly policy successes like the DURSA (Data Use and Reciprocal Support Agreement). NwHIN was supposed to be a network of networks that connected every provider in the country… why hasn’t that happened?

ONC has forgotten what the actual ambition was in 2010. It was not to create cool policy documents. The plan 5 years ago was to have the “interoperability problem” solved in 5 years. The plan 5 years before that was probably to solve the problem in 5 years. Apparently, our policy makers look at interoperability and say “wow this is a big problem, we need at least 5 years to solve it”. Without any sense of ironic awareness that this is what they have been saying for decades, even before Kolodner was the ONC.

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Martin SamuelsThis week I attended an all day “training” session in a new medical record system.  I thought it was interesting that the experience was called “training,” which prompted me to remind myself of a few useful definitions.

Education, from the Latin root meaning a drawing forth, implies not so much the communication of knowledge as the discipline of the intellect; an intra-cerebral process aimed in large part at creating principles upon which new knowledge may be elaborated.  Instruction is that part of education that furnishes the mind with knowledge.  Teaching is often applied to practice as in “teaching a dog to do tricks.”

Training is an element of education in which the chief characteristic is exercise or practice for the purpose of imparting facility, as in “training for the marathon.” Breeding relates to manners and outward conduct as in “standing when elders enter a room is a sign of good breeding.” Regimentation is the prescription of a particular way of life or thinking usually involving the imposition of discipline. The term, arising from military regiment, is related to the medical usage of regimen, as in “the patient keeps his prescription medications in separate compartments of a plastic container in order to accurately adhere to his regimen.”  Propaganda is the systematic propagation of a doctrine, cause or information reflecting the views and interests of those advocating such a doctrine or cause, as in “ACCME is propagating the view that elaborate re-certification maneuvers will improve the lives of patients.”

A cheerful instructor started the session by asking each of us to introduce ourselves and reveal a “secret guilty pleasure.”  Mine is to create elaborate cocktails.  If only I had had one of my famous Marty’s Beerjitos with me the whole experience could have been much more pleasant.  In addition to the instructor, there were several “super-users” in the room to facilitate the process.  It was immediately obvious to me that the super-users hovered behind my chair. These friendly young people had correctly identified me a “super-loser.”  Had I been litigious I would have reported the experience to our ombudsperson as blatant ageism.

But, alas, they were correct.  I was hopeless.  Besides, I don’t believe in ombudspeople.  I believe one should speak for oneself.