Why Privacy Must Die


Art Caplan 2I just finished my required training about the protection of patient privacy.  Every employee of New York University Langone Medical Center must take an online course and pass an admittedly not very difficult quiz as to our duties regarding patient privacy.  All other American medical centers have the same requirement.  I passed my quiz.  But, despite my certification, I think the effort to protect privacy in health care is a lost cause.  It is time to admit that privacy in health care is dead.  Confessing that privacy has passed on, while reporting a death is often very sad, has many benefits.  Not only is the continued effort to ensure privacy protection futile, it costs a lot of time and money, undermines trust in the health care system, causes confusion that interferes with family needs and, most importantly, likely gets in the way of giving greater benefit to the sick, soon to be sick and those who are not yet born but who will also become ill.

Much of the required teaching in the United States about privacy involves learning a bit about the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  The Federal Office for Civil Rights of the Department of Health and Human Services enforces the law that protects the privacy of health information that could identify a particular patient such as addresses, phone numbers, email address and medical record numbers.  I know from my training that hospitals and health care institutions must report any breach of information going to someone not providing care to a patient or paying for that care. 

Whether They Like It Or Not, The GOP Must Repair Obamacare



It’s very possible that the pejorative “Obamacare” could become the even more pejorative “Trumpcare” in a very short period of time. That is because Trump’s and the GOP’s promise to repeal Obamacare — the Affordable Care Act (ACA) — has already hit a snag called reality.

Reports are now circulating that the much-promised repeal of the health care law (60 plus House and Senate votes since 2010) won’t take effect until at least 2019, after the mid-term elections. The excuse is that it’ll take that long to figure out an alternative and get it into place. But congressional calendars and political expedience have nothing to do with the health care market. And without action early in 2017, the health insurance exchanges could collapse in 2018 or sooner — leaving millions without insurance, millions more without protections from pre-existing conditions, and possibly millions more cursing Trumpcare. The only constructive solution is to repair the ACA before, ironically, repealing it and then replacing it with a brand new, untested experiment in 2019.

Making the Physician-Patient Relationship Great Again


21st Century Cures is now law. Aside from its touted research and mental health provisions, it’s the most significant health information technology regulation since HITECH, now 8 years ago. A decent summary of the health IT provisions of the bill by John Halamka concludes with “That is just not realistic.” He’s almost certainly right to the extent your perspective is the hospital-centered mega-EHR model. You can’t get there from here.

Halamka and others who think that consolidated institutions will drive interoperability are in denial of the gap between financial integration and clinical integration. This recent post by Kip Sullivan describes some of the wishful thinking. But there’s another reason why HITECH’s institutional EHRs cannot get us to the Triple Aim, and it’s mostly about liability.

Halamka ignored one of the items in 21st Century Cures that could lead to clinical integration around a patient: a longitudinal health record. Section 4006 on page 149 includes:

“(1) IN GENERAL.—The Secretary shall use existing authorities to encourage partnerships between health information exchange organizations and networks and health care providers, health plans, and other appropriate entities with the goal of offering patients access to their electronic health information in a single, longitudinal format that is easy to understand, secure, and may be updated automatically.”

Useful longitudinal health records require curation and, almost by definition, the curators are not going to be affiliated with any single hospital or other institution operating a traditional EHR. Allowing licensed physicians, family caregivers, and the patient themselves to edit an institutional EHR is risky to the point of impossible. That’s why the current initiatives to introduce modern APIs into EHRs like SMART and Sync for Science are read-only.

The HIT Emperor Has Never Had Any Clothes


Over the last several months, I have worked to make the following the official policy of the Massachusetts Medical Society:

That the MMS will advocate to our State and Federal Representatives to end all legal constraints and financial inducements arising from the use or non-use of Office of National Coordinator (ONC) Certified EHR Technology.

That the MMS will encourage our Massachusetts Federal Legislators to introduce legislation to end the ONC’s EHR certification program, and will ask the President of the United States to immediately request that such legislation be introduced.

While the MMS’s Committee on Information Technology voted unanimously to support the above proposal, the MMS rejected the above and choose instead to make the following official MMS policy:

That the MMS will work with appropriate government entities to foster EHR innovation, affordability, and functionality by modifying the certification process for EHRs to improve patient care.

Without a doubt, ONC’s EHR certification program has stifled innovation in EHRs in particular and in health information technology (HIT) in general. In addition, the data accumulated to date has shown these ONC’s Certified EHRs have failed to have a meaningful impact on either the cost or quality of healthcare.

The 6 December 2016 issue of Annals of Internal Medicine has an article which shows that for every hour a physician is involved with direct patient care results in an additional 2 hours of EHR work (in the office/clinic) and then more EHR work from home. No wonder MDs are so dissatisfied with the practice of medicine. The accompanying editorial (Ann Intern Med. 2016;165:818-819) concludes “Now is the time to go beyond complaining about EHRs and other practice hassles and to make needed changes to the health care system ”

A Different Kind of Meaningful Use Penalty


Our clinic is worried about qualifying for this year’s Meaningful Use incentive payments. We have this hastily purchased EMR that was supposed to make life easier and quality better for all of us. The EMR vendor got paid a long time ago but we are still dealing with the administrative burdens imposed by our new system.

By attesting that we can use this thing reasonably properly, we can receive some Government incentive monies, which even under the best of circumstances don’t even begin to make up for all the extra expenses and productivity losses we have incurred through going digital.

What we are up against is a product that doesn’t do, or doesn’t easily do, what we were told it could.

Science in the Age of Trump



As Donald Trump seeks to build his administration, he will likely struggle with creating a science infrastructure, given his estrangement from the nation’s scientific community.

The distance between Trump and scientists seems to reflect mutual disdain. Trump famously trusts his gut over more data-driven methods. Trump’s success, against most expectations, can be read as a triumph of instinct over science, or at least to reveal the perils of data-driven overconfidence. Trump’s apparent intention to appoint a climate-change skeptic to lead the environmental protection agency suggests to many a disregard for the vast weight of scientific data here, while his comments about vaccinations during one of the Republican debates were charitably described by Steven Salzberg as “wildly inaccurate” and “thoroughly discredited.”

For their part, most scientists take a very dim view of Trump: Science prides itself on being inclusive, international, objective and collaborative–not generally the first adjectives used to describe Trump. (Whether science in practice lives up to these ideals is another question.) Add to this Trump-specific distaste the left-leaning bias of universities (well documented by centrist academics like Jon Haidt, among others–see here and references therein), and the result is a community that seems solidly united against the President-elect. (That said, I’d note that I’ve met more than a few political independents within academia who chafe at current norms.)

What Does the Recent Election Mean For Predictive Analytics In Healthcare?


The outcome of the recent election caught many people, and many forecasters, by surprise. How could their predictions have missed the mark so significantly? Granted, there were a number of people who predicted the outcome more accurately, but many of those who used data models to analyze the likely outcome are left now with head-scratching and postmortem analysis in order to improve their methods.

In their book Superforecasting, The Art and Science of Prediction, authors Philip Telock and Dan Gardner describe a subset of people who, on average, are significantly more accurate in their ability to predict upcoming events. “What makes them so good is less what they are than what they do—the hard work of research, the careful thought and self-criticism, the gathering and synthesizing of other perspectives, the granular judgments and relentless updating.”

What does this mean for healthcare? I’m not talking about the impact of the new presidency on health policy and healthcare delivery (that’s another discussion) – I’m talking about whether predictive analytics is really all that accurate in the first place. Where does it fail?

One Regulation Could Eliminate a Dozen Others


President-Elect Trump recently announced: “for every one new regulation, two old regulations must be eliminated.” Regulatory capture, the topic of a recent THCB post by Nortin Hadler, has enabled many regulations based on HITECH that restrict competition by allowing information blocking. Many other regulations around quality measures, documentation, decision support, contract transparency, and kickback safe harbors are now needed to counteract EHR vendor consolidation through regulatory capture.

One regulation designed to establish a patient-controlled interface (a patient-controlled API) to health records will enable competition for all aspects of the institutional EHR by decentralizing access to the patient information. The impact on health reform, ACA reform, and medical research would be immense.

So what does Trump mean for new health tech?


Matthew-Holt-colorI’m a pundit who like everyone else was surprised by Trump’s victory in the (profoundly undemocratic and hopefully-to-be-abolished-soon) electoral college, and everything I say here is prefaced by the fact that there was very little discussion of healthcare specifics by Trump. So there’s no certainty about what will happen–to state the obvious about his administration!

What we do know is that Trump said he’d repeal & replace the ACA and the House has voted to repeal it many times (but the Senate has only once & Obama has always vetoed that repeal). A full and formal repeal requires 60 votes in the Senate which it won’t get with the Democrats holding 48. Note that the Democrats needed 60 votes to to forestall a Republican filibuster in order to pass the ACA in 2010. That 60 vote total is a very rare state of events which existed for only only one year–from Jan 2009 until Scott Brown won Ted Kennedy’s old seat in Jan 2010 and one we likely won’t see again for many years.

But this doesn’t does not mean things will continue as usual for two reasons. Congress can change the budget with the Republican 52 seat Senate majority, and the Administration can change regulations and stop enforcing them. So we have to assume that the new Administration and its allies(?) on the Hill will roll back the expansion of Medicaid which was responsible for most of the reduction in the uninsured (even if it didn’t happen in every state). They’ll also reduce or eliminate the subsidies which enable about 10m people to buy insurance using the exchanges. Both of those were in the repeal bill Obama vetoed, although in the bill the process was delayed for 2 years.

This of course may not happen or may be replaced by something equivalent because many of the people who voted for Trump (the rural, white, lower-income voters) fall into the category of those helped by the law, and in a few of his remarks he’s also said that he’ll be taking care of them. Even this week Senator Wicker (R-Mississippi) said that they weren’t going to take away 20 million people’s insurance. In Kentucky which went from a Democratic to Republican governor 2 years ago, the new administration ended their local exchange (from 2017), but in fact not much consequential happened as people were sent to the Federal exchange. If there are changes to the exchanges and the individual mandate or they’re both abolished, there’ll be lots of commotion but it won’t be completely system changing.

My day job at Health 2.0 involves running a conference and innovation program based on a community of companies using SMAC technologies to change health care services and delivery–either by starting new types of health care services or selling those technologies to the current incumbents. So I’m acutely interested in what happens next, albeit somewhat biased about my preferences!

Overall I think that (unlike many other areas of American life) health care technology won’t be that greatly affected. 

An Early Prognosis: What Will Become of Healthcare IT in the Age of Trump?


In the United States, it’s the Day After. The future of American policy – from immigration to foreign trade to national defense – is full of kinetic uncertainty. One thing is certain: that Donald J. Trump – who has brought something very different from palpable policy proposals to the American electorate – is President Elect of the United States.

There is no shortage of morning-after polemic: some are crying, some are celebrating, and others still are sleeping off the night. Whatever one’s political belief, our industry is perhaps at the center of the new sea of trumpian uncertainty. Indeed, the future of healthcare in the United States, and particularly the role of technology in healthcare, is neither bright nor grim.  Unlike last night, it’s too early to call.

What we know about Trump and healthcare is both frustratingly limited but also widely telling. Trump has summarized his post-Obamacare vision as a system that boasts “lots of plans” that will function amorphously across state lines, toppling a partly imagined barrier against competition among plans in different states. We know he views the Affordable Care Act as a “disaster” and, like other drivers of federal spending, sees dealing with corruption, overspending, and “bad deals” at the core of the still-unknown solution to healthcare’s many woes.