Of the nearly 100 people I interviewed for my upcoming book, John Halmaka was one of the most fascinating. Halamka is CIO of Beth Israel Deaconess Medical Center and a national leader in health IT policy. He also runs a family farm, on which he raises ducks, alpacas and llamas. His penchant for black mock turtlenecks, along with his brilliance and quirkiness, raise inevitable comparisons to Steve Jobs. I interviewed him in Boston on August 12, 2014.
Our conversation was very wide ranging, but I was particularly struck by what Halamka had to say about federal privacy regulations and HIPAA, and their impact on his job as CIO. Let’s start with that.
Halamka: Not long ago, one of our physicians went into an Apple store and bought a laptop. He returned to his office, plugged it in, and synched his e-mail. He then left for a meeting. When he came back, the laptop was gone. We looked at the video footage and saw that a known felon had entered the building, grabbed the laptop, and fled. We found him, and he was arrested.
Now, what is the likelihood that this drug fiend stole the device because he had identity theft in mind? That would be zero. But the case has now exceeded $500,000 in legal fees, forensic work, and investigations. We are close to signing a settlement agreement where we basically say, “It wasn’t our fault but here’s a set of actions Beth Israel will put in place so that no doctor is ever allowed again to bring a device into our environment and download patient data to it.”
Continue reading “Black Turtlenecks, Data Fiends and Code. An Interview with John Halamka”
Filed Under: Tech, THCB
Tagged: Apple Store, Clinical Informatics, EMRs, HIPAA, John Halamka, Privacy
Jan 5, 2015
Karen DeSalvo started as the new National Coordinator for Healthcare Information Technology on January 13, 2014. After my brief discussion with her last week, I can already tell she’s a good listener, aware of the issues, and is passionate about using healthcare IT as a tool to improve population health.
She is a cheerleader for IT, not an informatics expert. She’ll rely on others to help with the IT details, and that’s appropriate.
What advice would I give her, given the current state of healthcare IT stakeholders?
1. Rethink the Certification Program - With a new National Coordinator, we have an opportunity to redesign certification. As I’ve written about previously some of the 2014 Certification test procedures have negatively impacted the healthcare IT industry by being overly prescriptive and by requiring functionality/workflows that are unlikely to be used in the real world.
One of the most negative aspects of 2014 certification is the concept of “certification only”. No actual clinical use or attestation is required but software must be engineered to incorporate standards/processes which are not yet mature. An example is the “transmit” portion of the view/download/transmit patient/family engagement requirements.
There is not yet an ecosystem for patients to ‘transmit’ using CCDA and Direct, yet vendors are required to implement complex functionality that few will use. Another example is the use of QRDA I and QRDA III for quality reporting.
CMS cannot yet receive such files but EHRs must send them in order to be certified. The result of this certification burden is a delay in 2014 certified product availability.
Continue reading “A Little Advice for Karen DeSalvo”
Filed Under: Tech, THCB
Tagged: CMS, HIPAA Omnibus Rule, HIT, ICD-10, John Halamka, Karen DeSalvo, MU Stage 2, ONC, The ACA
Jan 22, 2014
I’ve recently written about healthcare.gov and the lesson that going live too soon creates a very unpleasant memory.
As I work with healthcare leaders in Boston, in New England, and throughout the country, I’m seeing signs that well resourced medical centers will struggle with Meaningful Use stage 2 attestation, ICD-10 go live, HIPAA Omnibus Rule readiness, and Accountable Care Act implementation, all of which have 2013-2014 deadlines.
People are working hard. Priority setting is appropriate. Funding is available.
The problem is that the scope is too big and the timeline is too short.
What are the risks?
Continue reading “Fine Tuning the National Health IT Timeline”
Filed Under: Uncategorized
Tagged: Accountable Care Act, HIPAA Omnibus Rule, HIT, ICD-10, John Halamka, Meaningful Use Stage 2, National Health IT Timeline
Nov 20, 2013
I’ve written several posts about the frustrating aspects of Meaningful Use Stage 2 Certification. The Clinical Quality Measures (CQMs) are certainly one of problem spots, using standards that are not yet mature, and requiring computing of numerators and denominators that are not based on data collected as part of clinical care workflow.
There is a chasm between quality measurement expectations and EHR workflow realities causing pain to all the stakeholders – providers, government, and payers. Quality measures are often based on data that can only be gathered via manual chart abstraction or prompting clinicians for esoteric data elements by interrupting documentation.
How do we fix CQMs?
1. Realign quality measurement entity expectations by limiting calculations (call it the CQM developers palette) to data which are likely to exist in EHRs. Recently, Yale created a consensus document, identifying data elements that are consistently populated and of sufficient reliability to serve in measure computations. This is a good start.
2. Add data elements to the EHRs over time and ensure that structured data input fields use value sets from the Value Set Authority Center (VSAC) at NLM. The National Library of Medicine keeps a Meaningful Use data element catalog that is likely to expand in future stages of Meaningful Use.
Continue reading “Quality Measurement 2.0″
Filed Under: THCB
Tagged: HIT, John Halamka, Meaningful Use, Meaningful Use Stage 2, Quality measurement
Nov 6, 2013
Over the next few months, Jacob Reider will serve as the interim National Coordinator for Healthcare IT while the search continues for Farzad Mostashari’s permanent replacement.
What advice would I give to the next national coordinator?
David Blumenthal led ONC during a period of remarkable regulatory change and expanding budgets. He was the right person for the “regulatory era.”
Farzad Mostashari led ONC during a period of implementation when resources peaked, grants were spent, and the industry ran marathons every day to keep up with the pace of change. He was the right person for the “implementation era”
The next coordinator will preside over the “consolidate our gains” era. Grants largely run out in January 2014. Budgets are likely to shrink because of sequestration and the impact of fiscal pressures (when the Federal government starts operating again). Many regulatory deadlines converge in the next coordinator’s term.
The right person for this next phase must listen to stakeholder challenges, adjust timelines, polish existing regulations, ensure the combined burden of regulations from many agencies in HHS do not break the camel’s back, and keep Congress informed every step of the way. I did not include parting the Red Sea, so maybe there is a mere human who could do this.
What tools does the coordinator have in an era of shrinking budgets?
At present, Meaningful Use Stage 2, ICD-10, the Affordable Care Act, HIPAA Omnibus Rule, and numerous CMS imperatives have overlapping timelines, making it nearly impossible for provider organizations to maintain operations while complying with all the new requirements.
Can resources be expanded?
Continue reading “A Little Advice for the Next National Coordinator”
Filed Under: Tech, THCB
Tagged: CMS, Farzad Mostashari, HIPAA Omnibus Rule, HIT, ICD-10, John Halamka, MU Stage 2, ONC, The ACA
Oct 9, 2013
Now that Labor Day has come and gone, I’ve thought about the months ahead and the major challenges I’ll face.
1. Mergers and Acquisitions
Healthcare in the US is not a system of care, it’s a disconnected collection of hospitals, clinics, pharmacies, labs, and imaging centers. As the Affordable Care Act rolls out, many accountable care organizations are realizing that the only way to survive is to create “systemness” through mergers, acquisitions, and affiliations. The workflow to support systemness may require different IT approaches than we’ve used in the past. We’ve been successful to date by leaving existing applications in place and building bidirectional clinical sharing interfaces via ”magic button” viewing and state HIE summary exchange. Interfacing is great for many purposes. Integration is better for others, such as enterprise appointment scheduling and care management. Requirements for systemness have not yet been defined, but there could be significant future work ahead to replace existing systems with a single integrated application.
2. Regulatory uncertainty
Will ICD10 proceed on the October 1, 2014 timeline? All indications in Washington are that deadlines will not be changed. Yet, I’m concerned that payers, providers and government will not be ready to support the workflow changes required for successful ICD10 implementation. Will all aspects of the new HIPAA Omnibus rule be enforced including the “self pay” provision which restricts information flow to payers? Hospitals nationwide are not sure how to comply with the new requirements. Will Meaningful Use Stage 2 proceed on the current aggressive timeline? Products to support MU2 are still being certified yet hospitals are expected to begin attestation reporting periods as early as October 1. With Farzad Mostashari’s departure from ONC, the new national coordinator will have to address these challenging implementation questions against a backdrop of a Congress which wants to see the national HIT program move faster.
3. Meaningful Use Stage 2 challenges
Although attestation criteria are very clear (and achievable), certification is quite complex, especially for a small self development shop like mine. One of my colleagues at a healthcare institution in another state noted that 50 developers and 4 full analysts are hard at work at certification for their self built systems. I have 25 developers and a part time analyst available for the task. I’ve read every script and there are numerous areas in certification which go beyond the functionality needed for attestation. Many EHR vendors have described their certification burden to me. I am hopeful that ONC re-examines the certification process and does two things – removes those sections that add unnecessary complexity and makes certification clinically relevant by using scenarios that demonstrate a real world workflow supporting the functionality needed for attestation.
Continue reading “What Keeps Me Up At Night – 2013 Edition”
Filed Under: Tech, THCB
Tagged: BIDMC, EHR, HIPAA Omnibus Rule, HIT, ICD-10, John Halamka, Meaningful Use, The ACA
Sep 5, 2013
Last week I had the opportunity to test Google Glass.
It’s basically an Android smartphone (without the cellular transmitter) capable of running Android apps, built into a pair of glasses. The small prism “screen” displays video at half HD resolution. The sound features use bone conduction, so only the wearer can hear audio output. It has a motion sensitive accelerometer for gestural commands. It has a microphone to support voice commands. The right temple is a touch pad. It has WiFi and Bluetooth. Battery power lasts about a day per charge.
Of course, there have been parodies of the user experience but I believe that clinicians can successfully use Google Glass to improve quality, safety, and efficiency in a manner that is less bothersome to the patients than a clinician staring at a keyboard.
Here are few examples:
1. Meaningful Use Stage 2 for Hospitals – Electronic Medication Admission Records must include the use of “assistive technology” to ensure the right dose of the right medication is given via the right route to the right patient at the right time. Today, many hospitals unit dose bar code every medication – a painful process. Imagine instead that a nurse puts on a pair of glasses, walks in the room and wi-fi geolocation shows the nurse a picture of the patient in the room who should be receiving medications. Then, pictures of the medications will be shown one at a time. The temple touch user interface could be used to scroll through medication pictures and even indicate that they were administered.
2. Clinical documentation – All of us are trying hard to document the clinical encounter using templates, macros, voice recognition, natural language processing and clinical documentation improvement tools. However, our documentation models may misalign with the ways patients communicate and doctors conceptualize medical information per Ross Koppel’s excellent JAMIA article. Maybe the best clinical documentation is real time video of the patient encounter, captured from the vantage point of the clinician’s Google Glass. Every audio/visual cue that the clinician sees and hears will be faithfully recorded.
Continue reading “Five Potential Healthcare Applications for Google Glass”
Filed Under: Tech, THCB
Tagged: FutureMed, Google Glass, HIT, Hospitals, John Halamka
Jul 17, 2013
Recently I was asked if SaaS/Cloud computing is appropriate for small practice EHR hosting.
I responded: “SaaS in general is good. However, most SaaS is neither private nor secure. Current regulatory and compliance mandates require that you find a cloud hosting firm which will indemnify you against privacy breeches caused by security issues in the SaaS hosting facility. Also, SaaS is only as good as the internet connections of the client sites. We’ve had a great deal of experience with ‘last mile’ issues.”
Continue reading “Should Small to Medium-Sized Practices Use Cloud-Based EHR?”
Filed Under: Tech, THCB
Tagged: EHR, HIT, John Halamka, practice management, SaaS/Cloud Computing
Apr 5, 2013
Every day CIOs are inundated with buzzword-compliant products – BYOD, Cloud, Instant Messaging, Software as a Service, and Social Networking.
In yesterday’s blog post, I suggested that we are about to enter the “post EHR” era in which the management of data gathered via EHRs will become more important than the clinical-facing functions within EHRs.
Today, I’ll add that we do need to a better job gathering data inside EHRs while at the same time reducing the burden on individual clinicians.
I suggest that BYOD, Cloud, Instant Messaging, Software as a Service and Social Networking can be combined to create “Social Documentation” for Healthcare.
In previous blogs, I’ve developed the core concepts of improving the structured and unstructured documentation we create in ambulatory and inpatient environments.
I define “social documentation” as team authored care plans, annotated event descriptions (ranging from acknowledging a test result to writing about the patient’s treatment progress), and process documentation (orders, alerts/reminders) sufficient to support care coordination, compliance/regulatory requirements, and billing.
Continue reading ““Social Documentation” for Healthcare”
Filed Under: Tech, THCB
Tagged: Care management, EHR, HIE, John Halamka, post EHR, Social Documentation
Feb 13, 2013
Over the next few months, the majority of my time will be spent discussing topics such as care coordination, healthcare information exchange, care management, real time analytics, and population health. At BIDMC, we’ve already achieved 100% EHR adoption and 90% Meaningful Use attestation among our clinician community. Now that the foundation is laid, I believe our next body of work is to craft the technology and workflow solutions which will be hallmarks of the “post EHR” era.
What does this mean?
I’ve written previously about BIDMC’s Accountable Care Organization strategy, which can be summed up as ACO=HIE + analytics.
In a “post EHR” era we need to go beyond simple data capture and reporting, we need care management that ensures patients with specific diseases follow standardized guidelines and protocols, escalating deviations to the care team. That team will include PCPs, specialists, home care, long term care, and family members. The goal of a Care Management Medical Record (CMMR) will be to provide a dashboard that overlays hospital and professional data with a higher level of management.
How could this work?
Imagine that we define each patient’s healthcare status in terms of “properties”. Data elements might include activities of daily living, functional status, current care plans, care preferences, diagnostic test results, and therapies, populated from many sources of data including every EHR containing patient data, hospital discharge data, and consumer generated data from PHRs/home health devices.
That data will be used in conjunction with rules that generate alerts and reminders to care managers and other members of the care team (plus the patient). The result is a Care Management Medical Record system based on a foundation of EHRs that provides much more than any one EHR.
My challenge in 2013-2014 will be to build and buy components that turn multiple EHRs into a CMMR at the community level.
Continue reading “The “Post EHR” Era”
Filed Under: Tech, THCB
Tagged: ACOs, BIDMC, Care Management Medical Record, coordinated care, delivery innovation, EHR, John Halamka, Meaningful Use, post-EHR era
Feb 12, 2013