Meaningful Use

Digital DoctorFollowing the recession, the Obama administration sought shovel-ready projects.

One unlikely shovel wielding aggregate demand was health information technology. The Health Information Technology for Economic and Clinical Health (HITECH) Act passed in 2009 directed 5 % of the stimulus towards digitizing medical records.

Computerization of medical records doesn’t induce the images of public works as building freeways during the Great Depression does, but the freeway is a metaphor for exchange of information between electronic health records with the implication that such an exchange is a public good and so government intervention is justified.

Robert Wachter, voted the most influential physician by Modern Healthcare, sums the optimism and frustration with the electronic health record (EHR) in Digital Doctor – which stands to be a classic.

It was Bush Jr., not Obama, who started the digitization. Seeking bipartisanship after the war in Iraq, Bush was inspired by his closest ally, Tony Blair, who was wiring the National Health Service (NHS) – a $16 billion initiative which has since failed, spectacularly.

Bush founded the Office of National Coordinator of Health Information Technology (ONC) and appointed David Brailer – a physician, quant and entrepreneur – as head. Brailer wanted interoperability so that hospitals shared information. It is because of interoperability that we can use our debit cards in New York and Singapore. The market must agree on a common language, such as the TCP/ IP for the internet, to achieve interoperability.

Patients suffer when systems can’t talk. Were patients, not a third party, bearing the full costs of care – a free market – they might have forced hospital information systems to talk. Rightly or not, healthcare is not a free market and hospitals have little motivation in making cross-talking simpler.

Continue reading “Keep Calm and Interoperate On”

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.

Continue reading “Learning From Our Interoperability Failures”

Richard Gunderman goodLife is tough for physicians in solo and small group practice.  The federally mandated introduction this fall of ICD-10 requires physicians and their staffs to learn a new system of coding diseases.  “Meaningful Use,” another federal program, requires physicians to install and use electronic health records systems, which are complex and expensive.  And PQRS, the Physician Quality Reporting System, is beginning to penalize physicians for failing to report individual data for up to 110 quality measures, such as patient immunizations, each of which takes time to collect and record.

Of course, such requirements are not being imposed solely on solo and small-group physicians.  In many ways, they affect all physicians alike.  Yet the burdens of complying are disproportionately high for small groups, which cannot spread out the costs of purchasing equipment, hiring employees and consultants, and training personnel over so large a number of colleagues.  Hospitals and large medical groups can afford to hire full-time specialists to meet these challenges, but such approaches are not economically feasible for a group that consists of only a few physicians.

Such challenges are not just raining down –  they are pouring down on the heads of physicians.  Some physicians fear they smell a conspiracy to drive solo and small-group practitioners out of business.  And the problem is not just the money.  It’s also the time.  Many physicians already work long hours and simply cannot afford to shop for such systems, negotiate contracts, and enter data.  We personally know physicians who report spending two hours each evening completing records that they did not have time to attend to while they were seeing patients.

Continue reading “Will Independent Physicians Go Extinct?”

Optimized-roblambertsnew

I drank the kool-aid early.  We installed our first EHR in 1996 with me doing the lion’s share of pushing and pulling.  While I’d ultimately turn my back on this passion, I had a number of notable accomplishments before walking down my Damascus road.

  • Within a year of implementation, our practice became one of the top installations for our vendor.
  • Within 2 years I was elected to the board of our user group.
  • Within 4 years I was president.
  • In 2003, our practice was recognized by HIMSS as one of the top primary care installations of Electronic Records.
  • In subsequent years I lectured around the country (for HIMSS) extolling the benefits of EHR for both quality and efficiency of care.
  • As opposed to the experience of other physicians, our practice was not only successful in our implementation, we were in the top 10% in income for our specialty.
  • Our quality metrics were also routinely far above national norms.
  • In 2012, I was the physician representative for CDC public health grand rounds, discussing the upcoming EHR incentive program: Meaningful Use.
  • By 2013, we easily qualified for stage 1 of Meaningful Use, and I happily accepted the financial fruit of my labors.

But the final years were not, as I expected, a triumph. I became increasingly frustrated with the worsening of our EHR by the “features” needed to qualify us for MU1. I also chafed at the way most physicians were meeting this criteria: by abandoning patient-centered care and adopting a data-centered care model.  Patients were given useless handouts to summarize “care,” and the data requirement was satisfied.  Patient portals gave limited access to information were touted as “patient centered” care, while the product was left unused by most patients, but the data requirement was satisfied.

Continue reading “What Does Real Meaningful Use of an EHR Look Like?”

flying cadeuciiThe rush to implement patient portals to meet Meaningful Use Stage 2 deadlines has focused most attention on getting the technology up and running, and convincing patients and providers to move to shared communication online. Hospitals and health systems have implemented portals with the help of incentives from the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act,   and patients and providers have been migrating to them at a slow but steady pace.

I am one of the patients eager to see this move to transparency, and have been a user of my health system’s portal from the start. But I’m far from a happy customer and my experience leaves me scratching my head. Sure, I can get online without a problem, and I can read my results.

Recently, I read online that my results were “probably benign (not cancer)” and it would be important to follow up with retesting in six months. This news, delivered with no phone call or follow up from the hospital or my primary care provider, was disconcerting. The specter of cancer was anxiety producing, as it would be for many, especially with no clinical context for interpreting my test results.

I never received human follow up. When finally I reached someone at the hospital to set up an appointment for a retest, I asked about the portal and the message and was referred to the hospital IT Department. Hmmm…I wondered. What does this mean? Is this what patient engagement is all about? Continue reading “When Good Patient Engagement Goes Bad”

Fred's HeadThe US has spent several billion dollars on medical records, as part of the HITECH program. The goal of that spend was simple: portable medical records for patients. On our current path, we will have medical records, but without that magic word: “portable.” Ironically, the reason for this is identical to the root-cause of the problems with healthcare.gov

The root-cause of the initial failure of healthcare.gov was a lack of accountability and empowerment. There was no one person who was in charge of the operation, and those who were presumed to be in charge did not have the skill-set or political clout needed to make decisions about the project.

The result was the healthcare.gov train wreck. Thankfully, healthcare.gov was turned around.

That turn-around was the result of decisively fixing these exact issues.

Accountability restored, disaster averted.

You would think that the Obama administration and HHS would have learned the “accountability with empowerment” lesson well, if not for IT projects generally, then at least for projects involving Health IT.

Yet we are repeating this mistake with Meaningful Use. For those who are living in a cave with regards to healthcare reform, Meaningful Use is a set of standards designed to ensure that the money that the federal government spends on Electronic Healthcare Records (EHRs) for doctors results in clinically productive outcomes.

Continue reading “What Can Meaningful Use Learn From Healthcare.gov?”

Martin SamuelsI’m afraid that if we don’t drill down on our brand equity on the front end, we’ll have to model it out on the back end to align our incentives or pad our ask regarding the co-branding deliverables on the horizon.  As an FYI, this empowerment is going to require an elbow to elbow champion getting under the covers for a 360 of the eRoom to facilitate a paradigm shift in order to achieve buy-in among the stakeholders if we’re going to tip our toe into that water and get the low hanging fruit before our clients incentivize the burning platform with new metrics.  After all, you are the process owner who needs to reach out in the proper bandwidth to push back on the KOL’s or we’ll have to sunset your blue ribbon committee for not trimming the fat on the real-time escalation project.  We need to do more due diligence before we hitch our wagon to that indexed outcome measure, and let’s be careful how we message it and roll it out to the core constituency. 

We can model that projected gap, but we don’t want to get out ahead of our audience before sensitizing them to the moving target.  Let’s not drop the meat in the dirt but rather vet a pause point, collapse it up to a high level statement and assess the current state in order to connect the dots to achieve the ideal state and have you weigh in at the portal for service oriented architecture.

Continue reading “Meaningful Use Retreat Report”

flying cadeuciiNew Life for ACOs

CMS announces that 89 new organizations were selected to participate in the Medicare Shared Savings program, bringing the total number of participating ACOs to 424. The announcement comes on the heels of a recently released proposed rule that reflects an increased focus on primary care and improved incentives for participation. Were the pundits who predicted an early death for ACOs wrong?

Massachusetts Modifies Meaningful Use Mandate

The Massachusetts Board of Registration modifies a provision requiring providers to attest to Meaningful Use in order to retain their medical licenses. The final regulations establish multiple ways in which physicians can demonstrate proficiency using EHRs, including taking a three-hour continuing education class on EHR or registering with the state’s HIE.

Continue reading “HIT Newser: Massachusetts Modifies Meaningful Use Mandate”

flying cadeuciiAll of you Meaningful Use and Health IT junkies should read Data for Individual Health  Although long, it’s definitely worth a scan by everyone who cares about health tech. This is the third JASON-related report in a year out of ONC and it comes a month or so before the planned release of the first details of ONC’s announced 10yr plan. I think there’s a reason for that much of it introduced by ONC’s earlier post.

There are three key points I would highlight:

First, and most important, this report suggests that HIPAA Covered Entities (mostly hospitals, doctors and their EHRs) are no longer the center. The future, labeled as the Learning Health System, now makes mobile and patient-centered technology equally important as part of the architecture and talks about interoperability with them rather than “health information exchange” among HIPAA CE’s and their Meaningful Use mandates.

Second, this JASON report, unlike the previous two, does not talk about Meaningful Use any more. That money is spent. A lot of orgs are lobbying against any more MU mandates and, although I’m pretty sure there will be a Stage 3, it could be toothless or very much delayed.

Third, Direct, the original Blue Button, Blue Button Plus Push, and CCDA files are pretty much history.  Although the JASONs don’t say it as plainly as I am, document-based interoperability has failed and we’re moving on to Application Programming Interfaces (APIs) that don’t use CCDA or any of the stuff mandated by MU 1 and 2. Blue Button Plus Pull and FHIR, both with a modern industry-standard OAuth security scheme, are the future for all sorts of good reasons which you need to read the JASON reports with some care to understand. It’s all there.

Continue reading “ONC Signals a Shift From Documents to Interfaces”

Bob WachterThe policy known as Meaningful Use was designed to ensure that clinicians and hospitals actually used the computers they bought with the help of government subsidies. In the last few months, though, it has become clear that the policy is failing. Moreover, the federal office that administers it is losing leaders faster than American Idol is losing viewers.

Because I believe that Meaningful Use is now doing more harm than good, I see these events as positive developments. To understand why, we need to review the history of federal health IT policy, including the historical accident that gave birth to Meaningful Use.

I date the start of the modern era of health IT to January 20, 2004 when, in his State of the Union address, President George W. Bush made it a national goal to wire the U.S. healthcare system. A few months later, he created the Office of the National Coordinator for Health Information Technology (ONC), and gave it a budget of $42 million to get the ball rolling.

Continue reading “RIP Meaningful Use Born 2009 – Died 2014???”

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