Matthew Holt

Meaningful meaning? (with UPDATE)

6a00d8341c909d53ef0105371fd47b970b-320wiThe first draft of “meaningful use” came out early yesterday, and I was struck by two things. First, probably influenced by the NCVHS recommendations and the Consumer Partnership for e-Health (See Update), the work-group included a lot of consumer-facing aspects in the concept of meaningful use. Here’s the full draft. Comments are being accepted now (but hurry as they’re going to come back with version two in a month, you have 9 days!).

But in terms of getting consumer activities into the 2011 definition the “Objectives” suggest that meaningful use includes:

  • Providing patients with electronic copy of or electronic access to clinical information (labs, medication list, allergies, medical “problem” list)
  • Providing access to patient specific educational sources
  • Providing clinical summaries for patients at each encounter

Metrics would include the percentage of patients with

  • electronic access to personal health information
  • access to patient-specific educational resources
  • and percentage of encounters where clinical summary provided

The objectives and measurements get even more comprehensive by 2013 and 2015 including adding patient-physician communication, and including data from electronic devices in the home, and more personalized self-management tools. So overall this is, compared to where the standard EHR industry has been, fairly ambitious. Think back to two or four years ago and see exactly how few of those were in place then compared to now, and you’ll see how fast change will have to happen.

The second thought I had is that the major EMR vendors, (well Epic at least), can already provide all of what’s being talked about being necessary by 2011, and most of 2013’s requirements. But if we really are going to attach devices to the data systems and also engage patients with meaningful management tools, those vendors and their clients are really going to have to open up to the Health 2.0 world.

And funnily enough a group that includes David Kibbe & Clay Christensen, led by Isaac S. Kohane and Kenneth Mandl from Children’s Hospital Boston have today come out with recommendations for how to build a platform for plug & play applications to accomplish these goals using the iPhone App store as one potential model, and encouraging everyone to open their APIs Web 2.0 style.

That would achieve the ability to provide meaning in that meaningful use in a few short years—in fact many of these applications are already being developed and used. The question of course is, can the CCHIT certified EMRs interoperate with these platforms, and if not, will their use be meaningful. And again if not, will the vendors and the providers who’ve spent millions of dollars on them demand a downgrading of the new meaningful use metrics—locking them into the 2011 standards.

All will be watched very closely, but there’s no question that on health IT we have the potential for a great leap forward. Something that is looking very elusive for health reform in general.

UPDATE: My friend and colleague Josh Seidman from the Center for Information Therapy has written to correctly chastise me for not reading the blog post where already he gave his view on meaningful use, and more importantly for my missing completely the role of the Consumer Partnership for e-Health (supported by Markle) in the process–several of whose recommendations were incorporated pretty much wholesale into the workgroup’s current version. Josh also wrote a description of the process which I engaged in with the Consumer Partnership for e-Health earlier this month. It’s important to realize that beyond those of us ranting on the sidelines, consumers have real advocates like Josh and his team working on their health information needs in DC.

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7 replies »

  1. insurers have near ludicrous caps on this service. Who’s going to pay for all the time docs will spend answering patient questions (whether they arrive in Health 2.0 style via a txt message or email or IM or via old-skool means like a face to face visit or Pony Express)? can u explain more

  2. I applaud the work of the Health IT Policy Committee and, like Matthew, am frankly pleasantly suprised by the intial language and framework for definition in the preliminary recommendations. Clearly, as Joshua notes, considerable work from the individuals and organizations he mentions have influenced the perspective of the committee to emphasize the consumer and patient-centeredness of “meaningingful use” out of the gate. I’m also heartened by the inclusion of quality metrics, albeit in 2011, that support a shift to population health. I would also argue all stakeholders and certainly patients be made aware of this information about quality as part of the recommendations. Now is the time to make the case for full transparency.

  3. Matthew,
    I appreciate your UPDATE.
    We also should add that there are many excellent members of the HIT Policy Committee and its MU Workgroup who have demonstrated great leadership on this issue, including Christine Bechtel (National Partnership for Women & Families), Neil Calman (Institute for Family Health), Deven McGraw (Center for Democracy & Technology), David Lansky (Pacific Business Group on Health) and workgroup co-chairs Paul Tang (Palo Alto Medical Foundation) and Farzad Mostashari (New York City Department of Health), among others. They have been strong voices for consumer access to health information.
    There also is still a long way to go, which is why they and everyone else who cares about consumer access to health information should contact ONC in the next 9 days (information on how is in the blog post that Matthew referred to in the UPDATE).
    Josh

  4. All this meaningful use discussion and transfer of info from docs to patients to payors etc. won’t mean a thing if we don’t begin to, as Steve Beller points out, provide decision support tools and services.
    We can start by paying providers for time spent on patient education. Many insurers have near ludicrous caps on this service. Who’s going to pay for all the time docs will spend answering patient questions (whether they arrive in Health 2.0 style via a txt message or email or IM or via old-skool means like a face to face visit or Pony Express)?
    Whenever you implement IT in an organization, a priority is to have the Help Desk up and running. Who are going to be healthcare’s Help Desk personnel?

  5. I like Joshua’s additions.
    One of the essential element missing from every meaningful use definition I’ve read to date, however, is a requirement for “patient-centered cognitive support.”
    Following is a 1,000 word response I just submitted to the HHS HIT Policy Committee’s request for comments on a definition …
    Proposed definition: Using Health IT to increase care value (effectiveness and efficiency) by providing ever-better patient-centered cognitive support.
    As discussed in a recent report by the National Research Council of the National Academies, patient-centered cognitive support (PCCS) is a computerized process that improves decision making by fostering profound understanding through use of a “virtual patient” model. The PCCS process employs a computerized model of a “virtual patient” that reflects (i.e., is an “abstraction of”) an actual patient. An HIT tool would use this virtual patient to guide the selection and analysis of data. These targeted data would be:
    …relevant to a specific patient and suggest their clinical implications…[This would] provide decision support…that helps clinicians decide on a course of action in response to an understanding of the patient’s status…[These tools would take into account] patient utilities, values, and resource constraints…[and they would] support holistic plans [of care]…These virtual patient models are the computational counterparts of the clinician’s conceptual model of a patient. They depict and simulate the clinician’s working theory about interactions going on in the patient and enable patient-specific parameterization and multicomponent alerts. They build on submodels of biological and physiological systems and also exploit epidemiological models that take into account the local prevalence of diseases. The availability of these models would free clinicians from having to scan raw data, and thus they would have a much easier time defining, testing, and exploring their own working theories. What links the raw data to the abstract models might be called medical logic—that is, computer-based tools examine raw data relevant to a specific patient and suggest their clinical implications given the context of the models and abstractions. Computers can then provide decision support—that is, tools that help clinicians decide on a course of action in response to an understanding of the patient’s status. At any time, clinicians have the ability to access the raw data as needed if they wish to explore the presented interpretations and abstractions in greater depth.
    In other words, the virtual patient used in the PCCS process is a computer program with advanced computational algorithms (mathematical and logical operations/steps). The algorithms “…incorporate physics (such as mechanical and electrical properties of tissue) and biology (from physiological to biochemical information) into a platform so that responses to varied stimuli (biological, chemical, physical, and…psychological) can be predicted and results viewed” [Ref: Oak Ridge National Laboratory].
    Furthermore, a HIT tool implementing the PCCS process takes “…observations of an individual patient and relates them to a vast dataset of observations of others with similar symptoms and known conditions. By processing all this information, the model can simulate the likely reaction of the individual patient to possible treatments or interventions. Such tools will not only improve the quality of treatment offered to patients who are already ill or injured, but could also be used in preventive medicine, to predict occurrence or worsening of specific diseases in people at risk, for example through family history [Ref: Europe’s Information Society Portal]. These simulations and predictions are used to support decisions by identifying the treatment and preventive approaches most beneficial to the virtual patient model, which would then be most likely to benefit the actual patient upon which the virtual model is based.
    Unfortunately, today’s mainstream HIT systems do not employ the PCCS process. This, according to same National Research Council report, is a most serious HIT gap. The reason is that PCCS-enabled HIT tools are essential for helping clinicians to understand their patients’ problems and needs without having to:
    “…spend a great deal of time and energy searching and sifting through raw data about patients and trying to integrate the data with their general medical knowledge to form relevant mental abstractions and associations relevant to the patient’s situation…[Unfortunately, today’s HIT systems] squeeze all cognitive support for the clinician through the lens of health care transactions and the related raw data, without an underlying representation of a conceptual model for the patient showing how data fit together and which data are important or unimportant…As a result, an understanding of the patient can be lost amidst all the data, all the tests, and all the monitoring equipment. In the committee’s vision of patient-centered cognitive support, the clinician interacts with models and abstractions of the patient that place the raw data into context and synthesize them with medical knowledge in ways that make clinical sense for that patient.”
    Since they do not use the PCCS process, mainstream HIT tools do not:
    • Help clinicians gain substantially greater understanding of their patients’ situations (i.e., their strengths, weaknesses, risks, needs, and options)
    • Enable patients to understand their own situations better.
    Decision-making suffers as a consequence.
    Eliminating the HIT-PCCS gap would enhance understanding and promote better shared decision-making about treatment, prevention, health promotion, and self-maintenance (see this link and this link). Because both clinicians and patients would be better informed through the PCCS process, the decisions they make would be more likely result in better outcomes (higher quality and safety) at lower cost. This would translate into increased care value (effectiveness and efficiency). In other words, using HIT tools that implement the PCCS process would help realize important benefits to individuals and society. These benefits include achieving the goals of both the Federal HIT Strategic Plan and the Institutes for Healthcare Improvement’s “Triple Aim.”
    Based on the discussion to his point, it seems reasonable to conclude that HIT tools are used meaningfully if they employ the PCCS process in order to:
    • Save clinicians time and energy by automating searching and sifting through a patient’s clinical details and related research guided by a virtual patient model.
    • Promote a deep and broad understanding of a patient’s health status, including the interplay of biological, psychological, and social (i.e., biopsychosocial) influences—past, present, and future.
    • Provide effective, personalized decision support regarding diagnosis, treatment, prevention, and health promotion. And this decision support would:
    o Account for patient preferences, qualities, and circumstances
    o Help improve overall care value
    o Continually evolve.

    For more, see http://curinghealthcare.blogspot.com/2009/06/meaningful-use-clinical-decision.html

  6. Regarding your first observation about the consumer-facing side of the draft meaningful use definition, many of the elements derive directly from the recommendations of the Consumer Partnership for eHealth. For background, see http://is.gd/15cQn.
    And, for some recommended improvements to ensure stronger attention to consumer access to meaningful, useful information, see http://is.gd/15cGo.

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