A Time for Boundless Energy and Optimism

2012 has been a challenging year for me.

On the personal side, my wife had cancer. Together we moved two households, relocated her studio, and closed her gallery. This week my mother broke her hip in Los Angeles and I’m writing from her hospital room as we finalize her discharge and home care plan before I fly back to Boston.

On the business side, the IT community around me has worked hard on Meaningful Use Stage 2, the Massachusetts State Health Information Exchange, improvements in data security, groundbreaking new applications, and complex projects like ICD10 with enormous scope.

We did all this with boundless energy and optimism, knowing that every day we’re creating a foundation that will improve the future for our country, communities, and families.

My personal life has never been better – Kathy’s cancer is in remission, our farm is thriving, and our daughter is maturing into a fine young woman at Tufts University.

My business life has never been better – Meaningful Use Stage 2 provides new rigorous standards for content/vocabulary/transport at a time when EHR use has doubled since 2008, the State HIE goes live in one week, and BIDMC was voted the number #1 IT organization the country.

It’s clear that many have discounted the amazing accomplishments that we’ve all made, overcoming technology and political barriers with questions such as “how can we?” and “why not?” rather than “why is it taking so long?” They would rather pursue their own goals – be they election year politics, academic recognition, or readership traffic on a website.

As many have seen, this letter from the Ways and Means Committee makes comments about standards that clearly have no other purpose than election year politics. These House members are very smart people and I have great respect for their staff. I’m happy to walk them through the Standards and Certification Regulations (MU stage 1 and stage 2) so they understand that the majority of their letter is simply not true – it ignores the work of hundreds of people over thousands of hours to close the standards gaps via open, transparent, and bipartisan harmonization in both the Bush and Obama administrations.

I spoke with the authors of the Wall Street Journal article “A Major Glitch for Digitized Health-Care Records” and discovered that their issue was not interoperability standards but a lack of usability in non-standard EHR user interface design. When a clinician goes from Epic to Cerner to Meditech and tries to perform the same task (e-prescribing, managing a problem list, or looking up a lab), the learning curve can be steep. The authors and I reviewed the Consolidated CDA specification that is required by Meaningful Use Stage 2 and they are completely satisfied that interoperability standards gaps are no longer a rate limiting step.

Many reporters have asked me about the New York Times article “Medicare Bills Rise as Records Turn Electronic” I’ve said three things:

1. In the past, paper documentation lacked details to accurately document acuity. As we make the multi-year journey from simple EHRs that support electronic billing to complex EHRs that include decision support, interoperability, and patient/family engagement, there will be an interim period when increasing detail in documentation results in higher acuity, which results in increased reimbursement.

2. These trends long pre-date the health IT incentive program. Meaningful Use re-orients the healthcare IT industry away EHRs supporting billing to EHRs which focus on prevention, care coordination, population health management. It is these functionalities that will both enable, and be incentivized by the shift in payment policies towards value, and away from volume. In a healthcare reform world, clinicians will be paid for wellness not sickness and the EHR will help them increase efficiency, safety, and quality, which will be required for reimbursement.

3. As quoted in the Center for Public Integrity’s Cracking the Code series, Donald Berwick said he believes that only a small portion of the upswing in coding is the result of fraud. In most cases, he said, the hospitals have learned “how to play the game,” and are targeting the vulnerabilities of the Medicare payment system. “If you create a payment system in which there is a premium for increasing the number of things you do or the recording of what you do, well, that’s what you’ll get”.

Our current society tries to find fault in everyone and everything. Social media and our increased connectedness has turned criticism into a spectator sport. If everyone could align their efforts into an agenda of optimism, we’d all be better for it.

I may be asking too much to expect positive energy and optimism from Congress, the Wall Street Journal, and the New York Times, but as 2012 has proven to me, anything is possible if you try hard enough.

John D. Halamka, MD, MS, is Chief Information Officer of Beth Israel Deaconess Medical Center, Chief Information Officer at Harvard Medical School, Chairman of the New England Healthcare Exchange Network (NEHEN), Co-Chair of the HIT Standards Committee, a full Professor at Harvard Medical School, and a practicing Emergency Physician. He’s also the author of the popular Life as a Healthcare CIO blog.

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18 replies »

  1. I would like to see updates on the WSJ and NYT articles. How many EHR notes on real time patients in a real clinic has Dr Halamka written (entered) and what is his assessment of his EHR and can he recommend it to any one? If so, what does it cost, and is it at all adaptable to physician needs, or did he have to adapt his practice to the EHR? Some MD’s feel it is their duty to make their EMR “work” at any cost, just like they dedicate themselves 100%sd to their patients.

  2. “If everyone could align their efforts into an agenda of optimism, we’d all be better for it.” someone had to say it! 😀

  3. I am truly inspired by the passion and purpose in your words. The status quo is unsustainable and a path to systemic integrity and sustainability must be found. A wiser, saner health care system is a prize so worth the effort. As we labor to build a human relationship to the world that works, we must guard against forces that would dehumanize the clinical problem-solving process. The solutions we seek must merge honest science and high performance technology with a profoundly human understanding of the physician’s task. To make this work, doctors in the weeds must find their voices, and the courage to use them for the benefit of our patients, and of humanity as a whole.

  4. I’m glad to read some positive spin on the present and future of the massive changes underway in our nation’s health care sector. I trust that congressional staffers, policy wonks, and IT directors are among the smartest people in any room. I also believe that you can’t really know what it’s like to be a doctor these days unless you are one, in the trenches, trying to do all that is being asked of you by a growing collection of third parties to the patient-physician relationship.

    My experience has me fearing we’re digitizing a broken paradigm that oversimplifies the physician’s cognitive task and forcibly redistributes precious face-to-face time to face-to-device time spent haplessly trying to complete a laundry list of administrative demands, most of which do little to help us understand and properly respond to the uniquely complex patient in the room.

    If we don’t fix this problem, I guarantee you that patients and doctors will not be pleased with our infrastructure advances, including decision support. Sorry to be a downer, but also glad to learn that your wife and daughter are doing well.

    • As a full-time family med clinic doctor, the realities of this declaration ring true; as does the positive timbre of Dr. Halamka’s post. We are the folks who are wedged between two fundamentally different worlds in medicine – and our hybrid experience is more difficult perhaps than either was or will be. But going back is not an option; we must make it work, and each of us has a role to play in birthing this next form of health care that can literally help heal the problems of the world. There is enormous potential – and that is worth celebrating. Let us not forget that as we labor in these weeds…it is for a purpose, and a high one. Let’s determine to make it work.

    • BFD

      Until the senate is willing to be a legislative body again and vote on a budget, letters like these are of no import or significance, since nothing will change.

  5. There is a lesson to be learned by the HIT industry from the tail of two tablet computers. One tablet is much more capable than the other – it functions just like a real computer with file management, word processing, spreadsheets, email, web browsing, you name it – it has it. It does everything, EVERYTHING better than the other except for one – the user interface is lousy and interacting with the device – navigating and entering data – is cumbersome. This tablet was released to much fanfare but flopped in the marketplace. It ran Windows XP tablet edition.
    The other tablet computer was barely a computer. No real word processor. very poor file management, navigating the web was less satisfying at times (no tabbed browsing), poor multitasking. And yet it has sold billions. This tablet is of course the iPad. It is the user interface stupid! (Note – not talking about the author or anyone on this blog). Fix that, and you’ll see docs embrace EHRs like never before. Just remember that fixing this is not as simple as making it run on an iPad. It has to be designed from the ground up to be an integral part of the patient care experience.

  6. They sent her a letter. The “letter” came from bipartisan leadership of Ways and Means and Energy and Commerce, so do not depreciate its significance as being political.

    You HIT zealots ignore the reality that the devices have not been assessed for safety, efficacy, and usability, and that there is not any after market surveillance.

    The Congressmen are correct in that these devices do not save money and do not improve outcomes. You zealots have had decades to show benefits.

    There just are not any, but these devices sure facilitate errors.

  7. Thrilled to here your wife is doing well. Sorry about your mother. As for HealthCare IT, it sucks to be a doctor in 2012. Any physician who must touch a computer to write prescriptions, enter orders and create medical documentation has been rendered less valuable than before. The high reimbursement physicians simply hire more helpto do the realtime computer stuff. That does not work in an urgent care or in an ER.

  8. Yes, thank you for the encouragement. The negative voices are so strident that it is hard to keep positive.

  9. Thank you for a very refreshing post. It is easy to become discouraged at Mile 9 or so of this HIT and health care reform marathon, facing another hill and the late morning sun. Yes, we really are building something beautiful here. May we all keep up the good work.

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