My World in 2015

Jacob RiderI started my blog over 15 years ago.  Yes – it’s been less active in recent years, and as I reflect on why I’ve been less active – only part of the reason is that I was working for a publicly traded company from 2008-2011 .. and a federal agency from 2011 – 2014.  Both of these organizations have reasons to control the messages of their employees.  I needed to be cautious about what I blogged.  So I didn’t blog publicly very much. 

But since November, I’ve had no excuse.  And yet nothing much flowed from these fingertips.  

It should have.  Back in the day – THCB and Docnotes – and a handful of other sites offered bookmarks and observations on health care delivery, the convergence of health care and IT, and random observations.  These days – there is a tidal wave of these things on the Internet. I sometimes question whether MY contributions are of any value now that there is so much out there.  I remember when Dave Winer toyed with killing his blog.  He didn’t.  Nor should I.  This post celebrates the not-killing of my new blog, and the beginning of the NEXT 15 years of my public observations.

Here goes ..

I’ve been learning so much.  I owe it to you to share what I’m seeing out there, beyond the ivory towers of government, beyond the walnut paneled board rooms of hospitals and health IT companies, and beyond even the ping-pong tables of Silicon Valley start-ups and the crisp offices of their venture capitalists.

I started blogging so that I could make the thought processes of a physician transparent to “normal humans.”   15 years ago, concepts like “shared decisions” were neither mentioned nor understood.  Real-world applications of genomics were a twinkle in the eyes of Watson and Crick (and perhaps some others).  Physician blogs are now plentiful.  We know how they feel about thir long days, the meaningful use EHR incentive programMaintenance of CertificationSGR fixes (or attempts at least) and electronic health records.

So here’s some of what I’ve observed recently – to make the thought process of this physician more transparent:

  • There is growing interest in DPC models (see this recent Time article about QLiance and others – experimenting with new payment models) – and “full risk” medicare advantage care delivery models, such as what Chris Chen and his family/team have done in Miami.  “Patient Centered” is more than just a catch-phrase to these folks.  They live it every day. I witnessed the T’ai chi class at ChenMed – which turns out to be much more effective at managing  patients’ osteoarthritis than lortab.  
  • Other organizations like Iora HealthLandmark Health,  and Caremore are finding ways to really achieve the triple aim.
  • None of this was possible 20 years ago, and the difference today is that technology is better, smaller, faster, more ubiquitous, and easier to implement, iterate and optimize.
  • Yet the IT we have in health care remains “dumb.”  The systems remain focused on the capture, aggregation, and (ideally) transmission of data.  Yes – there are sometimes decision support interventions that remind us to do the things we forgot – or NOT to do the things that might be harmful – but these capabilities are not adaptive or dynamic in the way that Google Maps or Waze adapt to changing conditions ahead, or even a change in the destination.    How do we know what this patient’s optimal goal really is?  (I vividly remember Eric Dishman’s anecdote about his cancer treatment:  his goal was to maximize time on the ski slopes – not necessarily the length of his life.  How could the oncology team manage toward THIS endpoint?  It wasn’t in the guideline or their training.  But it was the most important endpoint to the patient.  Current processes, systems can’t do this – in part because they can’t capture and understand “maximize skiing.”)
  • Consumer applications leverage machine learning and even deep learning so that they can anticipate our needs.  Amazon’s patent filing for “anticipatory shipping” is just one example of the many ways in which we increasingly leverage intelligent IT in our day-to-day lives.
  • In health care, we have seen enhanced interest in analytics, predictive modeling, and machine learning.  Indeed – my first “real job” in health IT was at Medremote, where we applied machine learning to transcribed progress notes in order to create structured data from narrative documents.  But as an industry, we’ve failed to make scalable applications of IT that really help improve health – that leverage tools capable of predicting how this individual will find the path toward better health.  The EHRs remain repositories of information.  Analytics platforms generate reports of care gaps, but are rarely actionable.  Predictive models abound in the financial sector, but are rarely leveraged in the average clinician’s daily routine.

These vectors will converge:

  • Care providers who are focused on the health of an individual and a population will manage their decisions, their information, their processes, and their communications differently from how care providers who are paid to maximize volume.
  • We will see continued “shifting left” of health care.  What used to happen in the hospital will now happen in the clinic.  What used to happen in the clinic will now happen in the home. Practices will increasingly share (or own) risk.  Employers will drive providers to improve quality, just as Intel has done.
  • Innovative care models will drive new requirements for IT that focus on care quality, collaboration, communication, shared decisions, and patient empowerment (not just “engagement”).
  • Machine learning tools will provide real-time insight into the best choices for patients, and these decision support tools will be the core of next-generation health IT systems (rather than “bolted on” as we have today).  Our technology infrastructure in health care will (finally) provide some of the adaptive, anticipatory assistance that we have come to expect from the rest of our interactions with the technical tools we use every day.
  • Because of the enhanced intelligence of the IT infrastructure, safety of health IT systems will become increasingly important, and the government agencies such as the FDA and ONC (and their international counterparts) will need to find the right risk based regulatory framework to allow for innovation while protecting public safety.

What does this mean?

I’ve expressed above what I believe to be a set of self-evident observations.  Yes – I’ve over-simplified a bit, and one can find exceptions to many of the statements I make about both existing systems and the absence of 21st-century solutions in health care.  Both would be valid critiques.

But I stand by my statements as good representations of the majority of current state health IT, and the obvious progression toward the future.  These systems will be more intelligent.  Care delivery will evolve – finally – both due to the federal government’s deep interest in reaching the triple aim – and from the private sector finally understanding that we simply deserve better, as do our children, our parents, and our neighbors.  

So it’s obvious (to me) what I need to work on next.  I need to weave together my passion for reforming care delivery with my interest in usability/user experience, and my interest in decision support and shared decisions between care providers and individuals/families.

I’ll blog about my personal work to skate to where this puck will be over on docnotes – for the next 15 years. 

This is an exciting time.  2015 will mark the real transition as we start to turn the corner from “fee for volume” – and the motivators that maximize volume of care (with the harm that comes along for the ride) – to “fee for value” and the use of intelligent systems that will get us to where we need to be.

Jacob Reider MD, FAAFP is the former Deputy National Coordinator at ONC and is now Founder & Chief Strategy Officer at Kyron, and physician-in-residence at Khosla Ventures.  His blog, docnotes.com, started in 1999 and is the longest-running medical medical blog.


22 replies »

  1. Who was the “one”? And you mean to say that none of those on the list receive funding from HIT vendors and HIM$$, or are in some other way, compensated HIT vendor booth bunnies?

  2. Thanks! I’m just a curmudgeonly old clinical guy who has a healthy “skepticism” that computers, informatics, CPOE, or health-care administrators will somehow save the world for us . . . take care my friend!

  3. LOL. You don’t qualify. I may not agree with you much of the time, but your views are at least substantive and go beyond parroting the same old crap.

  4. Reading with interest.

    “ONC, ECRI, Mitre, AHRQ and many others are doing work to better understand patient safety risks of health IT. Real work – done by passionate people who care about patient safety.”

    What have they done, exactly, to remove dangerous functionality from these devices? None have enforcement capability.

    Think of these organizations as HIT safety lite. Euphemism for safety.

    Why not the FDA whose sole purpose is to assure the safety of drugs, devices, and food for the people?

  5. Thanks for your thoughts. I’m curious to get your thoughts on DPC a bit more since you mentioned it.

    It still seems to be a micro niche market even compared against traditional concierge practices in terms of the numbers I have. I was wondering where you see DPC fitting in with retail clinics/retail health and hospitals/IDN efforts to build clinically integrated networks whether through physician practice ownership or a revised PHO operating structure or other legal structure?

  6. Harrison and Williams are just two resident naysayer trolls whose long-standing M.O. is to cast aspersions on the intelligence and efforts of others.

  7. @Curly Harrison: I think we’ll need to agree to disagree. ONC, ECRI, Mitre, AHRQ and many others are doing work to better understand patient safety risks of health IT. Real work – done by passionate people who care about patient safety. At ONC, Kathy Kenyon, David Hunt, Jodi Daniel, and Andy Gettinger are all actively engaged. Please reach out to learn more before you assume that they “have no idea.” We can let the readers decide if the IOM group was “dominated by vendors” as you suggest. As one who is passionate about data – here is the list of the IOM committee members – I don’t see ANY vendors on the list – a far cry from dominance:
    James Bagian
    Richard Baron
    David Bates
    Dedra Cantrell
    David Classen
    Richard Cook
    Don Detmer
    Meghan Dierks
    Terhilda Garrido
    Ashish Jha
    Michael Lesk
    Arthur Levin
    John Lumpkin
    Vimla Patel
    Philip Schneider
    Christine Sinsky
    Paul Tang

    — @KimThomas – I’ll describe my work @ Kyron and Khosla on my personal blog over time. Yes! There will always be doctors and nurses and physical therapists and pharmacists and many other care providers. What these folks do, and how they do their work will be changed by health IT, just as the work of most other professionals has changed.

  8. What is Kyron and Khosla? What do you do there? Why will there be doctors if the IT becomes intelligent?

  9. Jacob–Very well done. 15 years of anything is amazing and you started Docnotes before there was a Blogger, or WordPress, and probably before Geocities!

    As we can both sympathize, writing much or anything at all when you have a real job is a great pain for us bloggers. Not to mention getting out of the thought pattenr of “well I said that in 2005, why bother telling these new kids who never read it then what I knew then”.

    But you’ve hit on the real value. What you saw at Allscripts and ONC and what I saw in my wondering around consulting and then at Health 2.0 are positions that not many get to see. And we do help by sharing. Back before 2003 (or 19999 if you insist) this stuff was locked up in expensive consulting reports only seen by a few. You say there is too much online, and you’re right, But it’s better that way!–Matthew

  10. @jacobreider, you speak and conclude without the data, since neither you, nor anyone else at ONC or its mother HHS, has any idea of the incidence of near misses, care delays, misidentifications, privacy violations, EHR crashes, truncated results, lost data, cognitive disruptions, cut and paste errors, jabberwocky notes, obfuscated formats, and other CPOE and CDS impediments to effective care and their ultimate culmination in injury and death…cause you ain’t asking for them, and those who have reported such have been quashed. You simply do not want to know, especially with the vendors infiltrating the committees to which you refer.

    You are wrong about the IOM report, which too was dominated by vendors.

    #realsolutions: get these devices assessed for safety, efficacy and usability as would be done for all other medical devices by the FDA. Establish a user friendly and robust system for busy users to report HIT associated near misses and adverse events. The end.

  11. @Curly Harrison – As you recall – one member of the independent group of experts IOM gathered to review the subject of health IT safety in 2011 agreed with you that health IT should be regulated as a medical device – and 20+ disagreed with you. My view is that the 20+ were correct – which means I disagree with your assertion that health IT should be regulated as a medical device. Can health IT harm patients? Yes. Of course. Just as any powerful tool (car, airplane, chain saw) can cause harm. That doesn’t mean the tool is fundamentally flawed. It just needs to be used with proper care, be well designed, and studied carefully to reduce all possible risks of harm. This risk of heath IT is real, and more research must be done to understand that risk and work to reduce it toward zero. Is there evidence that health IT improves patient care? Reduces risk? Is safer that the paper alternatives? Absolutely! Your other comments: a) HIMSS didn’t create certification. b) The industry OPPOSED certification – and many health IT developers still (like you) question its value. c) Safety hasn’t been sufficiently addressed by certification, nor has there been any claim that it has. ONC (with FDA) has an obligation to find methods of assuring that health IT products are safe. Some have questioned ONC’s regulatory authority to do this. Congress – through FDASIA – asked HHS and FCC to take this on, and hopefully we’ll see a clear risk-based regulatory framework for this in the near future. FDA’s draft guidance last week on wellness applications was only one part of this. I encourage you to engage in the discussion by sharing your thoughts with the Health IT Policy Committee, and through the public comment process as proposed rules and guidance are published. It’s easy to throw snarky “what’s the evidence that ..” questions at the government (or former feds) as you have. They’re not bad questions – but I don’t think that asking them in this way helps solve the problems. It’s harder to roll up your sleeves and participate in defining in detail what the real solutions should be. I challenge you to do so. You’re clearly knowledgeable and passionate.

  12. Thanks for that thoughtful response. There’s not much more important than family so your decision is certainly understandable. The CCM program is long overdue and I believe will be welcomed by many who have long put in the extra hours to coordinate care, with their only compensation being the satisfaction that they’ve helped their patients. It’s been interesting to see the number of HIT vendors already marketing products to meet the need. No doubt just a small sampling of the vast number of vendors who’ll claim the capability at HIMSS.

  13. Hey @jacobreider, you are still talking about (the sham of) certification. Certification had been spawned and used by the industry, courtesy of HIMSS, to give the impression (to Congress) that the EHRs being promoted were safe.

    Whatever happened to the evidence, if any, on the safety and efficacy of these medical devices?

    While EHR libraries of data seem benevolent, the CPOE and CDS accessories subject patients to risk.

    Why have the adverse events associated with these CPOE and CDS devices, EHR crashes, delays in care, and others not been systematically quantified and offered to the FDA for analysis as would those from any other medical device? Just wonderin

  14. @Whatsen Williams: well, thank you for your DSM diagnosis! My dad is a retired psychiatrist – and his dad was a psychiatrist, so I am grateful that you have offered your diagnostic services – as clearly the shoemaker’s child has no shoes. I’d be interested in your thoughts about exactly what part of the picture I paint is a delusion, and what your alternative depiction would look like. It is such an open, engaged debate that will help us all learn more about what’s ahead. I welcome your perspective, and I thank you for responding to mine.

  15. @CuriousAboutONC – You’re not the only one with this question. I was asked about this when I was still @ ONC, and still get asked – as if there is a deeper, darker story to my departure. There is not. When I joined ONC, my goal was do to my best to help the organization tangibly understand some of the “real world” impact of the certification regulations. There were no physicians in the organization with hands-on experience using certified EHRs in their practices, and there was nobody in the organization who had actually managed the certification of EHRs. I had done both. I had no expectation of becoming the leader, deputy, or “chief” anything of the organization. I really just wanted to serve. I’d been impressed that the folks at ONC are dedicated to doing what’s best for the American people. My primary goal was to help get ONC’s policies better informed by my real-world experience. I live in Albany, New York. My wife is the Dean of the Law School here. She has a long-term commitment to the institution – an organization she’s worked in for two decades. My plan was to commute to DC for a year or perhaps two. We’re a happy, stable family. A year or two would be a sacrifice, but we decided that it’s a sacrifice the family could manage. So I got on that plane every Monday morning at 5 AM for three years – a year longer than planned. Farzad left, David left, Karen arrived. I needed to stay that extra year. I loved working at ONC. I loved the people, the mission, HHS, Washington. But I love my family more – and it was time to finish. So I did. How would I rate future prospects of ONC? I think the future is bright. ONC has important work to do. It’s different from the work of 2010-2013. The EHR incentive programs are not the only policy lever that can/will motivate folks to use health IT. In 2015 – we have the first example of an incentive – the Chronic Care Management fee – that CMS put in the Physician Fee Schedule – that requires the use of certified health IT. Some practices could end up earning more from CCM than they do under MU! But they will need certified products – and it’s ONC’s job to define the certified capabilities – and maintain a certification program that we can trust will assure us all that the products do what they say they can do – without creating too much of a burden to the industry. It’s a delicate balance.

  16. Thanks for this window into your view of the market, Jacob. My curiosity stems not so much from the content of your observations about the market as from what you have not stated – that is, why did you leave ONC? And how would you rate the future prospects of the agency visa vis Meaningful Use with their top clinical leader now gone, along with their director?