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Tag: Interoperability

More Work Is Needed on the Safety and Efficacy of Healthcare Information Technology

If one were writing about the improvement of gastronomy in America, one would probably not celebrate “over 300 billion hamburgers served.”  But that’s very much the type of success Dr. Ashish Jha is celebrating in last week’s piece on recent US healthcare IT sales. Unfortunately, the proliferation of Big Macs does not reflect superior cuisine, and healthcare IT (HIT) sales do not equate with better healthcare or with better health. Quantity does not equal quality of care.

To be sure, Dr. Jha acknowledges the challenges of rolling out HIT throughout US hospitals. And he should be strongly commended for his admission that HIT doesn’t capture care by many specialists and doesn’t save money. In addition, Dr. Jha points to the general inability of hospitals, outpatient physicians and laboratories to transfer data among themselves as a reason for HIT’s meager results.

But this is a circular argument and not an excuse. It is the vendors’ insistence on isolated proprietary systems (and the government’s acquiescence to the vendors) that created this lack of communication (non-interoperability) which so limits one of HIT’s most valuable benefits.

In our opinion, the major concern is that the blog post fails to answer the question we ask our PhD students:

So what? What is the outcome?

This entire effort is fueled by $29 billion in government subsidies and incentives, and by trillions of dollars spent and to be spent by hospitals, doctors and others [1].

So where is the evidence to back up the government’s and industry’s promises of lower mortality, improved health and lower health care costs?

Single studies tell us little. Sadly, as many as 90% of health IT studies fail the minimal criteria of the respected international literature syntheses conducted by the Cochrane Collaboration.

In other words, studies with weak methodology or sweetheart evaluation arrangements just don’t count as evidence.
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Defense Probably Goes Commercial, Not Necessarily Proprietary

Secretary of Defense Chuck Hagel’s long-awaited (in health IT circles, anyway) decision on the Department of Defense’s core health IT system has been made. The VA’s VistA system is out as the preferred DoD. Unless it’s not.

I’ll explain.

In his May 21 memo, Hagel directed the DoD to initiate a competitive process for a commercially available electronic health record (EHR) solution.  Understandably, the secretary has to create a level playing field, a competitive process, so he can tell Congress with certainty that due diligence was done. Hate it a lot or hate it a little, this is the nature of our political process.

Already, many are spinning Hagel’s decision as a huge win for proprietary solutions; popular blogger Mr. HIStalk has already established Epic as the frontrunner in the upcoming DoD derby.

But before we simply anoint Judy Faulkner the queen of American health IT, I want, as the Brits say, to throw a spanner in the works.

Commercial ≠ Proprietary

A careful review of the Hagel memo and other recent statements from his top lieutenants reveal a more progressive vision and clear requirements for an open architecture and service model.

From the Hagel memo:

I am convinced that a competitive process is the optimal way to ensure we select the best value solution for DoD … A competitive process will allow DoD to consider commercial alternatives that may offer reduced cost, reduced schedule and technical risk, and access to increased current capability and future growth in capability by leveraging ongoing advances in the commercial marketplace … Also, based on DoD’s market research, a VistA-based solution will likely be part of one or more competitive offerings that DoD receives.

To sum up, the secretary has directed the DoD to go commercial instead of developing and maintaining their own VistA-based solution, but commercialized VistA-based solutions will be included in the competitive process.

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Straight Talk About Direct

Those of us who have spent years arguing in favor of standards based health information exchange (HIE) have just had a few good months. The federal government has asked IT vendors and providers what it can do to advance health information sharing across organizations. This has drawn new attention to “interoperable” health IT systems and the quality and economy of care delivered to Medicare and Medicaid beneficiaries.

In late March, the Office of the National Coordinator for Health IT (ONC) awarded cooperative agreement grants to two non-profit trade groups working to certify and credential electronic health records (EHRs) and health exchange service providers whose products are capable of secure data sharing — that is, of “talking to one another.”  (Disclosure: I am the President and CEO of one of these alliances, DirectTrust.)  The tone of the conversation has definitely changed.

My sense, though, is that most people still don’t have a firm grasp on the issues. They remain uncertain or confused about what interoperable health information exchange really means to providers and patients, how it can be achieved, the barriers that remain to be overcome, and who is making the decisions about these matters. So this seems like a good time for both an update and a refresher of sorts on the nature of health information exchange, and to explain why this is not a good time to reduce spending on health IT in America.

Let’s start with what is probably the most important thing to understand: we are very, very close to national deployment of a relatively simple standard, known as Direct, that enables secure Internet transport of health information between people, organizations, and software. Direct exchange permits users of any EHR to send and receive messages and files from any users ofany other EHRs, regardless of operating system or vendor. In fact, Direct facilitates secure messaging, with attachments, to and from anyone with Internet access. It makes EHRs interoperable with one another, but also facilitates secure communication with providers and patients using Internet devices of almost any kind.

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The Independent Purchase Decision Support Test

It’s a busy time in Washington, DC. June 3 marks the Datapalooza and begins a week of cheering and reflection on the success of federal initiatives designed to improve health while reducing cost. This year, the big claim is “information following patients” – a combination of federal Stage 2 Meaningful Use regulations, federal Health Information Exchange guidelines and federal open pricing data policies. We’re surely beyond 1,000 pages of federal initiatives around health data and the policy fog seems to be getting thicker every day. The Independent Purchase Decision Support Test is my beacon for whether we’re headed in the right direction.

Here’s a quote from the Meaningful Use Implementation Guidelines to Assure Security and Interoperability just released by ONC:

“In effect, HISPs are creating “islands of automation using a common standard.” This will hamper information following patients where they seek care―including across organizational and vendor boundaries―to support care coordination and Meaningful Use Stage 2 requirements.”

How will “information following patients” improve health while reducing cost?

It all depends on where the patient goes to get what. Not surprisingly, federal Accountable Care Organizations and related accountable quality contracts with private payers are exactly about where the patient goes too. The difference between these health reform innovations and the old managed care approach is supposed to be the patient’s ability to choose where to go for a healthcare service. Will Stage 2 and the new federal health information exchange implementation guidelines actually lead to effective patient engagement or is it time to “reboot” the HITECH incentives as some have suggested?

The Independent Purchase Decision Support Test cuts through the techno-jargon and paternalistic framing and goes straight to the heart of the policies that influence the physician-patient decisions to drive health care quality and cost. This the essence of patient engagement and the place where the money in healthcare is actually spent.

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Universal EHR? No. Universal Data Access? Yes.

A recent blog posting calls for a “universal EMR” for the entire healthcare system. The author provides an example and correctly laments how lack of access to the complete data about a patient impedes optimal clinical care. I would add that quality improvement, clinical research, and public health are impeded by this situation as well.

However, I do not agree that a “universal EMR” is the best way to solve this problem. Instead, I would advocate that we need universal access to underlying clinical data, from which many different types of electronic health records (EHRs), personal health records (PHRs), and other applications can emerge.

What we really need for optimal use of health information is not an application but a platform. This notion has been advanced by many, perhaps most eloquently by Drs. Kenneth Mandl and Isaac Kohane of Boston Children’s Hospital [1,2]. Their work is being manifested in the SMART platform that is being funded by an ONC SHARP Award.

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The Story Behind the CommonWell Story

Arguably, the biggest news story coming out of HIMSS last month was the announcement of the CommonWell Health Alliance – a vendor-led initiative to enable query-based, clinical data sharing. So much has been written about CommonWell that there is little need to rehash what has been said before.

What has not been said, or at least has been sensationalized nearly to the point of irrelevance is the whole controversy surrounding Epic and how they were not invited to join the CommonWell Alliance until after the announcement. None other than Epic’s own founder and CEO, Judy Faulkner, has gone on record stating the Epic was unaware of CommonWell prior to the announcement. Faulkner has gone on to question the motives of CommonWell, in an effort to subvert it, in her highly influential role on the Dept of Health & Human Services HIT workgroup committee.

That was the last straw.

It is one thing to moan and groan at the HIT love fest that is HIMSS, where vendors commonly discount the announcements of competitors. But it is quite another thing to be a part of a highly influential body that is defining nationwide HIT policy and make the same claims over again, especially when they are frankly not true.

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ONC Holds A Key To the Structural Deficit

It’s called Blue Button+ and it works by giving physicians and patients the power to drive change.

The US deficit is driven primarily by healthcare pricing and unwarranted care. Social Security and Medicare cuts contemplated by the Obama administration will hurt the most vulnerable while doing little to address the fundamental issue of excessive institutional pricing and utilization leverage. Bending the cost curve requires both changing physicians incentives and providing them with the tools. This post is about technology that can actually bend the cost curve by letting the doctor refer, and the patient seek care, anywhere.

The bedrock of institutional pricing leverage is institutional control of information technology. Our lack of price and quality transparency and the frustrating lack of interoperability are not an accident. They are the carefully engineered result of a bargain between the highly consolidated electronic health records (EHR) industry and their powerful institutional customers that control regional pricing. Pricing leverage comes from vendor and institutional lock-in. Region by region, decades of institutional consolidation, tax-advantaged, employer-paid insurance and political sophistication have made the costliest providers the most powerful.

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The Napsterization of Health Care


Two weeks ago I had the good fortune to be invited back to the South by Southwest Conference (SXSW) to participate as a judge of a digital healthcare start-up competition. SXSW, which takes place in Austin, TX, is historically an indie music gathering that has evolved into a massive mainstream music conference as well as a monumentally huge film festival, like Sundance times twenty. There are literally hundreds of bands and films featured around town. There has now evolved alongside this a conference called Interactive that draws more than 25,000 people and focuses on technology, particular mobile, digital, and Internet.

In other words, SXSW has become one of the world’s largest gatherings of hoodie-sporting, gadget-toting nerd geniuses that are way too square to be hip but no one has bothered to tell them. Imagine you are sitting at a Starbucks in Palo Alto, CA among 25,000 people who cannot possibly imagine that the rest of the world still thinks the Internet is that newfangled thing used mainly for email and porn. SXSW is a cacophonous melting pot of brilliance, creativity, futuristic thinking, arrogance, self-importance, ironic retro rock and roll t-shirts and technology worship. One small example: very hard to get your hands on a charger for anything other than an iPhone 5 because, seriously, who would have anything else?

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Why Haven’t Electronic Health Records Made Us Any Healthier?

Almost 20 years ago close to 4,000 people from 200 companies gathered in San Diego for a conference to discuss the future of health-care information technology. This was before the Web. This was back when computers in physicians’ offices, to the extent they were present at all, were used only for scheduling and billing patients. Paper charts bulged out of huge filing cabinets.

It was one of the first big conferences held by the Healthcare Information and Management Systems Society (HIMSS). I was among a grab bag of physicians, technologists, visionaries, engineers and entrepreneurs who shared one idealistic goal: to use information systems and technology to fundamentally change health care.

We didn’t just want to upgrade those old systems. We imagined a future that looked a lot like what we were being promised throughout the economy as it sped into the Internet era. Computers would enable improvements in the practice of medicine—and make it safer, higher quality, more affordable and more efficient—all at the same time. We wanted people to be healthier.

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Moving Toward An Identity and Patient Records Locator

Last week, five health IT vendors came together to announce the CommonWell Health Alliance, a nonprofit focused on developing a national secure network and standards that will:

  1. Unambiguously identify patients
  2. Provide a national, secure record locator service. For treatment purposes, providers can know where a patient’s records are located.
  3. Enable peer-to-peer sharing of patient records requested via a targeted (or directed) query
  4. Enable patients and consumers to withhold consent / authorization for participation in the network

Unambiguous patient identity matters

In banking, without certainty about identity, ATM machines would not give out cash.  And in healthcare without certainty about identity, physicians are working with one hand tied behind their backs.

This problem will never be solved by the Feds. In fact, Congress has restricted any spending on it by the government at all.  Industry working together may be the only practical alternative.

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