Today, an intensive care unit patient room contains anywhere from 50 to 100 pieces of medical equipment made by dozens of manufacturers, and these products rarely, if ever, talk to one another. This means that clinicians must painstakingly review and piece together information from individual devices—for instance, to make a diagnosis of sepsis or to recognize that a patient’s condition is plummeting. Such a system leaves too much room for error and requires clinicians to be heroes, rising above the flawed environment that they work in. We need a heath care system that partners with patients, their families and others to eliminate all harms, optimize patient outcomes and experience and reduce waste. Technology must enable clinicians to help achieve those goals. Technology could do so much more if it focused on achieving these goals and worked backwards from there.
This week marks a step that holds tremendous promise for patients and clinicians. On Monday the Masimo Foundation hosted the Patient Safety Science & Technology Summit in Laguna Niguel, California, an inaugural event to convene hospital administrators, medical technology companies, patient advocates and clinicians to identify solutions to some of today’s most pressing patient safety issues. In response to a call made by keynote speaker former President Bill Clinton, the leaders of nine leading medical device companies pledged to open their systems and share their data.
Lack of interoperability between medical devices plays no small role in the 200,000 American deaths caused by preventable patient harm each year, such as in the case of 11-year-old Leah Coufal. After undergoing elective surgery, Leah received narcotics intended to ease her pain.
When Leah received too much medication, it suppressed her breathing, eventually causing it to stop altogether. Had she been monitored, a device could have alerted clinicians when Leah’s breathing slowed to a dangerous level.
But as we know, clinicians are busy and unfortunately don’t always respond to alarms from bedside machines. If a machine measuring her breathing had been linked with the device delivering her medication, it could have automatically stopped the drugs from infusing into her blue, oxygen-deprived veins.
All of this is possible today; technology is not a barrier. Until now, the only thing that’s stood in the way is a lack of leadership and a lack of willingness for device manufacturers to cooperate.
Mohammad Al-Ubaydli: Let’s just start from the beginning. Tom, can you please give us an introduction about yourself and your background?
Thomas Tsang: I’m a general internist by training. I practiced internal medicine in New York City, first at a small community hospital where I predominantly worked with residents and medical students and mostly taught principles of outpatient medicine, ambulatory care and interviewing techniques.
Then I was recruited by the Charles B. Wang Community Health Center. That’s when I got to use some of the public health knowledge that I had acquired: I worked on various public health initiatives for the community in New York City. The health center itself served a predominantly Asian population. It had four sites and one of the things that I did in the beginning was implement an electronic health record. That work led to my involvement with the Board of Health of New York City, which, in turn led to my work in Congress.
I was then selected for the Robert Wood Johnson Foundation/IOM Health Policy Fellowship on the Committee on Ways and Means-Subcommittee on Health and worked on some of the policies that led to the creation of ACO’s, i.e., Value-Based Purchasing, Pay for Performance and so on. I was fortunate enough to actually help implement some of the policies that I worked on! It’s a long answer to your question, but that’s the route I took.
Mohammad: It’s perfect. It’s really interesting to learn. Among the many things under your belt, it sounds like you have a successful electronic health record deployment, which is good–so well done! Tell me and our readers a bit about Accountable Care Organizations. What is an ACO and what is the point of it?
Thomas: The ACO is not a very new concept. It was a term that was coined by Elliott Fisher from Dartmouth Medical School, who is the director of Center for Health Policy and Clinical Practice. I hate to use the word HMO, but in a way, it’s almost like an HMO. It’s not really an HMO because it is actually a provider-led organization, not an insurance-led one.
Does anyone in their right mind believe that these are the best of times in healthcare or health IT?
Does anyone besides Judy Faulkner and Neal Patterson believe these are the best of times? (I mean, everyone knows that Dramatic Transition + Industry-wide Upheaval + Piles of Cash = Satisfaction / Contentment, proving the point mathematically.)
The question: At what cost to overall healthcare improvement do Epic and Cerner (and others, to be fair … except you, Allscripts) reap massive profits?
The short answer: We don’t really know.
While it is generally acknowledged by most (certainly not all, which you know if you’ve spent any time on HIStalk) that the ready availability and automated cross-checking of electronic health records improves care, there is no definitive study showing dramatic clinical improvement, demonstrable return on investment, etc.
Indeed, we now have a number of studies suggesting exactly the opposite:
Today I’m speaking at the ONC annual meeting as part of panel discussing interoperability.
For years, patients, providers and payers have complained that EHRs “do not talk to each other.”
By 2014, I expect this issue to disappear.
Do I expect that every state and territory will have a robust, sustainable healthcare information exchange by 2014? No
Do I expect that every provider will be connected to a Nationwide Health Information Network by 2014? No
Do I expect that a single vendor will create a centrally hosted method to share data by 2014 just as Sabre did for the airline industry in the 1960’s? No
What I expect is that Meaningful Use Stage 2 will provide the technology, policy, and incentives to make interoperability real.
Stage 2 requires that providers demonstrate, in production, the exchange of clinical care summaries for 10% of their patient encounters during the reporting period. The application and infrastructure investment necessary to support 10% is not much different than 100%. The 10% requirement will bring most professionals and hospitals to the tipping point where information exchange will be implemented at scale, rapidly accelerating data liquidity.
A recent report issued by the Institute of Medicine – titled “Best Care at Lower Cost” – calls for a dramatic transformation in health care delivery, saying “America’s health care system has become far too complex and costly to continue business as usual.” Its first recommendation (“The Digital Infrastructure”) focuses on the importance of health information systems and highlights a crucial aspect of their development that is too often overlooked – the issue of interoperability. Will the individual systems that are created be able to work together efficiently?
It’s an enormously important issue for health care broadly, and it will determine how effective those systems can be on a national level. At present, health care providers across the country are creating or enhancing their health information systems. In some cases, like ours at Intermountain Healthcare, those systems have a long history; we began instituting electronic medical records 40 years ago. Others are early in the journey. But all are being developed essentially for their own internal needs. Interoperability is low on the priority list.
Five health care providers who have been in the forefront of using electronic medical records have been collaborating on the creation of a Care Connectivity Consortium to pioneer the effective connectivity of electronic patient information across their systems. Those five are Intermountain Healthcare (based in Utah), Geisinger Health System (Pennsylvania), Group Health Cooperative (Washington), Kaiser Permanente (California), and Mayo Clinic (Minnesota). But even that ground-breaking effort, in which I’m heavily involved, will result in a multi-provider network, not a national one.
Tomorrow the Presidential election process comes to an end and the advertising will finally stop. We’ll all be relieved. I especially look forward to a quiet dinner at home without robotic election-related calls.
What about healthcare IT? Will differences in the Obama and Romney platforms impact the momentum of Meaningful Use?
Here’s what I believe.
The Obama Healthcare IT platform builds on what we’ve created over the past few years. It will continue to leverage the federal advisory committees (Policy and Standards) to engage a wide array of stakeholders. It will persist the progression to Meaningful Use Stage 3 and possibly future stages. It will embrace certification now the temporary certification process has been replaced with a permanent one. It will support the initiatives of the Standards and Interoperability framework (S&I), although the end of stimulus funds from ARRA means that ONC will move some of the S&I initiatives to private/public partnerships. It will support the current leadership at ONC – Farzad and his delegates such as Steve Posnack, Doug Fridsma, and Judy Murphy.
The Romney Healthcare IT platform notes that Healthcare IT is an issue which has broad bipartisan support. No one argues that a foundation of healthcare IT implemented properly is essential for accountable care organizations. Quality, safety, and efficiency all benefit from the process enhancement afforded by healthcare IT. Michael Leavitt, former Secretary of HHS and chair of the American Health Information Community (AHIC) will lead the Romney transition team and Leavitt has years of experience with healthcare IT issues from the early days of ONC. As Governor of Massachusetts, Romney supported the early EHR rollout efforts of the Massachusetts eHealth Collaborative.
As those of us who work in health care prepare to analyze Stage 2 Meaningful Use rules – which are due any day now – it will be helpful to consider new data commissioned by the Optum Institute and conducted by Harris. The research finds that hospitals are progressing with adoption of electronic medical records (EMRs) but that the adoption is not creating the type of provider connectivity we need to support a more collaborative and aligned healthcare system.
To be sure, the survey of 301 U.S. hospital chief information officers has some very encouraging findings. In particular, the research finds that nearly nine out of 10 hospitals surveyed (87 percent) now have EMR systems in place – up significantly since 2011, when the Health Information and Management Systems Society (HIMSS) reported that only slightly more than half of CIOs had a fully operational electronic health record in at least one facility in their organization.
In addition, the survey finds that 70 percent of CIOs report their systems have attested to meaningful use 1 criteria (MU1) and three quarters anticipated being able to meet expected meaningful use 2 (MU2) criteria by 2014.
However, the survey also identifies six critical technology concerns facing hospital CIOs:
To achieve interoperability, simply reduce the cost of interfaces. The economic value will follow.
Vendors, hospitals, patients and the states are all the wrong places to look for interoperability. Vendors prefer to lock-in their customers, differentiate their product and derive revenue from interfaces. Hospitals prefer to lock in their patients, differentiate their service and derive revenue from pricing power in the marketplace that results from consolidation. Patients confused by the technical nature of interoperability are easily misled into erecting privacy barriers that obscure quality and cost transparency. Finally, the states spend federal money designed to seed interoperability following established bureaucratic and political paths dominated by unchallenged input from vendors, hospitals and misinformed patients.
The cost of interfaces is the sum of Identity, Consent, Transport, Software and Opportunity. Reducing the cost of all five to near zero is possible and relatively easy. The Web and DICOM interfaces to radiology systems demonstrate many of the details at a large scale and for over a decade.
Identity can be free and easy if it’s voluntary to the person or system being identified. On the Web, identity is an email address. Email is free and available to all, even if they have to go to the library to use it. Email IDs are voluntary, you can use one or another as you choose without prejudice or permission. For a system example, DICOM interface IDs are IP (Internet Protocol) Addresses. They too are free and voluntary. The Direct Project is healthcare’s version of a free and voluntary ID for people and for systems. For both patient and clinicians, Direct Project identity is based on email addresses. Patients can already get a free Direct email ID from Microsoft HealthVault. Doctors can get one from Surescripts/AAFP for $15/month and free options are sure to follow. Free, voluntary identity eliminates one of the major costs of health information exchange: the Master Patient Index (MPI). MPI is one of those technologies that costs more the larger it gets. It’s time we abandon MPI as a path to interoperability.
Interoperability is front and center, again. Stage 1 of HITECH was about health records for doctors. Stage 2 is about interoperability. The President’s Council of Advisors on Science and Technology (PCAST) report is all about interoperability. At a recent state medical society meeting, the most animated questions by physicians to Dr. Blumenthal were about the lack of interoperability in electronic health records.
While HITECH is designed to regulate the behavior of technology vendors, it is struggling to encourage doctors to accept the result. Growing interest in ACOs may, at last, drive doctors to demand effective interoperability, and using the patient as a principal or intermediary can jump-start the clinical integration they seek.
For more than 5 years, interoperability has been approached from the perspective of doctors and hospitals. The results speak for themselves. As we process the innovations proposed by PCAST and consider the specifics of Stage 2 regulations, it’s time to put patients first and technology second by giving patients (and their designated agents) convenient access to their health records in their choice of electronic formats including Blue Button, CCR and CDA. Market forces will take care of the rest. Experience with Blue Button and the Direct Project shows that patient-centered and secure, directed exchange avoid the privacy and policy issues that delay technological approaches to interoperability.