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FUD Part II: The Return of Fear, Uncertainty and Doubt

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By JOHN HALAMKA

John HalamkaA Time of Uncertainty …

The upcoming presidential election has everyone spooked  – what if Donald Trump is actually elected?  What will the transition of administrations, regardless of who is elected mean to healthcare and existing healthcare IT regulations?   Will our strategic plans and priorities need to change?

I’ve spoken to many people in government, industry and academia over the past month about the rapid pace of change stakeholders are feeling right now.   Here are a few of their observations:

1.  In the next year or two there will continue to be consolidation  in the healthcare IT industry.    Many smaller EHR companies will fold due to declining market share and some established incumbents with older technologies are likely to sell their healthcare IT businesses or reduce their scope.

2.  Mergers and acquisitions will continue to accelerate, reducing the number of stand alone community hospitals and practices.   The end result is that the market for software supporting midsize hospitals and small group practices is likely to shrink since ACOs/networks/healthcare systems will probably mandate a single centralized EHR solution for the enterprise.

3.  Although the election may change the regulatory burden, many incumbent vendors will be spending the next year or two complying with certification demands, reducing their ability to innovate.     It’s quite a conundrum.  The market is demanding innovative solutions in the short term, but vendors cannot produce them because their development resources have been co-opted by regulatory demands.    Thus, vendors may see a reduction in new sales, which will diminish their ability to hire new staff to meet the regulatory demands, putting them even further behind.   It reminds of a classic unstable system – beer pong.  The more you miss, the more you drink, the more you miss.   The more regulation, the fewer new sales, the less ability to deal with regulation.

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E-mail Liberacion!

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By JOHN HALAMKA

John HalamkaIn 2011 and 2012 I wrote about the increasing problem of Business Spam – unsolicited, unconsented advertising that has grown in volume to the point that it constitutes more than half of my email .   In 2016, I’ve done an experiment – I’ve not opted in to any newsletter, any website offering notifications or any vendor offering information.   I’ve monitored my mailbox for violators of good email practices.

This month, we put a stop to it – cold turkey.   Anyone sending business spam is now blocked from the 22,000 users of Beth Israel Deaconess and its affiliates.

Here’s how we did it – using a commercially available appliance we have black listed organizations which send bulk email and companies which violate unsolicited email policies.

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What Does Real Meaningful Use of an EHR Look Like?

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By ROB LAMBERTS, MD

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I drank the kool-aid early.  We installed our first EHR in 1996 with me doing the lion’s share of pushing and pulling.  While I’d ultimately turn my back on this passion, I had a number of notable accomplishments before walking down my Damascus road.

  • Within a year of implementation, our practice became one of the top installations for our vendor.
  • Within 2 years I was elected to the board of our user group.
  • Within 4 years I was president.
  • In 2003, our practice was recognized by HIMSS as one of the top primary care installations of Electronic Records.
  • In subsequent years I lectured around the country (for HIMSS) extolling the benefits of EHR for both quality and efficiency of care.
  • As opposed to the experience of other physicians, our practice was not only successful in our implementation, we were in the top 10% in income for our specialty.
  • Our quality metrics were also routinely far above national norms.
  • In 2012, I was the physician representative for CDC public health grand rounds, discussing the upcoming EHR incentive program: Meaningful Use.
  • By 2013, we easily qualified for stage 1 of Meaningful Use, and I happily accepted the financial fruit of my labors.

But the final years were not, as I expected, a triumph. I became increasingly frustrated with the worsening of our EHR by the “features” needed to qualify us for MU1. I also chafed at the way most physicians were meeting this criteria: by abandoning patient-centered care and adopting a data-centered care model.  Patients were given useless handouts to summarize “care,” and the data requirement was satisfied.  Patient portals gave limited access to information were touted as “patient centered” care, while the product was left unused by most patients, but the data requirement was satisfied.

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Halamka Speaks: athenahealth & the Future of AMCs as Tech Innovators

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By MATTHEW HOLT

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It’s always interesting to talk with John Halamka, and last week–after athenahealth bought the IP but apparently not the actual code of the Beth Israel Deaconess Medical Center (BIDMC) web-based EHR he’s been shepherding for the past 18 years–I got him on the record for a few minutes. We started on the new deal but given that had already been covered pretty well elsewhere we didn’t really stay there. More fun that way–Matthew Holt

Matthew Holt: The guys across town (Partners) ripped out all the stuff they’ve been building and integrating for the last 30 years and they decided to pay Judy Faulkner over a billion dollars. And you took all the stuff that you’ve been building for the past 15 to 20 years and sold it to Jonathan Bush for money.  Does that make you a better businessman than they are?

 (Update Note 2/11/15: While I’ve heard from public & private sources that the cost of the Partners project will be between $700m and $1.4 billion, Carl Dvorak at Epic asked me to point out less than 10% of the cost goes to Epic for their fees/license. The rest I assume is external and internal salaries for implementation costs, and of course it’s possible that many of those costs would exist even if Partners kept its previous IT systems).

John Halamka:  Well, that is hard to say, but I can tell you that smart people in Boston created all these very early systems back in the 1980s. On one hand, the John Glaser group created a client server front end. I joined Beth Israel Deaconess in 1996 and we created an entirely web-based front end. We have common roots but a different path.

It wasn’t so much that I did this because of a business deal. As I wrote in my blog, there is no benefit to me or to my staff. There are no royalty streams or anything like that.  But sure, Beth Israel Deaconess receives a cash payment from Athena. But important to me is that the idea of a cloud-hosted service which is what we’ve been running at Beth Israel Deaconess since the late ’90s hopefully will now spread to more organizations across the country. And what better honor for a Harvard faculty member than to see the work of the team go to more people across the country?

MH: There’s been a lot of debate about the concept of developing for the new world of healthcare using client server technology that has been changed to “sort of” fit the integrated delivery systems over the last 10 years, primarily by Epic but also Cerner and others. In particular how open those systems are and how able they are to migrate to new technology. You’ve obviously seen both sides, you’re obviously been building a different version than that.  And a lot of this is obviously about plugging in other tools, other technologies to do things that were never really envisaged back in 1998. You’ve come down pretty strongly on the web-based side of this, but what’s your sense for how likely it is that what has happened over the last five or ten years in most other systems including the one across the street we just mentioned is going to change to something more that looks more like what you had at Beth Israel Deaconess?Continue reading…

Black Turtlenecks, Data Fiends and Code. An Interview with John Halamka

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By ROBERT WACHTER, MD

John Halamka-Google Glass

Of the nearly 100 people I interviewed for my upcoming book, John Halmaka was one of the most fascinating. Halamka is CIO of Beth Israel Deaconess Medical Center and a national leader in health IT policy. He also runs a family farm, on which he raises ducks, alpacas and llamas. His penchant for black mock turtlenecks, along with his brilliance and quirkiness, raise inevitable comparisons to Steve Jobs. I interviewed him in Boston on August 12, 2014.

Our conversation was very wide ranging, but I was particularly struck by what Halamka had to say about federal privacy regulations and HIPAA, and their impact on his job as CIO. Let’s start with that.

Halamka: Not long ago, one of our physicians went into an Apple store and bought a laptop. He returned to his office, plugged it in, and synched his e-mail. He then left for a meeting. When he came back, the laptop was gone. We looked at the video footage and saw that a known felon had entered the building, grabbed the laptop, and fled. We found him, and he was arrested.

Now, what is the likelihood that this drug fiend stole the device because he had identity theft in mind? That would be zero. But the case has now exceeded $500,000 in legal fees, forensic work, and investigations. We are close to signing a settlement agreement where we basically say, “It wasn’t our fault but here’s a set of actions Beth Israel will put in place so that no doctor is ever allowed again to bring a device into our environment and download patient data to it.”

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A Little Advice for Karen DeSalvo

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By John Halamka, MD

Karen DeSalvo started as the new National Coordinator for Healthcare Information Technology on January 13, 2014.   After my brief discussion with her last week, I can already tell she’s a good listener, aware of the issues, and is passionate about using healthcare IT as a tool to improve population health.

She is a cheerleader for IT, not an informatics expert.  She’ll rely on others to help with the IT details, and that’s appropriate.

What advice would I give her, given the current state of healthcare IT stakeholders?

1.  Rethink the Certification Program – With a new National Coordinator, we have an opportunity to redesign certification. As I’ve written about previously some of the 2014 Certification test procedures have negatively impacted the healthcare IT industry by being overly prescriptive and by requiring functionality/workflows that are unlikely to be used in the real world.

One of the most negative aspects of 2014 certification is the concept of “certification only”. No actual clinical use or attestation is required but software must be engineered to incorporate standards/processes which are not yet mature.   An example is the “transmit” portion of the view/download/transmit patient/family engagement requirements.

There is not yet an ecosystem for patients to ‘transmit’ using CCDA and Direct, yet vendors are required to implement complex functionality that few will use. Another example is the use of QRDA I and QRDA III for quality reporting.

CMS cannot yet receive such files but EHRs must send them in order to be certified.   The result of this certification burden is a delay in 2014 certified product availability.

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Fine Tuning the National Health IT Timeline

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By John Halamka, MD

I’ve recently written about healthcare.gov and the lesson that going live too soon creates a very unpleasant memory.

As I work with healthcare leaders in Boston, in New England, and throughout the country, I’m seeing signs that well resourced medical centers will struggle with Meaningful Use stage 2 attestation, ICD-10 go live, HIPAA Omnibus Rule readiness, and Accountable Care Act implementation, all of which have 2013-2014 deadlines.

People are working hard. Priority setting is appropriate. Funding is available.

The problem is that the scope is too big and the timeline is too short.

What are the risks? 

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Quality Measurement 2.0

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By John Halamka, MD

I’ve written several posts about the frustrating aspects of Meaningful Use Stage 2 Certification.   The Clinical Quality Measures (CQMs) are certainly one of problem spots, using standards that are not yet mature, and requiring computing of numerators and denominators that are not based on data collected as part of clinical care workflow.

There is a chasm between quality measurement expectations and EHR workflow realities causing pain to all the stakeholders – providers, government, and payers.   Quality measures are often based on data that can only be gathered via manual chart abstraction or prompting clinicians for esoteric data elements by interrupting documentation.

How do we fix CQMs?

1.  Realign quality measurement entity expectations by limiting calculations (call it the CQM developers palette) to data which are likely to exist in EHRs.   Recently, Yale created a consensus document, identifying data elements that are consistently populated and of sufficient reliability to serve in measure computations.   This is a good start.

2.  Add data elements to the EHRs over time and ensure that structured data input fields use value sets from the Value Set Authority Center (VSAC) at NLM.    The National Library of Medicine keeps a Meaningful Use data element catalog that is likely to expand in future stages of Meaningful Use.

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A Little Advice for the Next National Coordinator

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By John Halamka, MD

Over the next few months, Jacob Reider will serve as the interim National Coordinator for Healthcare IT while the search continues for Farzad Mostashari’s permanent replacement.

What advice would I give to the next national coordinator?

David Blumenthal led ONC during a period of remarkable regulatory change and expanding budgets. He was the right person for the “regulatory era.”

Farzad Mostashari led ONC during a period of implementation when resources peaked, grants were spent, and the industry ran marathons every day to keep up with the pace of change. He was the right person for the “implementation era”

The next coordinator will preside over the “consolidate our gains” era. Grants largely run out in January 2014. Budgets are likely to shrink because of sequestration and the impact of fiscal pressures (when the Federal government starts operating again). Many regulatory deadlines converge in the next coordinator’s term.

The right person for this next phase must listen to stakeholder challenges, adjust timelines, polish existing regulations, ensure the combined burden of regulations from many agencies in HHS do not break the camel’s back, and keep Congress informed every step of the way. I did not include parting the Red Sea, so maybe there is a mere human who could do this.

What tools does the coordinator have in an era of shrinking budgets?

At present, Meaningful Use Stage 2, ICD-10, the Affordable Care Act, HIPAA Omnibus Rule, and numerous CMS imperatives have overlapping timelines, making it nearly impossible for provider organizations to maintain operations while complying with all the new requirements.

Can resources be expanded?

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What Keeps Me Up At Night – 2013 Edition

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By John Halamka, MD

Now that Labor Day has come and gone,  I’ve thought about the months ahead and the major challenges I’ll face.

1.  Mergers and Acquisitions

Healthcare in the US is not a system of care, it’s a disconnected collection of hospitals, clinics, pharmacies, labs, and imaging centers.  As the Affordable Care Act rolls out, many accountable care organizations are realizing that the only way to survive is to create “systemness” through mergers, acquisitions, and affiliations. The workflow to support systemness may require different IT approaches than we’ve used in the past. We’ve been successful  to date by leaving existing applications in place and building bidirectional clinical sharing interfaces via  “magic button” viewing and state HIE summary exchange. Interfacing is great for many purposes.  Integration is better for others, such as enterprise appointment scheduling and care management. Requirements for systemness have not yet been defined, but there could be significant future work ahead to replace existing systems with a single integrated application.

2.  Regulatory uncertainty

Will ICD10 proceed on the October 1, 2014 timeline?  All indications in Washington are that deadlines will not be changed. Yet, I’m concerned that payers, providers and government will not be ready to support the workflow changes required for successful ICD10 implementation.    Will all aspects of the new HIPAA Omnibus rule be enforced including the “self pay” provision which restricts information flow to payers?  Hospitals nationwide are not sure how to comply with the new requirements.   Will Meaningful Use Stage 2 proceed on the current aggressive timeline?  Products to support MU2 are still being certified yet hospitals are expected to begin attestation reporting periods as early as October 1.   With Farzad Mostashari’s departure from ONC, the new national coordinator will have to address these challenging implementation questions against a backdrop of a Congress which wants to see the national HIT program move faster.

3.  Meaningful Use Stage 2 challenges

Although attestation criteria are very clear (and achievable), certification is quite complex, especially for a small self development shop like mine.   One of my colleagues at a healthcare institution in another state noted that 50 developers and 4 full analysts are hard at work at certification for their self built systems.   I have 25 developers and a part time analyst available for the task.   I’ve read every script and there are numerous areas in certification which go beyond the functionality needed for attestation.    Many EHR vendors have described their certification burden to me. I am hopeful that ONC re-examines the certification process and does two things – removes those sections that add unnecessary complexity and makes certification clinically relevant by using scenarios that demonstrate a real world workflow supporting the functionality needed for attestation.

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