The US has spent several billion dollars on medical records, as part of the HITECH program. The goal of that spend was simple: portable medical records for patients. On our current path, we will have medical records, but without that magic word: “portable.” Ironically, the reason for this is identical to the root-cause of the problems with healthcare.gov
The root-cause of the initial failure of healthcare.gov was a lack of accountability and empowerment. There was no one person who was in charge of the operation, and those who were presumed to be in charge did not have the skill-set or political clout needed to make decisions about the project.
The result was the healthcare.gov train wreck. Thankfully, healthcare.gov was turned around.
That turn-around was the result of decisively fixing these exact issues.
Accountability restored, disaster averted.
You would think that the Obama administration and HHS would have learned the “accountability with empowerment” lesson well, if not for IT projects generally, then at least for projects involving Health IT.
Yet we are repeating this mistake with Meaningful Use. For those who are living in a cave with regards to healthcare reform, Meaningful Use is a set of standards designed to ensure that the money that the federal government spends on Electronic Healthcare Records (EHRs) for doctors results in clinically productive outcomes.
I’m afraid that if we don’t drill down on our brand equity on the front end, we’ll have to model it out on the back end to align our incentives or pad our ask regarding the co-branding deliverables on the horizon. As an FYI, this empowerment is going to require an elbow to elbow champion getting under the covers for a 360 of the eRoom to facilitate a paradigm shift in order to achieve buy-in among the stakeholders if we’re going to tip our toe into that water and get the low hanging fruit before our clients incentivize the burning platform with new metrics. After all, you are the process owner who needs to reach out in the proper bandwidth to push back on the KOL’s or we’ll have to sunset your blue ribbon committee for not trimming the fat on the real-time escalation project. We need to do more due diligence before we hitch our wagon to that indexed outcome measure, and let’s be careful how we message it and roll it out to the core constituency.
We can model that projected gap, but we don’t want to get out ahead of our audience before sensitizing them to the moving target. Let’s not drop the meat in the dirt but rather vet a pause point, collapse it up to a high level statement and assess the current state in order to connect the dots to achieve the ideal state and have you weigh in at the portal for service oriented architecture.
New Life for ACOs
CMS announces that 89 new organizations were selected to participate in the Medicare Shared Savings program, bringing the total number of participating ACOs to 424. The announcement comes on the heels of a recently released proposed rule that reflects an increased focus on primary care and improved incentives for participation. Were the pundits who predicted an early death for ACOs wrong?
Massachusetts Modifies Meaningful Use Mandate
The Massachusetts Board of Registration modifies a provision requiring providers to attest to Meaningful Use in order to retain their medical licenses. The final regulations establish multiple ways in which physicians can demonstrate proficiency using EHRs, including taking a three-hour continuing education class on EHR or registering with the state’s HIE.
The policy known as Meaningful Use was designed to ensure that clinicians and hospitals actually used the computers they bought with the help of government subsidies. In the last few months, though, it has become clear that the policy is failing. Moreover, the federal office that administers it is losing leaders faster than American Idol is losing viewers.
Because I believe that Meaningful Use is now doing more harm than good, I see these events as positive developments. To understand why, we need to review the history of federal health IT policy, including the historical accident that gave birth to Meaningful Use.
I date the start of the modern era of health IT to January 20, 2004 when, in his State of the Union address, President George W. Bush made it a national goal to wire the U.S. healthcare system. A few months later, he created the Office of the National Coordinator for Health Information Technology (ONC), and gave it a budget of $42 million to get the ball rolling.
Karen DeSalvo, MD, the national coordinator for health information technology for HHS, is leaving her post to to address public health issues, including becoming a part of the Department’s team responding to Ebola. She took over as the ONC head in January, 2014.
The ONC’s COO Lisa Lewis will serve as the agency’s acting national coordinator.
HHS spokesman Peter Ashkenaz told THCB:
“HHS Secretary Burwell asked National Coordinator for Health IT Karen DeSalvo to serve as Acting Assistant Secretary for Health, effective immediately. In this role she will work with the Secretary on pressing public health issues, including becoming a part of the Department’s team responding to Ebola. Dr. DeSalvo has deep roots and a belief in public health and its critical value in assuring the health of everyone, not only in crisis, but every day.
Lisa Lewis, ONC’s chief operating officer, will serve as the Acting National Coordinator. However, Dr. DeSalvo will continue to support the work of ONC while she is at OASH.”
The transition comes at a time when critics are asking tough questions about the government’s Meaningful Use program and providers’ lackluster progress qualifying for Stage 2.
It’s time to think carefully and look at the large systems (human and technical), institutions, and individuals that contributed to Mr. Duncan’s death. Systems should be designed to protect people and prevent human errors. Certainly we rely on the healthcare system to improve our health and to protect our privacy, especially our rights to health information privacy.
Looking at the death of Mr. Duncan, the poorly designed Epic EHR was a critical part of the problem: the lack of clarity, poor usability, hard to find critical information, and no meaningful quality testing to ensure the system prevents critical errors contributed to his death and endangered many others. Why wasn’t the discharge of a patient with a temperature of 103 from the ER flagged?
EHRs are one of several critical systemic problems.
Current US EHRs were not designed or tested to ensure patient safety or privacy (patient control over the use of PHI for TPO). The Meaningful Use requirements for EHRs don’t address patient safety or ensure patients’ legal rights to control use of PHI. Let’s face it, the MU requirements were set up by the Health IT industry, not by a federal agency charged with protecting the public, such as NIST or the FDA. Industry lobbying resulted in industry ‘self-regulation’, which has failed to protect the public in every other sector of industry. Industry lobbying is another critical systemic problem.
Our public discourse also is a critical systemic problem. The 24/7 US media drives us to play the ‘blame game’—and look at what happens: it’s a sham. A massive public and social media exercise substitutes for a crucial scientific and ethical oversight process by government and industry to face or examine the systemic causes and key actors—both people and institutions. We end up with no responsibility being assigned or addressed. Or the media hoopla and confused thinking leads to the opposite conclusion: everyone and everything is responsible and blamed, which has the same effect: it lets everyone and everything off the hook. Either way, no one and no institutions are to blame.
Making Sense of Blue Button, Meaningful Use, and What’s Going on in Washington …
At the recent Health 2.0 Conference in Santa Clara, co-chair Matt Holt expressed frustration about the difficulty of getting copies of his young daughter’s medical records. His experience catalyzed a heated discussion about individuals’ electronic access to their own health information. Many people are confused about or unaware of their legal rights, the policies that support those rights, and the potential implications of digital access to health data by individuals. The Health 2.0 conference crowd included 2000 entrepreneurs, consumer technology companies, patient advocates, and other potentially “disruptive” forces in healthcare, in addition to more traditional health system players.
Why is this topic so important? Until now, most people haven’t accessed their own health records, whether electronically or in paper, and I believe that making it easier to do so will help tip the scales toward more meaningful consumer/patient engagement in healthcare and in health. Access by individuals and their families to their own health records can empower them to coordinate care among multiple healthcare providers, find and address dangerous factual errors, and take advantage of a growing ecosystem of apps and tools for improving health-related behaviors, saving money on health services, and getting more convenient, personalized care.
A shorthand phrase for this kind of personal empowerment through access to digital health data is “Blue Button,” which is also the name of a public-private initiative in which hundreds of leading healthcare organizations across the US participate. The Blue Button Initiative is bolstered by the electronic access to health information requirements for patients in the “Meaningful Use” EHR Incentive Program, which is administered by CMS (the Centers for Medicare & Medicaid Services) with companion standards and certification requirements set by ONC (the Office of the National Coordinator for Health Information Technology).Continue reading…
The Meaningful Use program is at a critical inflection point. On one hand, the payers could jump on the MU bandwagon, follow Medicare’s example and demand provider MU attestation.
On the other hand, they could throw private practice a bone and help them weather the storm until MU goes away or loses its teeth. Let me explain.
Payers could take the easy money and penalize according to the upcoming ACA “adjustment” schedule. Lots of people think this is inevitable. This would certainly provide an easy way to increase payer revenue and is as simple as letting the practices [continue] to do all the work.
However, this would be incredibly short-sighted.
Meaningful use, as things stand in 2014, has not been shown to improve patient care. Indeed, it is common for Stage 1 attesting MDs to abandon the program during Stage 2, with many doctors citing lack of efficacy of the program. Stage 3 MU is projected to have even worse results.
What this tells me is that the stress and time-cost of MDs and their staff is not worth the benefits of Meaningful Use. Don’t get me wrong – there are some great things in the MU guidelines, and we are implementing them in the software we create, but they are overshadowed by the onerous, less-effective 5% and it’s all or nothing. There is no MU wiggle-room. These days you have to have real grit and determination to stay in private practice, no matter your specialty.
Without financial support or legislative reform, Meaningful Use will eventually drive independent doctors out of business.
That’s bad news for payers.
As a result of the determined efforts by Massachusett’s politicians, businesses, health insurance companies, hospitals, individual physicians and the Massachusetts Medical Society, nearly 100% of patients in Massachusetts now have health insurance. This is something all the healthcare players in Massachusetts can be proud of, and “universal insurance” enjoys broad public support here in Massachusetts
In an attempt to improve healthcare quality and reduce cost, Massachusetts is moving away from the “fee-for-service” system and replacing it with “physician groups” which contract with insurance companies. Most of these contracts include financial incentive/disincentive clauses about “quality” and “cost.” As a result, in Massachusetts, it is now almost impossible for a solo practitioner to obtain a contract directly with one of the state’s largest insurance companies. Almost all contracts are mediated through a local physician organization, such as an IPA, PHO or ACO.
As a result, health insurance companies now have much greater influence over the Massachusetts healthcare industry. These large insurance companies define the terms of the contract and can tell the small or medium-sized hospitals/physician contracting group their contract is a “take it or leave it” proposition. Needless to say, it is impossible for any small or medium-sized hospital/physician contracting group to refuse to accept the insurance contract when their financial viability is predicated on having access to the insurance company’s patient panel.
Originally Certified EMRs and Meaningful Use policies were created so as to provide the financially incentive to encourage primary care physicians to adopt electronic medical record programs and then use these electronic medical record programs according to specified “meaningful use” mandates. It was the hope that the appropriate use of EMRs would improve the quality or reduce the cost of healthcare. Since the program’s introduction, Meaningful Use has been expanded to almost every medical specialty and subspecialty, regardless of the appropriateness/relevance.
There has now been a fair amount of data accumulated regarding the effectiveness of electronic medical record programs. Unfortunately, most of the published data is not high quality and the majority of clinical trials are now being funded by the EMR industry. As we have seen with clinical trial sponsored by the pharmaceutical industry, only an irrational person would accept the results of a vendor sponsored EMR trial on face value.
Recently, The Office of the National Coordinator for Health Information Technology (HHS) asked the RAND corporation to review all EMR data. RAND created the “Health Information Technology: An Updated Systematic Review with a Focus on Meaningful Use Functionalities”