Here’s a Crucial Technological Fix to Rising Health-Care Costs

Via Wall Street Journal »

Dr. Peter Pronovost (@PeterPronovost) is a practicing anesthesiologist, critical-care physician, professor, Johns Hopkins Medicine senior vice president and director of the Armstrong Institute for Patient Safety and Quality. He blogs fromVoices for Safer Care.

If we want to rein in the costs of the U.S. health-care system – now equal to nearly 18% of the nation’s gross domestic product – we cannot ignore the fragmented technologies used to help heal and save lives.

At first glance, the devices, monitors, electronic health records and machines found in today’s hospitals might inspire awe. Look beyond the slick displays with blinking lights, however, and the picture is less reassuring. Rather than working as an integrated whole, these technologies rarely “speak” to one another, reducing productivity and increasing costs. As a result, time that clinicians might spend at the bedside or discussing patient cases with colleagues is used to fill in the gaps between uncoordinated technologies.

For example, nurses scribble down a physician’s instructions for a drug infusion from one computer screen, do math to find the right dose, and then walk to the medication pump and enter the order. Every high-risk medication requires a second nurse to double-check that the pump is programmed accurately — a task that drains staff time. On a 12-bed intensive care unit, these double-checks add up to two full-time nursing positions, we found at Johns Hopkins. Yet if the electronic orders communicated with the pump, this extra work would not be needed, and the risk of entering the wrong dose would diminish.

Clinicians who want to gauge a patient’s progress and risk of complications need to make hundreds of clicks on computer screens, check devices and eyeball the settings on the patient’s bed. In one of our ICUs, the work of ensuring that patients received steps to prevent seven common harms – such as blood clots and infections – takes nearly 20 minutes. Integrate systems and that time can be cut by two-thirds, we found in a pilot project.

Hospital beds typically come with alarms that alert staff when a patient starts to get out of the bed on his or her own. Yet sometimes staff forget to turn the alarm back on — for instance, after the patient returns to the bed following an X-ray. An integrated system would quickly flag patients who are deemed a high fall risk but whose bed alarms aren’t activated. Instead, in many hospitals, staff still must walk from room to room to visually check that bed alarms are on for patients who need them.

Other fields have used systems integration approaches to become high-performing, less costly and ultra-safe. In aviation, for example, controls, instruments and mechanical systems communicate with each other, enhancing pilots’ situational awareness. Pilots don’t spend time poring over topographical maps to make sure they don’t fly the plane into a mountain; the plane gets that data and warns them if they are approaching a cliff. Yet health care has not embraced similar approaches.

Such a change is overdue. There are certainly other solutions to improve health-care productivity and decrease costs. Complications and substandard care make hospital stays longer or lead to readmissions. Staff spend too many hours on required documentation. Hospitals devote enormous administrative resources to working with hundreds of different insurers. Drug prices are constantly rising. Yet we cannot ignore the dysfunctional systems at the heart of how we care.

If we improve productivity by integrating technologies and extracting their data, we can do more than reduce costs. We can transform the patient experience: fewer complications, more “quality time” with their care team, and more opportunities to engage in their care.

EHR interoperability’s uncertain future

Via Medical Economics »

For urgent care physician John Kulin, DO, interoperability of electronic health records (EHRs) has long been a dream—one that remains unfulfilled.

In his Manahawkin, New Jersey, practice, he and his staff of 17 physicians have access to complete medical records for fewer than 5% of all patients despite significant investments in interoperability software. With 60,000 patient visits annually, he gets the patient information he needs electronically from only 3,000. For the rest, the practice relies on paper records. 

“Interoperability is a huge problem,” he says. “Yet, it’s one of the holy grails of actually engaging patients more and using our EHRs to make patient care better so that we’re not operating in different silos. But so far, it’s not happening well at all.”

The federal Office of the National Coordinator for health information technology (HIT) defines interoperability as the ability of information systems to exchange patients’ electronic health information and use information from other EHR systems without any special effort from the user.

For many patients, Kulin has a semblance of interoperability because he benefits from data on prescription medications and lab test results sent directly to his EHR . 

“When we get lab results back through our lab interface, it all comes right into the chart, so now we can compare and graph that data against prior lab work,” Kulin says. “That’s one of the few systems where we have prior data from other providers. That gives us a much better understanding of what’s going on with patients and enhances care.”

Kulin shares patient records via Direct secure messaging (Direct), a protocol for exchanging clinical messages and attachments such as patient records. In the second quarter of this year, physicians and other providers sent 24 million Direct exchange transactions via this secure email system, which complies with federal privacy standards under the Health Insurance Portability and Accountability Act (HIPAA). 

But when it comes to getting patient information from area hospitals and other physicians or imaging test results, Kulin is mostly operating blind. “From an urgent care perspective, I want access to every one of our patients’ medical records, particularly from primary care physicians,” he says.

When he does get medical records from hospitals or physicians, they come mostly via fax. “That’s problematic because it’s a hard copy that we need to read and put into a PDF that goes into the chart,” he explains. 

Interoperability still out of reach

Certainly paper is inconvenient, but for Kulin it’s also a sign that true interoperability is still years away, a factor that drives up costs needlessly. Without access to records, for example, he can’t compare a current EKG with an earlier one, making it impossible to know what’s normal for a patient, he adds.

Not knowing what’s normal means Kulin or someone on his staff may need to send a patient to the nearest emergency department. “Without that information, we’re just operating in a vacuum, and that’s something we never want to do,” he says.

Earlier this year, physicians were optimistic when the Senate Health Education Labor and Pensions (HELP) Committee unanimously passed S. 2511, the Improving Health Information Technology Act, to reform the rules governing federal standards for health information technology and EHR systems. Finally, Congress seemed to be addressing the problems that resulted after it passed the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009.

But despite the unanimous committee vote and support from members of both houses and both parties, the bill has not come up for a vote. Action on S. 2511 may have slowed because physicians and the Centers for Medicare & Medicaid Services (CMS) are preparing to implement new payment systems next year under the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. Physicians and HIT vendors have expressed concerns to Congress that the U.S. Department of Health and Human Services (HHS) may be changing too many of the requirements they impose on how  physicians practice all at once. 

So how long will it be before we achieve true interoperability? HIT experts tell Medical Economics that HHS will need to provide more incentives to HIT vendors to make their systems truly interoperable and that HHS has the power to do so now.

In its October, 2015 report, “Connecting Health and Care for the Nation. A Shared Nationwide Interoperability Roadmap,” ONC predicted it would be 2021 to 2024 before the nation’s health system achieves interoperability, which it defines as one that would “enable a learning health system, with the person at the center of a system that can continuously improve care, public health, and science through real-time data access.”

Our experts agree, predicting that true interoperability will be in place by the ONC’s target date. “We definitely want a system where information moves around seamlessly,” says Robert M. Wachter, MD, author of “The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age”and a practicing hospitalist.

It would be best, he adds, if EHR vendors would allow physicians to move patient data easily from one system to another. But that seems unlikely given the restraints physicians face under HIPAA, the fear of system breaches that can—and do expose patients’ records to hackers, and the fact that vendors have little incentive to promote interoperability.

“There’s not a great market advantage for vendors to share. In fact, you could say there’s a market disadvantage to sharing information,” explains Wachter, a professor and interim chair of the Department of Medicine at the University of California, San Francisco. Some EHR vendors for hospitals and health systems don’t share patient information with physicians who are out of network, for example.

To address this problem, the federal government should use its clout as the nation’s largest purchaser of healthcare to get HIT vendors to enable patient data to flow more freely among systems, Wachter says. If necessary, he adds, the government should threaten that “interoperability will be forced on you if you don’t do it yourself.”

A combination of actions such as those called for in S. 2511 and government steps  to require HIT vendors to achieve interoperability will force those organizations standing in the way of interoperability to begin to do so, he explains. 

The double-sided coin of sharing data

But for now, even though all HIT vendors are not working toward true interoperability, Wachter says, “I don’t see any villains here.” He cites the problem of information blocking, which occurs when one EHR system does not allow providers working with another system or working for a different healthcare organization to access patient data. Information blocking is generally not malicious, says Wachter. 

Instead, most IT vendors working for physician groups, hospitals, and health systems serve the needs of their customers—healthcare providers–rather than the needs of the larger healthcare system. In these situations, committing scarce IT resources to sharing with other systems falls to a lower place on the priority list, Wachter says. Moreover, sharing patient data across multiple systems increases the risk that patients’ records could be hacked or stolen, he adds.

What’s more, if patient information leaks out due to a breach, leading to a $1 million fine, then a provider organization might be conflicted about data sharing, he says. “On the one hand, the provider might say, ‘Yes, we want to share information,’ but, on the other, they’re really saying, ‘No, we can’t do this because we don’t feel completely safe with that kind of risk,” he explains. 

The way Farzad Mostashari, MD, former National Coordinator for Health IT, sees it, physicians and other providers bear some of the responsibility for allowing hospitals and health systems to block information and should demand more, he says. 

Not only should physicians demand more from hospitals and health systems, they need to ask more from their EHR vendors, says Mostashari, the founder of Aledade, a company that helps primary care physicians form and operate accountable care organizations. Those vendors are required to meet specific certification requirements, and, previously, these systems were tested against the ONC’s certification standards and showed they could meet those requirements, he adds. But when Aledade evaluated 33 EHR systems to determine if they could meet those certification requirements, most of them failed, he says.

“Only 38% of those EHRs could actually give us an electronic download of the patient’s summary records in standard form,” he says. But when most don’t perform in the field, then neither legislation nor new regulations will solve the problem. “What we need is enforcement of the laws and the regulations we already have on the books,” he says. 

To ensure that their physician clients get the data they need from hospitals, Aledade pays EHR developers and interface vendors to improve the flow of patient information. “That’s a tax on physicians that we pay in order to ensure the success of population health,” he says. 

“Patient data shouldn’t be held hostage,” he adds. “If a physician has a certified EHR and that EHR can’t get the data physicians need, then physicians should complain to the certification body and to the ONC.” 

What’s the solution?

Still, it would be unfair to level all of the blame on providers and IT vendors, because regulators also bear some responsibility for the failure of HIT systems to achieve what physicians want, Wachter adds. “To a large degree we have not created a regulatory environment that promoted the development of an infrastructure for sharing,” he says. 

Congress anticipated that interoperability would reduce redundant services and lower costs, but that hasn’t happened. Realizing the benefits of interoperability will require Congress and regulators at HHS to urge vendors and health systems to allow a more unrestricted flow of patient data. “But exhortation is only the first step,” Wachter says, adding that HHS needs to flex its market power as a buyer and threaten to require interoperability.  

For John D. Halamka, MD, chief information officer of the Beth Israel Deaconess Medical Center in Boston, Massachusetts, interoperability requires technology standards and policies and a business case for sharing data, he says. 

S. 2511 would address some of these issues, such as commissioning the Government Accountability Office to investigate the possibility of a national healthcare identifier, critical for exchanging data, explains Halamka, the former chair of the US Healthcare Information Technology Standards Panel. Also, interoperability requires governance and data use agreements, he adds. “We need to understand who we can trust, the electronic address for sending them data, and how they’ll use the data,” he says.

The problem with new interoperability standards, he adds, is that they can impede progress. S. 2511 addresses the need for better standards by calling for the creation of a federal policy and standards committee, he says. In the past, members of Congress drafted policies and then staff members wrote the standards needed to implement those policies. But the act requires one group to produce policy and technology standards in parallel, he says.

Halamka agrees with Wachter that HIT vendors have an important role to play in solving the problems physicians face. Vendors already are taking steps to enhance interoperability, he adds, citing two examples that will ease the data-collection burden physicians face and the lack of true interoperability. 

First is the Argonaut Project, which aims to advance industry adoption of interoperability standards to foster the sharing of patient data in EHRs and HIT systems, he says. The project is a joint venture of EHR vendors such as athenahealth, Cerner, and Epic; health systems such as the Beth Israel Deaconess and the Mayo Clinic; and consultants such as Accenture. 

Second is a system to measure interoperability that KLAS is developing. An HIT research organization, KLAS rates EHR systems in such areas as usability and plans to report publicly on physicians’ experience using the interoperability functions of every EHR vendor, Halamka says.

Wachter cites another promising development: IT companies that were not previously involved with healthcare, such as Apple and Google, have seen the potential that follows when the federal government makes a $30 billion investment in HIT and Meaningful Use. “That amount of money woke up Silicon Valley,” he says. 

Consumer IT companies see a significant opportunity given that the United States spends $3 trillion on healthcare annually. While those companies are not solving physicians’ problems with interoperability or Meaningful Use, it is nonetheless significant that they are involved, even if it’s only to develop wearable technologies designed to get patients more involved in managing their health, he says. Apple and other companies making and selling gadgets to collect health data will start by serving consumers and then branch out to serve healthcare providers, he adds.

As consumers take on a larger role in managing their own health, Halamka says, they will demand improvements in HIT systems. “Every provider should have an EHR system and every patient should have access to that record,” he adds. And once EHRs can exchange data, if a consumer finds that his or her provider has one that cannot do so, that consumer should change providers, he says. 

In Health Affairs Blog, DeSalvo, Washington Share Ambitions for an Interoperable Future

Via Healthcare Informatics »

A new Health Affairs blog by Drs. DeSalvo and Washington shares thoughts on what will be needed to create an interoperable future

The immediate past National Coordinator for Health IT and the recently appointed National Coordinator for Health IT on Sep. 29 co-authored a blog online in Health Affairs touting the gains made in the adoption of electronic health records (EHRs) made in the years since the passage and implementation of the HITECH (Health Information Technology for Economic and Clinical Health) Act in 2009, and laying out their vision of a more digitally interoperable healthcare system. Writing on Sunday in the Health Affairs Blog,Karen DeSalvo, M.D. and Vindell Washington, M.D., the immediate past and current National Coordinators, highlighted the near-universalization of EHR adoption among U.S. hospitals and physician practices, while sharing thoughts on what elements will be needed to push forward the interoperability of healthcare information going forward.

Drs. DeSalvo and Vindell wrote that, “Over the past seven years, the United States has seen a historic health IT transformation, moving from a primarily paper-based health system to one where virtually everyone has a digital footprint of their care because of the dramatic uptake of electronic health records (EHRs). Recent data have helped quantify just how rapidly technology has transformed clinical settings. Today,” they noted, “nearly all hospitals (96 percent) and nearly eight in 10 (78 percent) physicians use certified EHRs. This transformation is the result of 2009’s Health Information Technology for Economic and Clinical Health (HITECH) Act, when fewer than one in 10 hospitals and 17 percent of physicians used EHRs. This rapid uptake of technology reflects the unyielding effort by clinicians and health systems across the board who helped usher in this new era of medicine. The result of this effort is a vast amount of electronic health data now exists which simply did not seven years ago.”

What’s more, DeSalvo and Vindell wrote in Health Affairs, “This transformation represents more than simply digitizing paper health records. It also puts us at a global competitive advantage and is leading to real-world impacts in the clinical setting. Systematic reviews of academic literature found that 84 percent of studies showed that certified EHRs had a positive or mixed positive effect on quality, safety, and efficiency of care. Other recent studies found that EHRs can reduce adverse events among cardiovascular, surgery, and pneumonia patients and that switching EHRs did not result in adverse safety events.”

As the federal officials noted, “These results reflect the vision we laid out in two key documents last year when we collaborated with more than 35 federal partners to develop the Federal Health IT Strategic Plan 2015-2020, and joined forces with the private sector to develop A Shared Nationwide Interoperability Roadmap, which outlines milestones, calls to action, and commitments that public and private stakeholders should focus on achieving, particularly in the near-term, to continue making progress.”

Moving forward, DeSalvo and Vindell wrote, it is the goal of federal officials at the Department of Health and Human Services (HHS), Centers for Medicare & Medicaid Services (CMS), and Office of the National Coordinator for Health IT (ONC) to create a “learning, person-centered health system,” one that helps the healthcare system to shift from the initial-adoption phase of the past few years to a more advanced phase involving “improving patient experiences and health outcomes” through EHR and other clinical information systems.

To do this, they write, ONC will focus on partnering with public and private partners to accelerate true interoperability of health information, via the following means: “the use of common, federally recognized, national standards; changing the culture around access to information—including combating data blocking; and, building the business case for interoperability.” They add that, “To achieve these goals, the Administration is leveraging impactful tools: delivery system reforms that drive a business case for interoperability; new guidance on the Health Insurance Portability and Accountability Act (HIPAA) to make providers and individuals aware of patients’ rights to access and transmit their data; and requiring publishing application programming interfaces (APIs) to enhance the connectivity between EHRs and provider and consumer applications.”

Interoperability, the cherished dream

Via Politico »

EXCHANGE OF VIEWS ON INTEROPERABILITY: CIOs who met at a Capitol Hill event Tuesday rejected comments by Allscripts CEO Paul Black suggesting that interoperability was just around the corner and that information blocking “has broadly been solved.” CHIME CEO Russ Branzell got the discussion going by asking panelists if they agreed.

“Not even close,” said Intermountain CIO Marc Probst, a former ONC adviser and never one to mince words. While some strides have been made by ONC and the private sector, “We have a long way to go to be truly, semantically interoperable, where data can be passed and not just PDF documents or automated faxes.”

Albert Oriol, CIO of Rady Children’s Hospital in San Diego, said his health system exchanged 500,000 records with others last quarter. Another 150,000 couldn’t be shared because they couldn’t correctly match records with the right patient, he said.

ONC head Vindell Washington also suggested that a culture of data sharing is a ways off. Providers and patients need to be able to expect information to be at their fingertips, he said — a far off goal. Health care providers need to incentivize information sharing, and standards need to be developed, he said.

Many of the doctors we’ve spoken to in recent weeks have given up on interoperability — at least in the lofty sense that HHS officials speak of it. They assume that the only way they can share data easily with another doctor is to belong to the same health care system — or at the very least share the same EHR. Some technologists agree, and think that EHRs are not the tools that will bring us free-flowing health information exchange.

Calling Apple….

Tweet of the Day: Brian Ahier @ahier Health insurers (finally) making use of #AppleWatch http://cnet.co/2d1Nyxb Looking forward to new #mHealth #apps for #wellness

Welcome to Wednesday eHealth, where we are too old to Twitch but still young enough to Zocdoc. Please send your reporting tips to aallen@politico.com, or tweet the most compelling and distracting rumors to @David_Pittman, @ arthurallen202, @DariusTahir @ POLITICOPro, @Morning_eHealth.

#AskVindell TWITTER CHAT: While Washington didn’t answer Branzell’s question about interoperability being “solved” during Tuesday’s event, he did say during a Twitter chat that “Information still does not flow as seamlessly as it needs to. That’s why we all need to work together to combat #datablocking.” Read a roundup of some of the key tweets in this post.

DIGITAL INSURANCE MOVEMENTS: Two pieces of business news point in a promising direction for health IT. First, HealthTap, which provides text, voice and video connections to doctors, announced Tuesday that health insurers are now covering its virtual consults. According to a news release, carriers such as United Healthcare, Cigna, Aetna and Humana will no longer require phoned permission to cover the visits; HealthTap will check patient eligibility in real-time, and the company also will submit electronic insurance claims on behalf of doctors to payors.

…. Aetna, meanwhile, announced that it will make Apple Watch available to some of its large employers and individual customers during open enrollment this fall, and will subsidize much of the cost, while allowing monthly payroll deductions to cover the rest. Aetna will provide Apple Watch for free to nearly 50,000 of its own employees as part of the company’s wellness program. Aetna is hoping that apps will help its customers improve their health and save it money. Apple Watch can help patients with medication adherence, wellness orientation, and decision support, according to a news release.

PDMP EXPANSION IN CALIFORNIA: Gov. Jerry Brown on Thursday signed into law a bill that requires all prescribers to check the state’s PDMP before prescribing opioids or other controlled substances. About 20 other states have laws requiring some degree of PDMP monitoring for physicians. Shatterproof CEO Gary Mendell, who lost his son Brian to addiction in 2011, led the fight for the bill in Sacramento.

PULL UP TO THE BUMPER, BABY: Ride-sharing provider Uber will start to work with hospitals in Massachusetts, Pennsylvania and Delaware to provide rides to medical appointments. Uber announced Tuesday it would partner with Circulation for the non-emergency medical transports. Because hospitals and health plans demand certain credentialing to get paid for lifts to doctors’ offices and hospitals, Uber needs a way to meet those higher standards, and Circulation provides it. Medicaid agencies spend $3 billion on non-emergency medical transportation, Uber says — and a third of the payments are inappropriate.

EVIDENCE TELEMEDICINE SAVES MONEY: Partners Healthcare has been using telemedicine to treat heart failure patients for some time and has data to show it has saved the sprawling Boston health system money — including for Medicare patients. At the CHIME event we mentioned above, CIO Cara Babachicos cited company data showing that remote monitoring of recently discharged heart patients has cut what Partners spends on Medicare patients by nearly 2 percent. It also reduced 30-day readmissions by 75 percent and 120-day readmissions in half. Congress has been working for years to boost Medicare reimbursement for telemedicine, but the Congressional Budget Office has said more remote doctoring will only increase federal spending on health.

EVERYBODY’S SHOOTING FOR THE MOON: The Patent and Trademark Office, which on Thursday announced the winners of its Cancer Moonshot Challenge, aims to leverage intellectual property data to illuminate new directions in research on cancer. First place was won by Dolcera, which makes rather “engaging visualizations” that offer insights on cancer research priorities. Second place went to Booz Allen Hamilton and Omnity, which built visual networks based on linguistic similarity among cancer patents and NIH-funded research. These findings, per the USPTO, will empower research funders of all stripes to point their money in the most promising directions. Get your details here.

KIBBLES ‘N BITS: The National Quality Forum’s Measure Applications Partnership brought on Chip Kahn, CEO of the Federation of American Hospitals, and Columbia psychiatrist Harold Pincus to co-chair a committee recommending the best measures to be used in federal programs that pay doctors. … Congress still hasn’t ponied up money to fight Zika, but University of Arizona researchers (who’ve been working with the CDC) launched a crowd-sourcing mobile app, called Kidenga, Tuesday to help detect outbreaks. … A VA inspector-general investigation showed that providers in the New Mexico VA Health Care System did not always respond to EHR alerts regarding irregular colonoscopies in a timely way — and as a result nine patients eventually diagnosed with colorectal cancer got their results late enough to potentially affect their clinical outcomes in 2013 and 2014.

Read more: http://www.politico.com/tipsheets/morning-ehealth/2016/09/interoperability-the-cherished-dream-insurers-start-buying-health-it-services-california-pumps-up-its-pdmp-216559#ixzz4Lm8gEIF5
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Jonathan Perlin’s ‘Elevator Pitch to the President’ on Health IT

Via Healthcare Informatics »

Focus on learning health system, interoperability, cybersecurity, he says

What would you say if you had to make an “elevator pitch” in just three to five minutes to the President of the United States about what to focus on in terms of the nation’s healthcare system? That was the question put to panelists at a Sept. 26 meeting of the National Academy of Medicine (NAM). Jonathan Perlin, M.D., chief medical officer of Hospital Corporation of America (HCA), responded: “It’s all about the data.”

To inform debate and decision-making, NAM has launched a program called Vital Directions for Health and Health Care. It commissioned expert papers on 19 priority focus areas for U.S. health policy, including health IT. Together, these papers represent the guidance of more than 100 leading researchers, scientists, and policy makers from across the United States. Perlin co-authored a paper with  a cast of well-known health IT experts, including Dixie B. Baker, David J. Brailer, Douglas B. Fridsma, Mark E. Frisse, John D. Halamka, Jeffrey Levi, Kenneth D. Mandl, Janet M. Marchibroda, Richard Platt, and Paul C. Tang.

Representing these authors at the Sept. 26 meeting, Perlin said that knowing that data is central to every strategy for research and discovery and point-to-point healthcare, there is an opportunity that is ripe for the taking. “With meaningful use, the president, if you will, has bought the car and now it is time to drive it,” said Perlin, who before joining HCA in 2006 was CEO of the Veterans Health Administration. “The president’s opportunity is not to drive on a slow toll road but to realize the vision of a fast superhighway.”

In his elevator pitch, Perlin focused on three themes: development of a learning health system, end-to-end interoperability and cybersecurity initiatives.

Data strategy for learning health system. The notion of a learning health system is defined as a system that commits to the continuous use of data as a byproduct of care for continuous learning and a virtuous cycle.  Perlin pointed out that 98 percent of hospitals and 95 percent of physician practices are computerized. “We are clicking, but we’re not yet learning,” he said. “By virtue of all that clicking, a ‘data exhaust’ is created, and in the data are answers to numerous questions,” he said. That data exhaust in the form of structured data could be fed back into the system to spur discovery, knowledge and better population health management. As an example, Perlin noted that he grew up as a physician lumping diabetics into a few categories, when actually there are 14 or more forms of diabetes. “I need the decision support tools so I can best treat the patient in a personalized and precise way.”

He gave as an example of a learning health system project the recently completed landmark REDUCE MRSA study, which demonstrated a 44 percent improvement on known best practices for reducing bloodstream infections.

Interoperability. Perlin said end-to-end interoperability must extend from formal settings of care to medical devices and importantly enfranchise patients as consumers of healthcare and their health data, encompassing patient-reported outcomes as well as patient-generated data.

“We are not talking about a single structured monolithic system,” he said, “but rather a set of architectures that take advantage of technologies we use today in things like web services that would allow for the development of an ecosystem of utilities that can support plug-and-play and clinical decision support for formal caregivers but also the opportunity for the patient to reach in and access of information.”

Referring to FHIR (Fast Health Interoperabilty Resources), Perlin said there are new standards that have very much in common with the infrastructure we take for granted in applications we use on our smartphones or when we use web services on the Internet. “We can also get data that are extremely granular so they are available to research and discovery.  And the patient can be enfranchised as part of that data equation in that virtuous loop.”

In their recently published Vital Signs paper, Perlin and his co-authors note that  “a generation of legacy EHRs that lack the design and features needed for interoperation is widely in place, so it will be challenging and potentially expensive to reach this goal.

“Progress toward interoperability could be accelerated initially by focusing on high-value use cases, such as transitions of care, outcomes measurement, and public-health reporting. Achieving interoperability is like building the interstate highway system: we need to construct on ramps and off ramps one at a time, but we also need a master plan.

“In the absence of an authoritative private source, the federal government should be highly specific about standards for end-to-end interoperability. Interoperability needs to extend from medical devices to EHR systems. In the absence of interoperability, end-user costs are higher because users are compelled to cobble together inherently non-interoperable systems. In addition to all the risks posed by imperfect interoperation, there is a loss of the value that could be gained through research, care, and public health when these systems interoperate.”

Cybersecurity. Finally, Perlin said he would tell the president that we have an obligation as well as an opportunity to aggressively address cybersecurity vulnerabilities and create protections in that regard. “We are in an era where the penetration and threats are significant, not only in terms of frequency but in terms of sophistication, even with state actors.” He stressed the importance of sharing threat information and strategies to mitigate the threat. He said policies might need to protect those organizations that meet all of the requirements but still may be subject to the action of a state actor.

Almost 70 Percent of Hospitals Provide Patients View, Download and Transmit Access to Health Information

While hospital adoption of key patient engagement functionalities is increasing, small and critical access hospitals are lagging behind

Seven out of 10 hospitals in the U.S. (69 percent) now provide their patients with the ability to view, download and transmit their health information electronically, an almost seven-fold increase since 2013, according to a data brief from the Office of the National Coordinator for Health IT (ONC).

The data brief takes a look at trends in hospitals’ adoption of key patient engagement functionalities between 2012 through 2015. The data, which is based on the 2015 American Hospital Association Health IT Supplement Survey, reflects trends among U.S. non-federal acute care hospitals. Vaishali Patel, Ph.D., senior advisor at ONC, also discussed the data findings during a joint meeting of the ONC Health IT Policy and Standards Committees on Tuesday.

According to ONC, the Shared Nationwide Interoperability Roadmap calls on health care providers to enable patients to electronically view, download, and transmit (VDT) their health information to a destination of the patient’s choice. The Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs required participating hospitals and health care professionals to enable patients with online access to view, download, and transmit their health information.

In 2013, only 10 percent of hospitals had adopted VDT capabilities. As of 2015, 95 percent of hospitals enable patients to view their health information electronically, up from 40 percent in 2013; 87 percent of hospitals enable patients to download their health information, up from 28 percent in 2013 and 71 percent of hospitals provide patients the capability to electronically transmit their health information, which is up from 12 percent in 2013.

“The tremendous growth in hospitals’ adoption of view, download, and transmit capabilities in a relatively short period of time points to the potential impact of the Medicare and Medicaid EHR Incentive Programs, and specifically to the measures related to view, download, and transmit that were required for Stage 2 of the program,” Patel wrote in the data brief.

The number and variety of patient engagement functionalities offered by hospitals continued to increase significantly in 2015, according to the data brief. Almost two-thirds of hospitals (63 percent) enable patients to send or receive secure messages and 37 percent provide the capability for patients to submit patient-generated data, an almost 3-fold increase since 2013.

In 2015, more than three quarters of hospitals (77 percent) enabled patients to request an amendment to their health data, and offered patients the ability to electronically pay their bills (74 percent).

It is interesting to note that fewer hospitals have, so far, adopted basic convenient electronic capabilities, such as enabling patients to request prescription refills online. Four out of 10 hospitals allowed patients to request prescription refills (42 percent) and schedule appointments online (44 percent).

Patel wrote in the data brief, “Certain ‘convenience’ functions that enable patients to schedule appointments or refill their medications electronically lagged behind in adoption compared to those that relate to the Medicare and Medicaid EHR Incentive Programs, Health Insurance Portability and Accountability Act (HIPAA) regulations, or billing.”

Nine in 10 hospitals possess four or more electronic patient engagement capabilities, while the percent of hospitals adopting seven to nine patient engagement functionalities increased from 38 percent in 2014 to 43 percent in 2015.

At the state level, the percent of hospitals with VDT capability has spread nationwide between 2013 and 2015, according to ONC. In 2013, no states had 40 percent or more of their hospitals with these three electronic capabilities; whereas by 2015, all states had 40 percent or more of their hospitals with these three capabilities.

However, ONC data also indicates that disparities exist in the adoption of view, download, and transmit functionalities between large hospitals and other types of hospitals, specifically medium, small and Critical Access Hospitals.

As an example, almost 8 in 10 large hospitals have all three VDT capabilities while only about 6 in 10 CAHs (61 percent) have all three capabilities. And, for further comparison, only 65 percent of small hospitals have all three capabilities and 71 percent of medium-sized hospitals have all three capabilities. There seems to be equity when it comes to providing the capability for patients to view their health information, as 93 percent of CAHs and small hospitals offer this capability and 97 percent of medium hospitals.

“Rural and smaller hospitals’ lower rates of VDT capabilities reflect lower rates of certified HER technology adoption, and will require continued monitoring,” Patel said when presenting the data at an ONC Health IT Policy and Standards Committee meeting on Tuesday.

Patel also noted that to increase usage of these capabilities, it will be important to make it easy for individuals to access, aggregate, and subsequently use their health information. And, she pointed out various ONC initiatives to foster patient engagement and access to health information, such as the patient engagement playbook, the consumer health data aggregator challenge and the Blue Button connector.

Moving forward, Patel said analysis of patient engagement should shift from gathering data on hospital adoption of patient engagement functionalities to now focus on usage of those functionalities and how it ultimately improves patients’ health.

Via Healthcare Informatics »

Tackling the health IT challenge: A Nashville case study

The health care sector is seen as both a blessing and a curse to cities. On one hand, the sector continues to be a solid and steady employment base for regions. On the other hand, many of these jobs aren’t high-paying. Nationally, steep health care costs have placed untenable financial burdens on both individuals and families.

Missing from this narrative, in any event, is another, newer storyline about how cities can use health care-related economic activity as a source of high-value innovation and entrepreneurship to create well-paying jobs and grow the economy. In a new publication, for example, my coauthors and I focus on metro Nashville as a case study, analyzing how cities can leverage information technology (IT) to build best-in-class regional health care industries. But unlike the preponderance of literature, our expertise is not on health outcomes, but on how cities can create competitive industries—industries based not on the legacy model of high-cost fee-for-service care, but on a new business model driven by technology and value to patients.

Massive changes are underway in the U.S. health care system, shifting the competitive landscape, opening up new opportunities for some regions, and undermining traditional strengths in others. Information technology is playing a revolutionary role in these trends.

First, the passage of the Patient Protection and Affordable Care Act in 2010 inaugurated an era of unprecedented expansion in access to both care and health insurance. It also signaled the government’s intent to drive health care toward a value-based system based on health outcomes, threatening the solvency of those care providers that refuse to adapt.

Second, as patients become fed up with high costs, new competitors are emerging—particularly in outpatient care. For example, CVS’s Minute Clinics have grown at an average rate of 18 percent annually during the last several years, and between 2007 and 2013, patients using retail clinics increased by 133 percent. As Brookings scholar Jonathan Rauch wrote, “Health care is beginning to taste the disruptive culture of Silicon Valley, retailing, and many other American sectors.”

To say IT has disrupted nearly every other sector of the economy is an understatement. Yet its most disruptive opportunities are yet to come in health care, a field that has lagged behind other segments of the economy in adopting IT and data-driven innovation. Providers, payers, and suppliers across the care continuum are ramping up investments in data, analytics, and IT and finding abundant opportunities to carve out value and increase quality and productivity throughout the system.

Given all these macro forces, why focus on Nashville? The opportunity for Nashville revolves around multiple areas of competitive advantage: large and stable health care companies; a young but growing software sector, and; a high concentration of health-related research at Vanderbilt University. All position the region to emerge as a center for inno­vation in health IT.

Like many American cities with longstanding strengths in clinical care, hospital management, and research, Nashville is facing new competition from tech insurgents in places like San Francisco, Austin, and Seattle that are literally decades ahead of most the country in terms of IT talent and companies.

Given legacy strengths, but a clear and present danger to its competitive position, what should a city like Nashville do? The region—including its public, private, higher education, and philanthropic leadership as well as state government—should focus on efforts to strength its capabilities and competences. To improve commercial innovation in health care, the city should work with Vanderbilt to simplify technology transfer from the university, which continues to be arduous. To enlarge the region’s software workforce, stronger connections need to be forged between the city’s large health care companies and Nashville’s many software entrepreneurs, enabling more creative actors to understand the complex world of care delivery and payment reimbursements. Finally, Nashville—like many cities not known for its software industry—needs to put itself on the map for health IT. The city and its private-sector partners should develop a comprehensive firm attraction and marketing strategy.

No one really knows what health care in America will look like in ten years. Many have only experienced a bloated, inefficient, costly, and unfair system. But policy and economic forces are putting that legacy system under extreme pressure. With any luck, a new system will emerge. The question now becomes: Which U.S. cities will seize the moment to gain economic advantage?

The Brookings Metropolitan Policy Program would like to thank UnitedHealth Group, HCA Healthcare, and other members of its Metropolitan Council for its support of the program. 

Via Brookings.edu » 

ONC’s Interoperability Experience Task Force: 4 steps to bolster health information exchange

The Office of the National Coordinator for Health IT advisory group, IXTF, outlined suggestions spanning government policy, technology, and public-private collaborations to improve health data sharing.

The Interoperability Experience Task Force recommended four tactics for enhancing the practice of health information exchange to national coordinator Karen DeSalvo, MD.

Created to advise the Office of the National Coordinator for Health IT, the IXTF suggested actions span policy, technical, and public-private approaches to improve the interoperability experience for providers and patients.

Here are IXTF’s recommendations:

1. Enable providers to effectively use health data. IXTF recommended that ONC stand up two new joint task forces, one to concentrate on reconciling and reducing the burden of importing clinical data, and the other to address IT systems design, usability and testing. ONC should also sponsor develop challenges to fuel user-centered design elements and create a national repository to test data that developers and technology vendors can tap to evaluate user interfaces in a standardized way.

2. Make it cost-effective for providers to exchange health data. IXTF recommended that ONC study total cost of ownership for EHRs as well the cost of patient-mediated exchange, outline best practices for including patient-generated health data in clinical decision-making, and work with the Center for Medicare and Medicaid Innovation to test Open APIs to determine whether to incent their use and what role they plan in IT systems other than EHRs.

3. Advance semantic and syntactic interoperability. This begins with enabling hospital and tech vendors to encode data and, as such, a new task force should home in on making non-clinical and unstructured information more valuable; IXTF cited behavioral data and social determinants of health as prime examples.

4. Monitor existing public-private collaborations. IXTF recommended that ONC engage efforts of Health Level 7 to optimize the CCDA (Consolidated-Clinical Document Architecture) standard, renew work to improve other codesets and terminologies, such as LOINC, collaborate with federal partners such as the National Quality Forum and Veterans Affairs on usability standards and quality measures.

IXTF explained in its letter to DeSalvo that these recommendations come from its own research and testimony by experts and industry professionals during a hearing in May 2016.

Clarification: ONC originally posted the IXTF letter to DeSalvo on its website for a short time then removed it because the Task Force decided more work is needed to focus the recommendations. A spokesperson said the task force chairs delayed the recommendations and took the materials down. So the recommendations could change. We’ll report those as well if changes happen.

Via HealthcareITNews »

AMIA questions whether EHR data can be used for research

The use of electronic health records for clinical research offers great opportunities to facilitate medical research but there’s a long road ahead before digital records can reliably used for that purpose.

That’s the warning of the American Medical Informatics Association (AMIA), which yesterday filed comments responding to the Food and Drug Administration’s proposed guidance on using EHRs for research purposes.

Both hospitals and physicians are gathering large amounts of information through the electronic records systems they’ve installed in recent years, AMIA noted. But the professional association, which represents the nation’s leading biomedical and clinical informaticians, said it doubted whether those systems contain data of high enough quality that could support randomized controlled trials.

“With more than 96 percent of U.S. hospitals and 83 percent of U.S. office-based physicians using EHRs to deliver clinical care, we have an unprecedented opportunity to utilize digitized healthcare data for supplemental uses, such as clinical investigations,” AMIA said in comments. “However, we strongly caution the FDA from assuming EHRs are readily configurable for clinical investigations, even among more advanced institutions.”

In proposed guidance issued in May, the FDA covers using EHRs that interoperate with electronic systems supporting trials, and discusses ensuring the quality and integrity of data collected and used. The new draft does not include provisions under which the FDA would assess compliance of records systems.

What the FDA eventually decides in this area is important because facilitating the correlation between EHRs and clinical trials would provide significant benefits in speeding and cutting the costs of clinical trials, as well as streamlining the process of finding patients for research.

FDA previously issued guidance on electronic source data in clinical investigations, which acknowledged that data can come from various sources and be entered into the trial sponsor’s Case Report Form (CRF), which is a paper or electronic questionnaire. This could include data from EHRs—this latest proposed guidance focuses on such data.

Another best practice for using EHR data in clinical trials is ensuring the data is attributable, legible, contemporaneous, original and accurate. Further, FDA recommends use of ONC-certified EHRs and other health information technology because of clear differences in interoperability and keeping data confidential.

Non-certified EHRs may be used, but should be assessed to determine if adequate controls are in place to ensure data confidentiality, integrity and reliability. The assessment should include limited access to electronic systems; identification of authors of records; audit trails to track changes to data; and availability and retention of records needed for FDA inspection.

Citing a lack of technical standards and an overreliance on the assurances resulting from ONC’s Health IT Certification Program, AMIA said data generated through the routine course of clinical care would likely fall short of more rigid research standards for data quality and integrity. EHR data is meant to support the care of individual patients, rather than generate research quality data, the organization noted.

“Ensuring data integrity and tracking data provenance in clinical settings is incredibly complicated because multiple, authorized individuals contribute to the EHR and the specificity of audit logs varies widely,” the association said in comments. “If the FDA is interested in which data populated the electronic data capture (EDC) system or electronic case reporting form (eCRF) and where they originated along the continuum of care, the answer could prove extremely difficult and burdensome.”

AMIA recommended FDA update the guidance by pointing clinical investigation sponsors towards data warehouses that utilize a common data model. “These sources may have better semantic interoperability and data integrity compared to sources that remain in the EHR default data model,” the group said.

“If we want to reach the goal of a learning health system, connecting our care systems to our research systems is essential, but we must do it right,” said AMIA President and CEO Douglas B. Fridsma, MD, PhD, FACMI. “Ultimately, we want every patient encounter recorded in the EHR to add to our knowledge about how to do a better job with all patients.”

Health IT Now reacted to the FDA’s proposed guidance, saying more direction is needed for data standards, saying the lack of standards could jeopardize the quality of data used in clinical research.

HITN, a diverse coalition of healthcare providers, patient advocates, consumers, employers and payers who support the adoption and use of health IT to improve health outcomes and lower costs.

“Data collected electronically in the clinical setting or by patients themselves through wearable technology can be useful in clinical research, pre-regulatory approval, and post-approval observation,” HITN’s statement said. “However, one barrier that remains for product sponsors and investigators in leveraging these data is a lack of clarity, especially around acceptable data standards and formats, from the Food and Drug Administration (FDA) and other regulators. Valuable electronic data can be sourced from data registries, wearables, and other forms of health IT which this guidance does not include.”

Via Health Data Management »

Do we need more or less healthcare IT regulation and legislation?

‘Sometimes when clinicians prescribe medication, although it does therapeutic good, it creates side effects which need to be addressed by changing a dose or by adding additional medications.’

Just as I clarified last week in my post about certification, the answer to the question “do we need more or less healthcare IT regulation and legislation” is that we need the right amount of the right regulation/legislation.

Sometimes when clinicians prescribe medication, although it does therapeutic good, it creates side effects which need to be addressed by changing a dose or by adding additional medications.

Such is the case with HITECH. It was generally good medicine, but now that we’ve seen the side effects on workflow, clinician burden and efficiency, there needs to be a dose adjustment.

I was recently asked to review the “Improving Health Information Technology Act” introduced by Senator Lamar Alexander, R-Tennessee, in February 2016 and placed on the Senate Legislative Calendar in April 2016. Its intent is good – to refine existing healthcare IT legislation with fixes that enable the right amount of the right regulation.

You’ll find the summary here and the full text of the bill here.

Here’s my analysis, section by section:

“1)  Assisting Doctors and Hospitals in Improving Quality of Care for Patients

Reduces documentation burdens by convening public and private stakeholders to develop goals, a strategy, and recommendations to minimize the documentation burden on providers while maintaining quality.”

This is a good thing. It fixes the language in HITECH which required each stage of Meaningful Use to be more stringent than the last.  That language required regulators to make each update to Meaningful Use more challenging.The Improving Health Information Technology Act enables regulators to better balance benefit and burden.

“Allows and encourages health professionals to practice at the top of their license, allowing non-physician members of the care team to document on behalf of physicians.”

This is a good thing. It encourages more team based care and documentation. Using electronic systems effectively is a team sport and should leverage social networking/groupware ideas to capture electronic data.

“Encourages the certification of health information technology for specialty providers and sites of service, like pediatric care, where more specialized technology is needed.”

As long as the Certification focuses on a few key important ideas, as noted in my previous post, this is a good thing.One set of required functionality does not make sense for diverse software supporting specific specialties.

“2) Transparent Ratings on Usability and Security to Transform Information Technology (TRUST IT)

Establishes an unbiased rating system for HIT products to help providers better choose HIT products.”

A government program to do this is unnecessary.The private sector has KLAS and other companies providing such information already.

“Allows HIT users to share feedback on the user experience of specific HIT products related to security, usability, and interoperability, among other concerns.”

A government program to do this is unnecessary. The private sector has KLAS and other companies providing such aggregations already

“3) Information Blocking
a. Gives the Department of Health and Human Services (HHS) Office of the Inspector General the authority to investigate and establish deterrents to information blocking practices that interfere with appropriate sharing of electronic health information”

Although I have not personally experienced information blocking, I hear anecdotally that there are some places in the US where competing systems refuse to share data with each other. Giving the OIG the ability to investigate is reasonable.It’s not clear there will be much to investigate.

“4) Interoperability

Convenes existing data sharing networks to develop a voluntary model framework and common agreement for the secure exchange of health information across existing networks to help foster bridging between networks.”

Convening stakeholders to develop a voluntary framework is reasonable. However, I believe the private sector will do this on its own in 2016.

“Creates a digital provider directory to both facilitate exchange and allow users to verify the correct recipient.”

This is a good thing. CMS could leverage the existing national provider identifier system.

“Requires that HHS give deference to standards developed in the private sector.”

This is a good thing. The private sector is moving very fast to embrace simpler standards such as FHIR.

“5)  Leveraging Health Information Technology to Improve Patient Care

Requires that certified HIT exchange data with registries if registries are certified to use standards endorsed by the Office of the National Coordinator (ONC).”

There are no mature/adopted standards for registry exchange at this time. In the interest of comprehensiveness, ONC has tended to publish/endorse standards that are not yet ready for adoption. Registry participation should be left to the marketplace.

“Includes vendors in Patient Safety Organizations to allow for improvements in the safety and effectiveness of HIT.”

This is very reasonable

“6) Empowering Patients and Improving Patient Access to Their Electronic Health Information
a. Supports the certification and development of patient-centered health record technology so that patients can access their health information through secure and user-friendly software that may update automatically.”

Although patient and family engagement is very important, it is not something that the government should certify.Apple and other consumer companies are innovating at the speed of the market, taking us in new directions that government could not have predicted.

“Encourages the use of Health Information Exchanges to promote patient access by educating providers and clarifying misunderstandings.”

Health information exchanges really do not have a role in patient/family engagement.The new approaches implemented by Apple  and other innovators directly connect the patient and provider.

“Requires HHS to clarify situations where it is permissible for providers to share patient information by providing best practices and common cases where sharing is allowed.”

Clarifying HIPAA through education is a good thing.

“7) GAO Study on Patient Matching
a. Directs the Governmental Accountability Office (GAO) to conduct a study to review methods for securely matching patient records to the correct patient. ”

This is a good thing. We are not going to be able to consolidate records across the care continuum unless we can identify the patient.

There you have it – a dose adjustment for HITECH. Dose adjustments can have their own side effects. Hopefully the bill will be adjusted as suggested above before it is passed. The goal of any new legislation/regulation, just as with medical care itself, should be to first do no harm.

This blog post first appeared on Life as a Healthcare CIO.

Via HealthcareITNews.com »