Reflections on the US HIT Policy Trajectory

I’m in China this week, meeting with government, academia, and industry leaders in Guangzhou, Shenzhen,  Beijing, Shanghai,  and Suzhou.    The twelve hour time difference means that I can work a day in China, followed by a day in Boston.    For the next 7 days, I’ll truly be living on both sides of the planet.

I recently delivered this policy update about the key developments in healthcare IT policy and sentiment over the past 90 days.

I’ve not written a specific summary of the recently released Quality Patient Program proposed rule which provides the detailed regulatory guidance for implementation of MACRA/MIPS, but here’s the excellent 26 page synopsis created by CMS which provides an overview of the 1058 page rule.

In general, it has many positive provisions.

The industry is welcoming the delays and accommodations it includes, especially the use of 2014 certified records for the 2018 year and the small practice exemptions which recognize the technologies/people/processed needed to succeed under MACRA/MIPS could overwhelm independent clinicians.

The Senate replacement for the Affordable Care Act continues to be debated and there is concern that loss of medicaid dollars may eliminate funding streams that supported healthcare IT.   It’s too early to tell where the ACA repeal/replace activity will converge.

What can we say about the IT policy direction of the US right now?

1. There seems to be great consensus that all stakeholders need to focus on enhancing interoperability technology and policy in support of care coordination, population health, precision medicine, patient/family engagement, and research.  

2.  There is also a consensus that usability of the IT tools in the marketplace needs to be enhanced.   Although the major EHR vendors are working on usability improvements, I believe the greatest agility will come from startup community via apps that get/put data with EHRs using APIs based on evolving FHIR standards.    Here’s my sense of each vendor’s approach

Epic - will support open source FHIR APIs at no cost for the use cases prioritized by the Argonaut working group and HL7.  Will also support proprietary Epic APIs for Epic licensees.

Cerner - similar to Epic with additional SMART on FHIR support

Meditech - will support open source FHIR APIs and give encourage developers to work with customers to leverage the SQL-based Meditech data repository at each customer site.

Athena - will support open source FHIR APIs at no cost but give much more sophisticated workflow integration through the more disruption please program, which involves revenue sharing with developers.

eCW - the department of justice settle should lead to additional eCW support for standards based data exchange.  

3.  Many organizations in industry, government, and academic are thinking about patient identity strategies.  It’s too early to know what solutions will predominate but leading contenders are biometrics (fingerprint, image recognition, palm vein geometry etc.), a voluntary national identifier issued by some authority (public or private sector), or some creative software solution such as OAuth/OpenID/Blockchain etc.  In July, I will co-chair a national consensus conference on patient identifiers hosted by the Pew Charitable Trust.   I’m hoping we achieve consensus on a framework that accelerates the availability of such an identifier for multiple purposes.

4.  Several groups are thinking about how best to converge our heterogenous state privacy policies, specifically focusing on  the role of the patient as data steward.   We can radically simplify privacy protection if the patient is the agent by which information is shared.

5.  Finally, there seems to be an overwhelming sentiment that the concept of certification  and prescriptive IT policy should be replaced by an outcomes focus.    Rather than counting the number of Direct messages sent, giving organizations the flexibility to each data using the the most locally appropriate technology but then holding them accountable for a result of that data exchange i.e. reduced readmissions, reduced redundant testing, reduced errors seems to be well aligned with a move to value-based purchasing.

In theory the members of the new Healthcare Information Technology Advisory Standards Committee (which replaces the former Policy and Standards Committees)  will be named in July.    I look forward to hearing about the initial challenges the group will tackle.   I’m hopeful they will choose some of the issues mentioned above.

In several recent lectures, I’ve reinforced my optimism for the future of the healthcare IT ecosystem.   I believe the next few years will be filled with market driven innovation, encouraged by new consumer demand for healthcare process automation and supplemented by low cost, cloud based utility devices such as the machine learning and image recognition APIs offered by Google and Amazon.    It will be a great time for entrepreneurs, providers, and patients, all of whom are fatigued after years of Meaningful Use, ICD10, and accelerating  numbers of quality measures.   As a CIO, I’m looking forward to doing what my customers want me to do instead of being told what I must do.

Building Unity Farm Sanctuary - First Week of July 2017

Admittedly, the pace of my writing has slowed this Summer since each day is filled with a combination of IT work, mentoring, and keeping 60 acres of farm/sanctuary running smoothly.    How’s it all going?  Our trajectory is good.

So much of what we’re doing  at the farm/sanctuary is improvisation that we have no choice but to create a vision and accept ambiguity on the daily journey.

We received a request to adopt a house pig - Rue, who’s 80 pounds at 4 years old and extremely well behaved.  We’ve been socializing her with the other pigs and thus far, all is proceeding as expected - they challenge each other across a fence and eventually accept their place in the social hierarchy.    Now that we have 5 pigs, the question we asked is what is their ideal living arrangement - how can we create a pig “condo complex” that works in summer and winter for everyone.  

Sometimes a sense of urgency is needed to motivate change.    We have 8 baby turkeys and they needed a safe outdoor home.    Although we built an aviary last year, Penny, the Yorkshire pig, was living in the aviary at night because she was not ready to spend the night with Tofu and Lunchbox, the pot belly pigs.    Although we knew it would cause one night of anxiety, we put all of them together in a paddock and gave Penny a separate crate so that she could have a private space.    After a few nights, she began sleeping with the other pigs and now all of them cluster in a single pig pile, completely happy together.   The empty aviary became the home for the baby turkeys.

We put Rue and Hazel together in a paddock separated by fence.    At this point they are rubbing noses and not fighting.  After another month, we’ll take down the fence.  

The new arrangement - 3 pigs living in one paddock and 2 pigs living in another - completely supports our daily routines and workflow.   The farm is a continuous experiment and this time it all worked.

Similarly, it’s clear that our 5 horses will have a natural grouping - the dominant Arabian (Amber) and the assertive Welsh Pony (Sweetie) will get along perfectly.    The older Welsh Pony (Pippin), the shy Welsh Pony (Grace), and the good natured Welsh Pony (Millie) will be a perfect herd.  

Our new paddocks and run ins are progressing well.   The horse groups above will occupy two paddocks, we’ll leave one paddock open for exercising/running, and leave a paddock for whatever flexibility we need to continue our sanctuary mission.

The last experimental animal grouping that is working very well is the combination of goats and a donkey.    Star the donkey is doing well on her diet/exercise program and after a year, she’ll have a healthy weight.   The goats can eat her food but she cannot eat the goats food.     They keep each other company and are very happy.

If you asked me a few years ago if we would be the stewards of horses, donkeys, pigs, llamas, alpacas, geese, ducks, chickens, guinea fowl turkeys, Great Pyrenees and bees, I would have questioned your sanity.     Now every creature is part of the daily fabric of our lives and we treasure all of them.

The Sanctuary volunteer program is in full gear with multiple people donating time to the sanctuary every day.    They are grooming horses, walking the donkey, feeding poultry, cleaning paddocks, and socializing with the pigs.   The sanctuary has become such a community destination that there is not a moment of private time left on the property - and we’re ok with that.    My advice to our family - always stay dressed!

A mother rabbit had a litter of 4 babies in the middle of the orchard.   I did not realize that rabbits create hidden burrows in grasslands so that their young are just under the surface.    While walking through the orchard I heard a squeak and picked up the baby pictured below - I returned her immediately to her mother and the family in the rabbit den.

It’s early Summer harvest time and we’ve picked a few hundred heads of lettuce, 4 beds of basil, strawberries, cucumbers, and peas.   Garlic, tomatoes, and peppers are next in line.

Will I ever have time to continue the volume of writing I once did?  As building the sanctuary and nursing the animals back to health is replaced with maintaining the sanctuary and helping the animals thrive, there is a certain routine that will return to each day.    Waking up a dawn, feeding/watering, walking, cleaning, and medications takes about 2 hours.   Then comes, the work day.  Evening chores to prepare everyone for a safe and quiet night takes about 2 hours.    It’s common for Kathy and I to sit down for the first time each day at 9pm.   As I reflect on this stage of life - 33 years of marriage, 20 years as a CIO, and a married daughter living in her own household - having the joyful chaos of the farm and sanctuary 7x24x365 is exactly right.