Reflecting on Our IT Progress

In a time of EHR naysayers, mean-spirited election year politics, and press misinterpretation (ONC and CMS do not intend to relax patient engagement provisions), it's important that we all send a unified message about our progress on the national priorities we've developed by consensus.

1.   Query-based exchange - every country in the world that I've advised (Japan, China, New Zealand, Scotland/UK, Norway, Sweden, Canada,  and Singapore)  has started with push-based exchange,replacing paper and fax machines with standards-based technology and policy.   Once "push" is done and builds confidence with stakeholders, "pull" or query-response exchange is the obvious next step.  Although there are gaps to be filled, we can and should make progress on this next phase of exchange.   The naysayers need to realize that there is a process for advancing interoperability and we'll all working as fast as we can.   Query-based exchange will be built on top of the foundation created by Meaningful Use Stage 1 and 2.

2.  Billing - although several reports have linked EHRs to billing fraud/abuse and the recent OIG survey seeks to explore the connection between EHR implementation and increased reimbursement, the real issue is that EHRs, when implemented properly, can enhance clinical documentation.  The work of the next two years as we prepare for ICD-10 is to embrace emerging natural language processing technologies and structured data entry to create highly reproducible/auditable clinical documentation that supports the billing process.  Meaningful Use Stage 1 and 2 have added content and vocabulary standards that will ensure future documentation is much more codified.

3.  Safety - some have argued that electronic health records introduce new errors and safety concerns.  Although it is true that bad software implemented badly can cause harm, the vast majority of certified EHR technology enhances workflow and reduces error.  Meaningful Use Stage 1 and 2 enhance medication accuracy and create a foundation for improved decision support.  The HealtheDecisions initiative will bring us guidelines/protocols that add substantial safety to today's EHRs.

4.  Privacy and Security - some have argued that EHRs reduce security by making records available in electronic form, possibly over internet connections.   Efforts to enhance certification of the security of EHRs, encrypt data at rest, and create guidance for EHR modules that interoperate with built in security will further protect the data that needs to be shared for care coordination and population health.

5. Innovation - some have argued that meaningful use led to the growth of a small number of vendors and dependency/lock in with those vendors.    Meaningful Use Stage 2 requires interoperability between vendors, export of data from EHRs to reduce lock in, and standards that will enable a new generation of modular "plug ins".   I'm confident that SHARP grant funded work, like the SMART initiative will lead to an ecosystem of applications from small vendors - an app store for health.

Thus, our mantra should be that Meaningful Use Stage 1 and 2 have created a foundation for query-based exchange, accurate billing, safety, security, and innovation.

Stage 3 work is already in progress and from the early thinking that I've seen (will post a blog about that in a few weeks), the trajectory of Meaningful Use will address all the naysayers concerns.

The Next Phase of State HIE Planning

With the Golden Spike on October 16, Massachusetts began a new era of healthcare information exchange.   Now that we have momentum and the perfect storm for innovation with alignment of government, industry, academia, stakeholders, and funding,  we want to rapidly advance to the next phase.

Last week, while I was in China, a group from Massachusetts visited CMS in Baltimore to present the Phase 2 plans.   Here is the powerpoint they used.

A few key points

1.  After summarizing the accomplishments of our Phase 1 go live, they presented the sustainability model in detail (see slide 15-16).   The tiered pricing was developed based on several key principles (see slide 13-14) such as the need for large organizations which derive high value from the HIE to subsidize small practices which have limited resources and bandwidth for new projects.   The end result is that comprehensive HIE services cost a solo practitioner just $5/month.

2.  We know that "push" transactions are easiest from a policy and technology perspective, so Phase 1 was limited to use cases like PCP to Specialist, Provider to Public Health, and Hospital to PCP exchange.    We also know that "pull" transactions have a great deal of value by providing just in time delivery of community wide longitudinal health records (slide 21).   Pull models require significantly more complex technology and policy.    Pull models require a master patient index/record locator service and some means of recording consent to disclose records.   Rather than declare that the standards are not ready, the informatics challenges are too great, and the consent models are too complex, we're just moving forward with an aggressive timeline to get it done in 12-18 months.  (timeline is on slide 31)

3.  With Phase 1, we built a guiding coalition of providers, payers, patients, government, and employers to break down barriers and create community wide demand for the service.  Where there were standards gaps we filled them with simple SOAP-based XML exchanges (provider directory query/response).   In this next phase, we're going to do the same thing as outlined in slides 23-30.   Is there a simple set of standards for managing consent that is widely deployed in the industry?  No - we'll create one and refine it in actual production across thousands of users and millions of transactions.   Is there a simple set of RESTful interfaces for query/response retrieval of records across a complex community of non-affiliated organizations?  No - we'll create one and show that it works really well.   To date, our implementation guides for SOAP/REST XML exchanges are less than 10 pages each and do the job well.   Of course we'll use existing mature standards where they exist but we will not select implementation guides that fail the standards readiness criteria simply because the right standards have not yet been invented yet.

Over the next few months our push HIE will grow to scale as more providers and vendor products are connected to it.   Currently NEHEN, our administrative transaction HIE in Massachusetts, does over 100 million exchanges per year, so we're confident we can achieve and support clinical healthcare information exchange at large volumes.    We'll dive headlong into the pull HIE work very soon as the funding is finalized.   We'll broadly share our lessons learned, our policies, and our technology.

It's a great time for HIE in Massachusetts and I hope we can be a catalyst for wider push and pull HIE adoption in the country.

On the Road in China

Last week I spent 5 days in Shanghai and Hangzhou as part of an American delegation advising Chinese government and private sector leaders about healthcare reform.

We met with the Mayor of Shanghai, the Health Minister of Shanghai, many hospital presidents, and several public health officials.

The themes we highlighted included:

*Quality must be measured, not assumed, and this should be enabled by the universal adoption of electronic health records

*Data should be shared among caregivers with a focus on longitudinal coordination of wellness rather than episodic treatment of illness

*A primary care model coordinating patient treatment via a team that knows patient care plans and preferences will be more efficient than the current model in China in which the patient can go anywhere without a referral.   A simple headache might be first evaluated by a neurosurgeon at a tertiary care facility.

*The measures of success should be healthcare value (quality/cost), safety, and patient satisfaction

My role was to spread the gospel of Meaningful Use.   I highlighted the multi-phased journey in the US and our focus on policy outcomes rather than hardware/software implementation.

I toured several facilities and had the opportunity to study the IT infrastructure and applications used in different settings.

A few observations:

*Shanghai community hospitals have deployed a standardized EHR that is good enough - it enables enough clinical documentation to provide continuity of care.

*Tertiary facilities have not widely adopted advanced clinical IT systems.  They have focused on  administrative transactions (registration/scheduling) and ancillary automation (lab/rad/pharmacy) but not provider order entry, decision support, or clinical documentation.   The systems are optimized for episodic and not continuous care.

*This is my third visit to Shanghai and I've advised their health information exchange efforts by suggesting content, vocabulary and transport standards.    Shanghai is piloting health information exchange that involves transport of XML-based summary records over VPN.  The Chinese have a national identifier they use for healthcare and have privacy policy that makes data sharing a public good in society.    Culturally, there seem to be few expectations of healthcare data privacy.    Limited regulatory/compliance oversight enables the Chinese to move quickly but also providers fewer controls.   There is very little assertion of malpractice.

My conclusion from these Chinese visits is that healthcare IT challenges are similar worldwide.   I enjoy sharing our US experiences with other countries and look forward to the day when continuous lifetime coordinated care based on interoperability of data is a worldwide possibility.

In Shanghai this Week

This week I'm in Shanghai and surrounding cities working on EHR implementation and health information exchange issues.

There will be a few days without blog posts this week due to my travels, but I will detail all the lessons learned when I return.

Aligning quality, safety, and efficiency with technology and politics pose the same challenges all over the world but the scale of China makes implementation particularly interesting.  

And now off to spread the gospel of Meaningful Use.

Cool Technology of the Week

Not exactly a cool technology, but a cool product of nature.   I was walking in the apple orchard at dawn this morning and found a Giant Puffball mushroom - Calvatia Gigantea

As a mycologist, I generally get calls about humans eating mushrooms.   With this one, I'm more concerned about mushrooms eating humans!

Fungi that's bigger than a car tire.   That's cool!

Building Unity Farm - the Barn

To me, the barn is the centerpiece of any farm.    The tools, the hay/food, animal stalls, season specific items, and heavy equipment are all protected from the elements in the barn.

In New England, barns are a classic barn red or white, having sliding access doors, and ventilation such as a cupola.    Ours is red with black accents.

At Unity Farm, our barn is about 40x40 feet in size, has two post and beam stories, and three access doors.    The front of the barn holds our grains and seeds in water proof metal cans held closed by spring loaded metal chains and hooks of my own design - call them unchewable bungie cords.    Our tools are racked in a Rubbermaid tool caddy.   The chainsaw and brush cutter are stacked against the east wall.   Our red dragon flamethrower (for weeding), and our commercial sprayer are hung on hooks.    A Craftsman workbench and pegboard provides storage for hammers, screw drivers and saws.

We store our portable animal pens (great for veterinary visits, isolating animals during their introduction to the herd, and for containing animals when they need to be haltered) and llama/alpaca scale against the west wall.

Our freeze proof water source - a yard hydrant - is also on the first floor inside a five foot deep french drain.

Fly management is via hanging fly tapes strategically placed in areas that flies gather.

Ventilation fans on the first floor keep the air moving.  

The animal stalls have heavy sliding wood doors that keep the animals separated from the tool and storage area.  Sliding weatherproof doors give them easy access to the paddocks.    Lighting inside the barn is all LED, consuming less than 100 watts for the entire structure.   Lighting outside the barn includes 4 classic gooseneck barn lights with halogen bulbs on a photo sensor circuit that turns them on during night time hours.

The stalls are outfitted with wall mounted buckets and hay feeders.  Floors are lined with one inch thick rubber mats that are easy to clean.  

The second floor hayloft can store up to 10 tons of hay.  Hay doors give us easy loading access using a hay elevator.   A heat activated ventilator fan keeps the hay cool and dry.

Kathy designed the Unity Farm signage that is mounted on rails attached to the clapboard.

The barn is so functional that all our animal chores are simple.  We can move animals in and out of stalls, retrieve hay, and fill water buckets seamlessly.

We clean the stalls twice a day - once in the early morning and once in the early evening, managing manure in our compost area.

Our Great Pyrenees Mountain dogs sleep with the alpacas and llamas, which is especially comforting for us when we hear a pack of coyotes calling from the apple orchard late at night.    Thus far, the security of the barn with its nighttime lighting and livestock guardian animals has kept the citizens of Unity Farm healthy and happy.

The scent of hay, sounds of humming camelids, and crunch of straw underfoot is so appealing, that I often sit in the barn with the animals at night before bed.  

If I'm ever asked about my manners, I can always claim that I feel at home in a barn!

The October HIT Standards Committee meeting

The October HIT Standards Committee reviewed the FDA Universal Device Identifer NPRM, the transition of the NwHIN to a public/private partnership, and an update from ONC on S&I Framework/related programs.

Jamie Ferguson presented a very thoughtful list of recommendations to the FDA, including the notion that all healthcare devices, including consumer devices, should have a universal device identifier that can be used as metadata when exchanging information.  A UDI will help us understand the nature of the data, the accuracy of the data, and the range of possible data from each healthcare device.

Mariann Yeager, Interim Executive Director of Healtheway, presented an overview of the public/private partnership successor to the NwHIN program.  As ARRA/HITECH funds diminish, it is important to move ongoing ONC operational components such as NwHIN to self- sustaining partnerships.   Healtheway will ensure continuity of the NwHIN Exchange efforts, regardless of the outcome of the election or fluctuations in Federal budgets.

Continuing the theme of public/private partnership, Doug Frisdma presented an overview of ONC project transitions to a combination of public, public/private, and private efforts.

I look forward to the next meeting in which we'll likely begin discussion of the testing and certification scripts as we move forward to the implementation of Stage 2 programs.