Monday, December 1, 2008

Interoperability Advice for the New Administration

As policymakers consider ways to reduce healthcare cost and improve quality, I'm often asked about the current readiness of standards and interoperability.

I believe that standards are no longer the rate limiting step.

On November 12, I presented an overview of standards readiness to Secretary Leavitt and AHIC. The video is available online

My presentation begins at 1 hour and 8 minutes. Anyone wanting to view it can just use real player to advance to that point.

You'll see that as a country, we have finished:

2006 - Personal Health Records, Laboratories, Biosurveillance
2007 - Medications, Quality, Clinical Summaries
2008 - Medical devices, Referrals, Family History/Genome, Secure messaging, Public Health Reporting, Immunizations

In 2009, we'll complete Newborn screening, Clinical Trials/Research and close a few minor gaps

All the stakeholders (vendors, government, academic, pharma, labs, payers, providers, patients) have agreed on the needed standards by consensus. Secretary Leavitt has Recognized all the 2006 and 2007 standards and will be Accepting the 2008 standards on January 8, 2009. Recognition means that the standards are required for use by all Federal agencies. Acceptance means that a year of testing begins and Recognition will follow.

Thus, there is no need to wait for the standards. Vendors are beginning to implement these standards and the Certification Commission on Health Information Technology is beginning to require them.

If standards are not the issue, what about security and privacy? As readers of my blog know, I am passionate about the need to protect confidentiality.

I believe that security is no longer the rate limiting step.

The standards for security were finished in 2007. They are available online and have been fully incorporated into all the HITSP interoperability specifications including all the needed security standards to support encryption, authentication, authorization, audit trials, non-repudiability, and patient consent.

These security standards can enforce any local privacy policies - from something basic like HIPAA to something complex like the Massachusetts approach to opt-in consent at the institutional level.

It is true that the US has very heterogeneous privacy policies in states and localities that pre-empt HIPAA, but that is not a security or technology issue.

What about architecture?

I think that we've done enough pilots and experiments to know what architecture we need.

The US already has a functional architecture for e-Prescribing including retrieval of comprehensive medication history. The US already has a functional architecture for exchange of lab results among providers, patients and commercial labs.

What's missing is a clinical summary exchange that ensures care coordination among providers of care and patients. I've written about a simple, internet-based, service oriented architecture that can securely exchange structured healthcare data between stakeholders. This can approach can be used to
a. Send / push / route hospital data to appropriate parties
b. Send / push / route visit and other data in support of referral consultation
c. Send / push / route visit and other data for standardized quality reporting
d. Send / push / route data for patient health records (PHRs)

Note that none of these transactions creates new privacy issues. Every one of them is currently required by good medical practice or by law, and are performed on paper today.

Thus, interoperability is implementable today with harmonized standards, appropriate security, and a service oriented architecture using the internet.

Now we need incentives to implement it.

Data exchange is a public good in many ways, so it will be challenging to fund purely based on local stakeholder contributions. There is a need for Federal leadership and funding to mandate very specific transactions on a defined implementation timetable. We should accelerate adoption through the same approach the US is using for e-Prescribing: regulation to create mandates and incentives to create urgency, followed by penalties for late implementation.

Experience has taught me that it's best to automate existing processes rather than trying to simultaneously change process and add technology. The approach I've presented above is a good short term solution. In the long term, let's hope that patients become a steward for their own data via PHRs or establish a "medical home" - a primary care giver who coordinates all their care. The architecture could easily evolve such that every entity which provides care has to push the data into a "medical home" EHR in a standardized fashion.


Medical Quack said...

Bravo! Dr. Halamka, you own that committee!

I had to chuckle a bit when they called you "the jet", it's where the rest of the folks in the meeting need to be! Would you go to Washington and take a fleet of jets with you? I mean that as a compliment for your work, knowledge and expertise you offer. "Be the jet".

I watched most of the video and the information shared and it stands out 100% that you are "hands on", something that I did not see in the presentations of any of the others in the video, and that is clearly one item in itself that gives you the undaunted credibility you have and exhibit.

How you are able to manage and handle both clinical knowledge and intertwine Health IT is truly something that I do not see coming from anyone else and is truly a talent as well as an act of balance and dedication between both. I say this as I only work in the data side of healthcare myself and work at bridging the gap with the clinical side as best I can, and that is a challenge for me with working with the clinical side to perhaps entice and inspire the move to electronic records, both EHR and PHR.

The one real item as well that sets you apart from the rest as well is the personal sharing of how you are using PHRs too. Everyone else sits around and talks about it, but you are the doer. I get question and hear a lot too about PHRs and lately the only one piece of advice I have been offering folks who just talk about them, is go get one, as this is a consumer product for everyone and they are free. Get involved and start with yourself instead of just spending time talking about it is my message I try to convey, something that comes across strong and clear from your presentations. I would have loved to hear a few more on the video discuss their experiences for even just a few minutes of the presentation myself as I started falling asleep as I watched about 2-3 hours more of the meeting, where was the enthusiasm, I think it stopped after your presentation.

Again, you might be chuckling a bit here here at this point, but gee someone needs to speak up and give a ton of recognition where it is due and you deserve it for all of your efforts as there's nobody else out there with the talent, knowledge, and the willingness to share with all to create a better system that will help benefit all with all the hats you are wearing.

Changing hats too is another quality and talent that most may not be aware of as is a challenge and takes balance to go back and forth from all the roles you handle, from business life to personal life and keeping everything together and just from reading your blog you have a great handle on that part too.

Thanks again for sharing the link and insight here and I hope others will partake and watch as well with some appreciation too.

We need more "jets" so keep on being "the jet".

Unknown said...

A quick question Dr. Halamka--

How do you think we can reasonably implement the Medical Home?

It seems like the primary care provider has little incentive right now to coordinate care, and that this might not change in the future as long as current incentive models are still in place (i.e. rewarding the practitioner for rapid completion of tasks rather than the outcomes of those tasks). But perhaps that's your point entirely--that the current incentive model does not reward practitioners for delivering maximally efficient care.

My question--if that is the case--is then if you think this new administration, or any administration, would be up to the task of revising CMS reimbursement in order to make this all possible? Can patchwork fixes do it, or do we just need to start over from scratch?

John Halamka said...

Thanks so much to the Medical Quack for your support!

Regarding the medical home, it's all about reimbursement and aligning incentives. I'm hopeful that the new administration will provide the needed payment reform to do this.

Medical Quack said...

You are most welcome! I used to write VB code and back a number of years ago I created an EMR, which by today's standards is a dinosaur, but the basic mechanics are still there as well as the understanding of where things need to go by today's standards to get the job done and of course that education still carries me through a lot today. I know first hand the challenges present to get others to embrace a little technology!

Adding the information on personalized medicine and genomics was impressive too and such a big unknown for many on how it exists and is evolving, as a few months back I had to really sit down and study before doing an interview and publicity post on my blog with the CSO of Helicos myself to bridge the gap between readers and the software technical side, and in the process I learned quite a bit by doing the interview as well!

Changing hats as I call it is truly something we all encounter, but not to the high level where you operate and then return back to layman's terms to work with end users too, been there and done that a bit too, so it really is a true talent and sometimes a challenge for me, so "time outs" for me are needed for the Health IT folks just as much as they are on the clinical side of the spectrum.

The more information and software one can get their hands on, the more value it creates all the way around and it shows in contrast to those who just read and talk about it, just no comparison to having knowledge on board if you will.

I have seen your case studies all over the web, Adobe for one and many more and there's just nobody else out there making the same effort by a long shot and further yet being able to bridge Health IT, Science, and Clinical Care under one roof if you will.

Perhaps we can clone you now that all your genes have been sequenced (grin). Again, there's nobody else out there contributing at the same levels and furthermore most may not realize the time and effort this entails to focus and cover so many different areas and levels at once and maintain some sanity while you're at it so I felt some good words were in order here. We need more jets by all means!

Scott A Finlay said...

With regards to "interoperability' you might not be aware of a solution that scales well and addresses the needs of Practices, Clinics, Hospital on all the day to day communications that keep practices and hospitals tied to phones and fax machines. This approach addresses the two most common objections of new technology applications namely "work flow" disruption and "cost".

At the heart of the issue surrounding the practice and administration of healthcare is HIPAA and the requirement to protect ePHI, both at rest and in transit. This has been a contributing factor in failure of the healthcare industry to adopt the web and capture some of the cost saving and productivity gains that other industries have realized. "The revenue cycle management company Emdeon estimates that the health care industry could save more than $50 billion annually by using electronic processes. (Tennessean, Health Data Management.)".

Yet the dialog surrounding Interoperability seldom focuses on the day to day administration of healthcare that does not land in an EHR/PHR. What about the level of communication between practices and their day to day business counter parties such as insurers, hospitals, labs etc and of course patients. Almost 70% of the consumers surveyed by the National Research Corporations Healthcare Market guide want to communicate with their physician online; an amazing number when you consider the survey touched 200,000 households.

Implicit in the current dialog and focus on the subject of healthcare interoperability appears to be a sort of .com myopia. By that I mean the efforts almost universally suggest versions of a fire-walled ASP or centralized Database. Big companies are putting a lot of effort into creating the centralized asp that they will monetize with revenue from users that are increasingly challenged financially.

The market could use a more fundamental approach to this facet of healthcare communications. A "cloud" approach would serve the Healthcare industry well. Some define cloud computing as anything an entity consumes outside the organizations firewall. The “cloud" is a reference to the internet. Cloud computing solutions offer a way to increase capacity or add capabilities on the fly without investing in new infrastructure, training new personnel, or licensing new software. Cloud computing encompasses any subscription-based or pay-per-use service that, in real time over the Internet, extends IT's existing capabilities.

We have developed a "Cloud" solution to interoperability by creating a secure communication platform (patent pending)at the Top Level Domain (TLD) level. .md Because Medicine is your Domain. It was developed to help independent organizations communicate securely with Zero chance for loss of ePHI. Those that register for the service can communicate with any other registrant in domain without any further encryption and externally with a SendAnywhere capability for pennies per user per day.

This is an Omni-directional encrypted communication capability that can be added on the fly without investing in new infrastructure, and without retraining existing or new personnel or licensing new software. The solution integrates with any modern email client (Outlook, Mozilla, Blackberry etc.) and provides each organization a means to communicate securely anywhere over the internet. The suite of tools was designed to increase staff productivity, protect ePHI and comply with HIPAA requirements. Once information is captured in an electronic format it can be easily retransmitted or moved into other applications. This is a low cost, high productivity, scalable solution to improving office productivity for every type of healthcare organization. The solution works just as effectively and economically for organizations that are currently operating their own exchanges servers as for practices that have no IT staff. No legacy system issues in a fragmented market like healthcare is a significant positive.

Many day to day issues can be accomplished faster and more efficiently with this approach; E-referrals, E-meetings with SecureIM, resolving claims disputes that are normally done over the phone, Communicating Lab results to patients, or forwarding to another Doctor, pre-filling forms before a visit, sending care instructions both post op and pre-op or pre-visit and post visit, passing information from a practice to hospital, and even communicating with all the day to day business partners electronically and securely. Email is ubiquitous because it is efficient. For many practices the lost time to phone tag and faxing is astounding. This is an Omni-directional secure communication capability that also reinforces the brand identity of the user. There is no need to subordinate the brand to a third party provider (ASP) and the cost is affordable to even the smallest healthcare organization.

This solution was developed with the Doctor, Practice and Hospital and their businesses issues in mind. By improving the ability of Doctors, hospitals or any other healthcare organization to communicate electronically helps them begin to capture the productivity gains alluded to above. That they can do it for pennies per user per day is exactly the type of web solution they are entitled to.

Scott Finlay , Founder/CEO of Max.MD