Tuesday, January 13, 2009

Update from Washington

Many people have asked me to comment about the latest Washington plans for healthcare IT.

The best and brightest on the Obama transition team, the House Committee on Science and Technology, and the Senate HELP Committee have been talking to academic, industry and government healthcare IT experts.

I believe the message from experts is consistent. The dollars allocated need to fund education, training, and implementation of interoperable CCHIT certified EHRs. What do I mean by interoperable? For 2009 it means result reporting, e-prescribing, and clinical summary exchange. For 2010 it means quality measures, population health, and personal health record exchange. For 2011 it means clinical research/trials support. Here is a document describing the the current CCHIT certification requirements written by Mark Leavitt and containing my thoughts on the interoperability that is available now.

Many in the press and in Washington have just read the pre-publication of "Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions" by William W. Stead and Herbert S. Lin, editors from the Committee on Engaging the Computer Science Research Community in Health Care Informatics of the Computer Science and Telecommunications Board, National Research Council of the National Academies. Some believe that the report concludes we should not invest in healthcare IT now.

What does the editor believe? In an email yesterday to the American College of Medical Informatics, Bill wrote:

"We do not need to wait for better IT before we move aggressively forward. However, near term success will require a fresh approach to managing the investment by health care organizations, our health care IT vendors and the government."

Here's my interpretation of the report and Bill's comments:

The National Academy does not call for a halt in health IT investment, rather for a balanced mix of investments that supports 'incremental progress' with real IT systems today, combined with long-term research that can revolutionize the medical decision-making process. The Academy suggests near-term use of clinical information systems that enable doctors to move toward higher-quality, data-driven medical decisions. Along with that, they recommend long-term research that will provide doctors with the tools necessary to support treatment decisions that draw on large amounts of data both from the individual patient they are treating and relevant research and treatment data from a broad range of research and clinical data.

Investments should pay for the improvement in outcomes resulting from the use of healthcare IT.

To my knowledge, the Obama Administration Economic Recovery proposal for HIT spending will support investment in electronic medical record systems for doctors with funds disbursed as Medicare incentive payments. It doesn't just pay for IT, it pays for quality-of-care outcomes facilitated by IT.

The Academy worries that if we fund large-scale deployment of electronic medical record systems for all doctors, we will implement systems that lack the most advanced features yet to be developed through the research they propose. However, Bill's letter to the informatics community suggests deploying now and my experience is that systems evolve incrementally as clinical workflow changes and new technologies become available. In Massachusetts, I have installed eClinicalWorks version 8.033 for my community-based physicians. It has all the decision support features and interoperability the report suggests, so I know the vendor community can deliver what it is needed.

What else am I hearing in Washington?

*The entire stimulus package is expected to cost between $700 billion - $1 trillion. Reportedly, Obama now wants to include up to $300 billion in tax cuts, primarily aimed at individuals and small businesses, in part to gain Republican support. The timing of the completed package seems to be targeted to late February.

*The dollars to be allocated to healthcare IT range from $5-$25 billion.

*In my conversation with Senators, the dollars allocated will not just fund hardware and software. They will include funding for quality measurement, evaluation, training, education, privacy/security, interoperability, and incentives to use the technology to improve care. There is not consensus between the Senate and House of Representatives on the final approach, but hearings are likely to begin soon.

I will watch the unfolding events and relay my interpretation of what is happening in the transition teams and Congress. If you are asked to testify, I hope you offer similar advice to my own:

The products available in the market today are good enough and continue to evolve to include more decision support and interoperability per the CCHIT roadmap.

The standards for labs, medications, and clinical summary exchange harmonized by HITSP are recognized by the US government and are good enough.

Now is the time to invest. We're at the tipping point. Wise investment, with accountability for use of EHRs and incentives to achieve coordinated quality care, is needed to transform healthcare in the US.


Unknown said...

I totally agree with your comment that there are good systems already in place so there is no reason to "throw out the baby with the bath water". What needs to be done is to harmonize the current installed base of systems into a true information supplying solution to improve all health care practices with a unified viewing structure that is available anywhere an authorized user may be located in our connected world.

Unknown said...

Good feedback. Too many people feel that they can throw money at an issue - perceived or real - and obtain instant results. I too have found that understanding the customer needs and providing incremental increases will provide reasonable results. Not perfect, but reasonable. I often find that customers think they want a solution one way and then decided, after they receive the solution, that it really work work better as solution B.

Also, I would like to see if you would be willing to provide me a short review/feedback, written or verbal, on how well eClinicalWorks performs. I am looking to partner with a software firm that works with the medical community and I would rather start discussions with someone that works well.

Best Regards,

Wayne Bogan
CTO Spirit Telecom

Medical Quack said...

I'll add my 2 cents of support here as well, there are good systems and architectures in place that work and plenty of integrators and to boot.

I posted on Monday about Peter Neuport testifying this week too from Microsoft, so perhaps if there's enough voices something will be heard and more importantly, funded!

Medical Quack said...

Watched the video coverage of the testimonies in the Senate, well worth watching to see where we are. Everyone, government speakers and private industry all in agreement as well and very well done!

So much to do with educating consumers too with PHRs. Put a link in there as well to the last AHIC meeting with the post.


Manick said...

As one who has implemented EHR solutions at various small physician sites, I endorse your view that this perhaps is the tipping point. However, should the new Administration provide just tax breaks and incentives to physicians, it will not necessarily result in a transformed world.

Monetary resources are a crucial factor, but more critical to the success is the attention that needs to be paid to the workflow, the cash flow and data conversion at the implementation site.

All practices have people who have been working with a workflow that has been in existence for a while. Changing that workflow could result in their failure to perform. Not because they are not capable, but because care has not been taken to blend the new workflow with the existing one.

Every implementation will have setup parameters, be it configuring a file to be readied for an upload to a clearing house or ensuring that the accounting links are maintained. These need to be inventoried and prepared for integration with the new system, thereby ensuring that there is no cash flow disruption to the practice.

Finally, one of the most important aspects of the implementation is the priming of the data on the new system from a paper based or a semi-electronic system. Typically it is the staff at the site, including the physician who are saddled with this task. They are not trained to do data conversion, which by itself is a task left only to experts. There is any number of ways that this task can be effectively done, but it needs to be planned for and taken into cost considerations. Methods range from onsite data entry to offshore data entry. The actual conversion can be done prior to the implementation, during the implementation and as an ongoing task for a period of time until the practice is ready to go paperless.

This is perhaps the best time in the history of healthcare to do it right. At this point, not all EHR software are built on an interoperable data schema. The prime reason is the evolving nature of that standards effort. As long as such vendors will be mandated to either provide upgrades to their software to be in sync with national standards or at the least, provide easy access to their data should a client want to move to another software vendor, the industry as a whole should move forward.