Tuesday, September 3, 2013

What Keeps Me Up at Night - Fall 2013

As Summer draws to a close, I have returned to my usual blogging schedule!

Now that Labor Day has come and gone,  I've thought about the months ahead and the major challenges I'll face.

1.  Mergers and Acquisitions

Healthcare in the US is not a system of care, it's a disconnected collection of hospitals, clinics, pharmacies, labs, and imaging centers.    As the Affordable Care Act rolls out, many accountable care organizations are realizing that the only way to survive is to create "systemness" through mergers, acquisitions, and affiliations.   The workflow to support systemness may require different IT approaches than we've used in the past.   We've been successful  to date by leaving existing applications in place and building bidirectional clinical sharing interfaces via  "magic button" viewing and state HIE summary exchange.   Interfacing is great for many purposes.   Integration is better for others, such as enterprise appointment scheduling and care management.   Requirements for systemness have not yet been defined, but there could be significant future work ahead to replace existing systems with a single integrated application.

2.  Regulatory uncertainty

Will ICD10 proceed on the October 1, 2014 timeline?  All indications in Washington are that deadlines will not be changed.    Yet, I'm concerned that payers, providers and government will not be ready to support the workflow changes required for successful ICD10 implementation.    Will all aspects of the new HIPAA Omnibus rule be enforced including the "self pay" provision which restricts information flow to payers?  Hospitals nationwide are not sure how to comply with the new requirements.   Will Meaningful Use Stage 2 proceed on the current aggressive timeline?  Products to support MU2 are still being certified yet hospitals are expected to begin attestation reporting periods as early as October 1.   With Farzad Mostashari's departure from ONC, the new national coordinator will have to address these challenging implementation questions against a backdrop of a Congress which wants to see the national HIT program move faster.

3.  Meaningful Use Stage 2 challenges

Although attestation criteria are very clear (and achievable), certification is quite complex, especially for a small self development shop like mine.   One of my colleagues at a healthcare institution in another state noted that 50 developers and 4 full analysts are hard at work at certification for their self built systems.   I have 25 developers and a part time analyst available for the task.   I've read every script and there are numerous areas in certification which go beyond the functionality needed for attestation.    Many EHR vendors have described their certification burden to me.    I am hopeful that ONC re-examines the certification process and does two things - removes those sections that add unnecessary complexity and makes certification clinically relevant by using scenarios that demonstrate a real world workflow supporting the functionality needed for attestation.  

4.  Maintaining agility in a resource constrained world

At the same time we have ICD10 (a multi-million dollar burden), Meaningful Use Stage 2 (a multi-million dollar burden), the Affordable Care Act (a multi-million dollar burden), the HIPAA Omnibus Rule (a multi-million dollar burden), and increasing compliance oversight (a multi-million dollar burden), reimbursement is declining, sequestration is squeezing budgets, and fee for service medicine is transitioning to risk based contracts.    The ability of provider organizations to maintain operations while implementing all the new regulatory requirements in parallel is straining healthcare operations to their limits.   Safety, quality, and efficiency innovations are no longer possible because regulatory requirements  have consumed all available resources.

5.  Leading in real time

My organizations maintain hundreds of applications and thousands of devices with 99.9% reliability.    Rather than praise us for our diligence, the average user in 2013 wants to now why we are not meeting their needs .1% of the time.  When I do not respond to a request in 5 minutes or less, I'm asked if something is wrong.   Leadership in the era of Twitter is expected to be all seeing, all knowing, and omnipresent.   Strategic thinking, planning, and consensus building is challenging in a real time world that expects instant gratification.

I do not mean to sound pessimistic in any way.   All of these challenges can be conquered.   For nearly 20 years, I've led an IT organization that has continuously delivered miracles with 1.9% of the operating budget.   I am ready for the challenges ahead but wonder if mergers/acquisitions, regulatory uncertainty, MU2 certification challenges, resource constraints, and real time demands will create a set of constraints that are impossible to optimize.    Given that my role is to understand all the constraints and find a path forward, it's the Kobayashi Maru scenario that keeps me awake at night .   As Captain Kirk figured out, if the rules of the game make it impossible to win, the only answer is to change the game.    I remain the eternal optimist and am convinced that if we all work as hard as we can, the rules of the game will be changed so that we can succeed.


Deborah C. Peel, MD said...

What keeps me up at night are geek doctors who have no idea what the public wants from the healthcare 'system' or technology. Geek doctors have designed systems that actually lock patients out of their own health data and prevent them from controlling it and using it for their own benefit.

Current technologies serve large institutions whose desire for profit and market share conflict with patients' expectations and rights to control PHI. Patients want technologies that serve them and help them to be well, compare quality and costs, and get independent advice from sources without conflicts of interest.

When technology violates patients' rights to decide who can collect and use their data, 40-50 million patients annually delay or avoid treatment or hide information. Those are very bad outcomes.

The public will risk health and life to keep sensitive personal health data private and prevent others from using that data to harm them. Technologies that cause patients to act in ways that harm them are failed technologies.

It's time to wise up and use technology that serves patients not industry. Institutions that take care of patients by putting them first will be trusted and survive.

Ivan M said...

For providers, systemness is interoperability. They were assured smooth record sharing could improve care.
However, no system was developed. No mandates regulated companies to develop such a system. The billions in meaningful use weren't used for systemness. Why?
The ACA aims to control care. With the ACA- systemness is not connecting private providers, it's combining them, in order to control them. The ACA allows the gov. to control private health spending by reducing fragmentation of private practices. Through impossible constraints, regulations & pessimism, the ACA intends to convince private practices their only hope is mergers & acquisitions. Your hard work & optimism sets an example for healthcare.

David Szabo said...

If you want to pass the test, you have to change the game. http://youtu.be/bDg674aS-F4

Anonymous said...

Ultimately the main problem I see with healthcare- is twofold- We need better physicians plain and simple in two specialties specifically- primary care and cardiology- My own experience-as a caregiver of two elderly parents is that PCPs and Cardiologists are extremely important for monitoring/preventive care for elderly and/or chronic condition patients, yet in my experience they are either excellent or terrible. i discovered that my parents' cardiologist was incompetent after the fact. Patients and caregivers put a tremendous amount of trust in their physicians, and unfortunately many are just not good- despite great credentials from top schools, etc...- I honestly believe that patients should get their medical records every six months from their PCP an cardioligists so that they can verify info in records as well as make sure they have not fallen through cracks regarding necessary follow up visits- echos, labs, etc.. Patients/caregivers need to be truly active participants in their care. Another area of medicine that often has weak doctors, is hospital medicine- this is a field that is also hit or miss-These three important fields of medicine are vital for the elderly and/or chronic condition patient, and yet often the physician is not dedicated, proactive, competent- leaving us with bad care and spiraling health care costs. I truly believe a big reason why we have rising health care costs and yet health care quality is often declining - is we need to monitor/review physicians - to make sure in some way they are doing their job. Maybe I am being simplistic, but let's try simple solutions first.