Friday, May 20, 2016

A Multi-Stakeholder Discussion in Washington

On Thursday, I spent the day in Washington with a group of government, provider, and developer sttakeholders convened by the Institute of Healthcare Improvement.      We operated under Chatham House Rules, so I can summarize the discussion but not identify any of the participants or their specific statements.       Below are three questions we discussed and the observations we made:

1.  What worked in CMS and ONC rules (HIT related regulations)?
*Meaningful Use  provided a foundation of basic electronic record functionality
*We enhanced systemness thinking and created learning groups to address vulnerabilities in discconnected systems
*We made safety improvements and enabled analytics
*We enhanced patient engagement and dispelled several myths
*We automated quality measurement processes and recorded social determinants of healthcare
*We encouraged EHR optimization
*We enhanced  Interoperability for public health transactions, eprescribing and entry of vocabulary controlled data (problems/meds/allergies/labs)
*We incentivized new entrants into the marketplace
*We enabled standardization of workflows
*We found that CMS was a good listener
*We began to engage post acute providers
*We caused infrastructure to be upgraded (to support EHR implementation)
*We enabled remote access to records
*We created an ecosystem for home care devices  and wearables to become relevant
*We taught stakeholders that clinical automation is not an  IT project
*We began to focus on the user experience

2. What didn’t work or could have been done better?
*Products were rushed to market and they were not as usable or as intuitive as we’d like
*We did not achieve a consensus on national priorities - where we want electronic records to be in 5 years
*We did not include behaviorial health providers
*We did not enable team communication
*We did not enable substitutable apps that can be shared across vendors
*We required too much non-valued data entry
*We often digitized the  paper world
*We ended up with regulatory complexity
*We required too many clicks, causing a loss of patient focus
*Once the foundation was laid we did not have time to digest the changes, interatively improve and innovate
*Certification consumed too many development resources
*We hired scribes as a workaround to overwhelming  data entry requirements
*We required documentation to satisfy legal and regulatory concerns rather than patient care needs
*We demanded Interoperability without first building enabling  infrastructure
*IT service levels did not always align with clinical requirements
*We underestimated the burden of the impact of HITECH on providers and developers
*We made patient engagement too hard
*We did not turn data into information, knowledge and wisdom
*We focused on compliance instead of joy in the workplace (or joy for the patients)
*We did not enable the marketplace to meet customer demands
*We focused on billing rather than clinical workflow
*We tried to do too much, too soon

3.  How do we shape the future based on lessons learned?
*IHI  Leadership Alliance/EHR workgroup should submit a comment letter about  MACRA/MIPS to CMS
*Reconciling the tension among Developers, Government , Providers, Patients   will required  argreement about who is the user/customer, what is success, what is considered a good outcome
*Instead of just Interoperability we need to think about the functionality needed for a collaborative work and a more uniform  user experience
*We need to build Infrastructure enablers - a catalog of constrained standards, a national patient identifer (or private sector solution i.e. CHIMEchallenge/Commonwell/Surescripts/CareEverywhere), a national provider directory, a trust fabric, uniform consent policies among states
*We need to align economic incentives among stakeholders
*We need to consider the impact of the emerging consumer driven digital ecosystem
*We need to recognize that the EHR is not the center of the universe and enable other tools such as EHR agnostic warehouse solutions
*We need liquidity of claims data
*Documentation/coding rules need  to enable team-based care by all clinicians
*We need education to dispel fear of HIPAA and enable a culture of sharing


  1. "Products were rushed to market and they were not as usable or as intuitive as we’d like"..I like to call this scenario "The Sebelius Syndrome":) I call it that as we all remember Healthcare.Gov and how it was pushed to market before it's time and now of all things she's slated to be a "guest speaker" at the ONC annual meeting? What's this world coming too I could ask? We definitely have a world of real world versus the virtual world going on with a lot of what you mentioned. There are other examples too, but nobody will forget that one:)

    On the sharing portions of the entire scheme, consumers have been robbed of the option to say "ok" with all the data selling taking place for profit as well. HIPAA is such as mess and has become so "wordy" how in the world do you "really" know what compliance is?

    There's a lot of "Health IT" fat out there that's not leading to better care and happier doctors, we all know that and at some point there's an important question to ask I think when it comes to technology that may go something like this "Is this a need to have or a like to have" as Health IT has its part today with increase what we pay for care as well as the high price of drugs.

    With much of what gets developed in Silicon Valley with healthcare apps and software, I see an over abundance of "risk assessments" for profit that somehow also get marketed as a potential "diagnosis", and the two are not the same, as risk does not mean you have the ultimate diagnosis all the time:)

    In my opinion, there seems to be way too much of the methodologies of the McKinsey Consultant influence today in healthcare, and if you read any of the books about the company, this comment might make a little more sense:)

  2. Many of those comments are "too little, too late". We have expensive, complex systems that few providers are able and willing to use, which means patient care is traded for financial analytics that only profit insurance and government payers.