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Partnerships Between Behavioral Health & Telemedicine Drive Real Value and Impact Outcomes

Posted on April 24, 2015 I Written By

The following is a guest blog post by Dr. Bill Bithoney, Managing Director and Chief Physician Executive with The BDO Center for Healthcare Excellence & Innovation.
Bill Bithoney
The behavioral health and medical care delivery systems have long been separate, but the tides are changing. We’re starting to see more of a push to integrate the two, and it’s a trend expected to continue. Increased efforts to grow behavioral health service capacity through better integration with clinical care have health systems turning toward telemedicine. The benefits of this partnership are almost considered a “no brainer” when you take a look at the numbers and the opportunity for growth:

  • $6 billion: Where the telemedicine market will grow by 2020, according to the American Medical Association.
  • 7 million: The number of individuals with co-occurring substance abuse disorders and mental health issues, according to SAMHSA’s most recent National Survey on Drug Use and Health.
  • 38 percent: The number of adults with diagnosable mental health problems who actually receive needed treatment, according to the Department of Health and Human Services.

Still, providers and payors often find themselves asking, “How can I ensure this partnership will drive real value for the organization and impact outcomes?”

Telemedicine provides caregivers the ability to be in multiple locations at once – and provides patients access to care at times and places more convenient to them. As noted above, only 38 percent of adults with diagnosable mental health problems actually receive treatment. This means that more than 60 percent of individuals who know they need help aren’t able to receive it due to commonly cited challenges of not knowing where to go, inconvenience and lack of transportation. Further, psychiatrists, particularly those certified in addiction treatment, are in high demand nationwide. Indiana, which is experimenting with behavioral health telemedicine, has 462 in a state that should have 600.

And telemedicine has been proven effective in behavioral health treatment in numerous studies. Smartphones and apps are actually preferred by patients over prescriptions for medication. Through practices such as screening, brief intervention and referral to treatment (SBIRT)—included in Medicare telehealth services since 2013­­—problematic use issues, abuse and dependence on alcohol and illicit drugs can be proactively identified, reduced and prevented before ballooning into something greater. Moreover, the reduction in facility costs and increased access to patients makes telehealth, and telepsychiatry specifically, a cost-effective alternative to in-person treatments, while delivering much needed care.

Virtual visits and virtual early intervention through SBIRT impact not only the consumer’s health by extending the potential reach of substance abuse and mental health providers, but also the finances of the individual’s employer and insurer since the risks of costly and unanticipated urgent care and emergency department visits are greatly reduced. Additionally, insurers view this aggregation of data as a way to proactively monitor patients’ health, which can help prevent the risk of costly hospital admissions and readmissions.

The era of a partnership between behavioral health and telemedicine is upon us. Developing new avenues to deliver care that support behavior change, while engaging individuals in their own health, can not only be a more cost-effective strategy than simply providing more (or different) health care services, but can also be a smarter strategy to ensure better quality of care.

Dr. Bill Bithoney is a Managing Director and Chief Physician Executive with The BDO Center for Healthcare Excellence & Innovation. He can be reached at bbithoney@bdo.com

 

Innovative Collaboration on Medication Management and Community Resources

Posted on April 23, 2015 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://radar.oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

Although experts agree that the future of health is coordinated care, it is sorely lacking in the US health care system now. This article focuses on the single, relatively simple issue of medication management. Patients are prescribed barrels of pills, but there is little coordination other than looking for contra-indications and drug interactions–and these often suffer from the caretaker’s not knowing the patient’s full complement of drugs.

Sandra Raup, president of Datuit, points out that all kinds of subtleties get lost when patients are simply told how often to take a medication. For instance, if medications are spaced out throughout the day instead of being being taken all at once when we remember to take them (as so many people do), they may be absorbed more effectively and tolerated by the body. Patients–especially those with lower incomes and less education, who are more likely to be on multiple medications in the first place–need all sorts of support.

Here we come to an interesting twist: coordinated care does not have to be initiated by doctors. Given the doctor shortage and the forces keeping clinicians from adopting new models of treatment, other professionals can take on the long-term goals of improving patient health.

In a pilot ramping up in a residence for low-income seniors and the disabled in Maryland, Connected Health Resources is working with Alfa Specialty pharmacy using its Community Health Gateway to help patients straighten out their medications and keep to their schedules. This works because the pharmacy is in a somewhat unusual position: they have supported this community for some time and have built relationships with patients informally. The Gateway pilot has created a service, using Datuit’s SafeIX public API, that can potentially fulfill these needs with less work on the pharmacist’s part. The service is designed for easy navigation by the patients and their family caregivers, making it attractive to the patients and the pharmacists.

Connected Health Resources logo

The SafeIX Platform is designed using modern programming technologies to integrate data from multiple sources (including EHRs and HIEs) into a patient record for both patients and healthcare providers to use, based on their rights to access and share it. In the Gateway implementation, the pharmacist uses the SafeIX Platform to receive CDA documents from the HIE and to auto-assist medical data reconciliation between the various documents.

This information, along with the pharmacist recommendations, are organized into a daily medication calendar using an application from Polyglot Systems Incorporated, a company that offers medication regimen summaries in 18 languages. Low health literacy and the estimated 50 million people who do not speak English at home result in many patients not understanding their medication instructions. The plain language and multilingual, easy-to-use daily calendar can make the difference between understanding and total confusion.

Datuit’s SafeIX Platform uses interoperability standards (including, in test mode, the next-generation FHIR standard) to create a patient record that can show patients everything seen by multiple clinicians and allow a patient’s self-selected care team to view and add to a shared care plan. Datuit is encouraging app developers to build mobile apps for SafeIX that would prompt patients to take medications and record whether they did so, but that’s outside the scope of the pilot. There are plenty of challenges just fulfilling the tasks they have already taken on.

First, Connected Health Resources has to break down the clinical data silos that make it difficult for patients to collect their information. According to co-founder Shannah Koss, Maryland has a relatively advanced Health Information Exchange (HIE) called CRISP. However, it is defined as a provider-to-provider exchange, so it was only after a long-term relationship and negotiation that Connected Health Resources could collect medical data on behalf of the patients. This is the first time CRISP has allowed data to be retrieved for a patient-facing organization that is not a provider.

When enrolling, the patient gives the Gateway permission to get data through CRISP. Family and friends can be invited by patients to be part of their health community and enroll in the Gateway. The invitation includes a unique code that allows the Gateway to securely share records and help with health and social services navigation. If the patient wants help or is incapable of managing the medication list, a caregiver can do so.

CRISP transmits data primarily from hospitals. To round out a more comprehensive listing of medications from clinics and other healthcare providers, CRISP has enabled the ability to query Surescripts, which provides prescription fill data from chain pharmacies and pharmaceutical benefit management companies.

Pilot participants authorize the Gateway and the Alfa pharmacists to access their medication information and maintain, share, and augment the information in the secure SafeIX Platform. The CRISP data gives more complete medication records for the pilot participants. CRISP also provides an event notification system that let’s the pharmacist know whether a patient has been admitted to a hospital or visited the emergency department. These types of transition are precisely when medications get changed, but the clinicians at those crucial junctures often don’t know all of a patient’s current medications.

Finally, over-the-counter (OTC) medications can play an important role in a patient’s care. This has to be added to the daily calendar. The Alfa Pharmacist is helping round out the complete medication picture by working with the patient and family to identify OTC medications, supplements, and the medications that are actually being taken through the medication therapy management (MTM) program. The Gateway provides the means for everyone to better understand and manage the medicines for the best outcomes.

Further, the Gateway Community Resource Finder has enabled information about important resources such as transportation, meal delivery, social services, and home nursing. The MTM pharmacist knows that patients without food or transportation to their physicians cannot adequately manage their health or medications. The underlying SafeIX Platform also allows the Gateway to offer secure messaging that looks like email and lets the pharmacist, patient, friends, and family exchange messages about the patient’s care.

Traditional EHRs don’t accommodate treatment plans of the specificity designed by the pharmacy for patients in the pilot. This is where Datuit is pushing the EHR to new horizons: its SafeIX Platform helps multiple clinicians (including long term care providers), patients, and family caregivers contribute data. For example, patients can enter their own healthcare problems, such as fear of falling. The patients, families, and clinicians can then add interventions to address them.

Like other new organizations I’ve spoken too in health care, Connected Health Resources has grand plans beyond the current pilot. They are taking it slow, because Koss believes personal health records (PHRs) have tried to do too much at once and have overwhelmed their users with too many possibilities. But she would like Connected Health Resources to grow in response to what patients and families say they need. The Gateway tools already include the ability to generate multi-lingual discharge instruction from Polyglot. The initial pilot purposefully focuses on the more narrow scope of medications along with the health and social services support. The next step will be to engage hospitals to provide the plain language multi-lingual discharge instructions.

Chronic care ultimately goes beyond medications to things supported by a patient-centered medical home (PCMH), community health workers, and the many community-based service providers. The Gateway in partnership with the Datuit SafeIX Platform are poised to allow all participants identified by the patient and families to contribute to and be part of their health community.

Slickest Solution I Saw at HIMSS15

Posted on April 22, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

This probably says something about me, but I’m always intrigued by really slick solutions that leverage creativity to solve a problem. While at HIMSS amidst all the vendor noise, I saw a solution that I fits this description. The solution came from a scanning company called Ambir and the solution is called nForm. Yes, I was a bit surprised that it came from a scanner company too, but that’s the beauty of HIMSS. You never know where you going to find something interesting.

In any office, one of the biggest annoyances during an EHR implementation is that you can’t go fully electronic. There are still a large number of forms that require a patient signature. In 95% of cases this means that you’re handing the patient a stack of paper forms which they can sign. Most organizations then scan those forms into their EHR. It makes for an awful workflow and we all know it.

The nForm solution from Ambir solves this problem and makes the process electronic. You can literally scan in any form and nForm will make that paper form an electronic form that can be completed electronically on an iOS, Android or the nForm 410x tablet device. The patient can literally fill out the form on the screen as if they were filling out the form on paper. Then, once the patient completes the form, nForm will upload it to your EHR using the same workflow you’d been using when you’d scan the form into your EHR.
nForm
To me the most powerful part of this solution is that it uses your paper form workflow without requiring any sort of new integration from your EHR vendor. Even if you usually print out your intake forms from your EHR, you can “print” them to nForm and then when the patient fills out the forms they’ll get pushed back to the EHR. If you’re a clinic that just has a stack of intake paperwork that you attach to a clipboard for the patient, you can have those already queued up on nForm and just hand the tablet to the patients to complete.

While I’ve talked about the intake forms, you can also use this for other forms you might need signed later in the office visit as well. We all know those pesky consent for treatment forms that we’re still doing on paper and hopefully scanning in later.

I love that this is a slick solution for healthcare, but I’m also interested in the product for my own personal use. The only things I print these days are when I need to sign something. How much nicer will it be for me to just print to nForm, sign it and then send it to the receiving party? Saves the hassle of going to the printer. Saves ink and paper which will make all you eco friendly people happy.

While nForm supports you writing anything on a form (it literally is like an electronic piece of paper), I’m skeptical about how well it will do for a really detailed form. Obviously in healthcare we’re moving these forms to a patient portal so we can get the granular data elements stored as unique data elements. So, we’re not handing a patient a lengthy paper form as much anymore.

With that said, I’m not sure how a lengthy health history form would look using nForm. People’s bad handwriting together with the digital input might make it hard to read. For signatures or basic forms it won’t be an issue at all. Plus, they’ve made it so the virtual pen color is different from the background of the form. It’s actually really easy to look at a form and see what was completed (or not completed) by the patient. In that way, it makes the form more legible than a paper form. Although, it still depends on the quality of their handwriting.

All in all, I’m really impressed with the nForm solution. I’ve implemented a Topaz style signature pad solution before, but that required integration with the EHR (which very few have done) and still felt awkward since you weren’t actually signing on the document itself. nForm has all the advantages of the paper form, but in a nice electronic solution. I love slick solutions like this.

Full Disclosure: Ambir is a Healthcare Scene advertiser.

Epic Belatedly Accepts Reality And Drops Interoperability Fees

Posted on April 21, 2015 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Unbeknownst to me, and perhaps some of you as well, Epic has been charging customers data usage fees for quite some time.  The EMR giant has been quietly dunning users 20 cents for each clinical message sent to a health information exchange and $2.35 for inbound messages from non-Epic users, fees which could surely mount up into the millions if across a substantial health system.  (The messages were delivered through an EMR module known as Care Everywhere.)

And now, Epic chose #HIMSS15 to announce grandly that it was no longer charging users any fees to share clinical data with organizations that don’t use its technology, at least until 2020, according to CEO Judy Faulkner.  In doing so, it has glossed over the fact that these questionable charges existed in the first place, apparently with some success. For an organization which has historically ducked the press routinely, Epic seems to have its eye on the PR ball.

To me, this announcement is troubling in several ways, including the following:

  • Charging fees of this kind smacks of a shakedown.  If a hospital or health system buys Epic, they can’t exactly back out of their hundreds-of-millions-of-dollars investment to ensure they can share data with outside organizations.
  • Forcing providers to pay fees to share data with non-Epic customers penalizes the customers for interoperability problems for which Epic itself is responsible. It may be legal but it sure ain’t kosher.
  • In a world where even existing Epic customers can’t share freely with other Epic customers, the vendor ought to be reinvesting these interoperability fees in making that happen. I see no signs that this is happening.
  • If Epic consciously makes it costly for health systems to share data, it can impact patient care both within and outside, arguably raising costs and increasing the odds of care mistakes. Doing so consciously seems less than ethical. After all, Epic has a 15% to 20% market share in both the hospital and ambulatory enterprise EMR sector, and any move it makes affects millions of patients.

But Epic’s leadership is unrepentant. In fact, it seems that Epic feels it’s being tremendously generous in letting the fees go.  Here’s Eric Helsher, Epic’s vice president of client success, as told to Becker’s Hospital Review: “We felt the fee was small and, in our opinion, fair and one of the least expensive…but it was confusing to our customers.”

Mr. Helsher, I submit that your customers understood the fees just fine, but balked at paying them — and for good reason. At this point in the history of clinical data networking, pay-as-you-go models make no sense, as they impose a large fluctuating expense on organizations already struggling to manage development and implementation costs.

But those of us, like myself, who stand amazed at the degree to which Epic blithely powers through criticism, may see the giant challenged someday. Members of Congress are beginning to “get it” about interoperability, and Epic is in their sights.

The Key to Healthcare Innovation

Posted on April 20, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

As I’ve thought through my own entrepreneurial journey, I think this is the biggest key differentiator between me and many others. Ideas are so easy. Everyone has them and great entrepreneurs have thousands of them. The really really hard thing is to do something about them.

I hate to think about the millions of ideas that have come to people in healthcare and nothing’s been done about them. They lie dormant in someone’s mind since someone doesn’t feel empowered to do something about it. They never see the light of day because someone is afraid to share the idea with someone else who could help them make it a reality.

While we love to tell stories of innovation that get wrapped up really nice with a pretty bow on top. The reality is that every innovation I’ve seen in healthcare is always much messier than a story portrays. This is why making an idea happen is so hard. Having the idea is easy. Actually acting on an idea is messy and often extremely difficult.

Thank you Dr. Shrestha for the challenge coming out of HIMSS where a lot of ideas are thrown around. Now’s the time to help make those ideas happen.

Cerner Dev Partnership With Advocate Fits Emerging Model

Posted on April 17, 2015 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

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For most of the time I’ve spent covering health IT — going back to the early 90s — vendor and provider technology development hung out in separate silos. Sure, the smarter vendors at least took time to talk with customers about their needs, but most pushed products and features developed in a vacuum.

While that’s still the case today for many vendors, I believe the paradigm has begun to shift. These days, health IT vendors are increasingly working with providers to create products for rapidly-emerging arenas like population health and tools to support ACO management.

One great example of this trend is a deal recently struck between Cerner and Kansas City, MO-based Advocate Health Care, along with Advocate Physician Partners (announced, not too surprisingly, the Friday before the glory that is HIMSS). While this deal is extending an existing long-term partnership, not kicking off a new project, it’s still gives us a nice look at how vendor/provider partnerships are evolving.

To be sure, Cerner is still playing the traditional vendor role to some extent. For example, Advocate has invested in Cerner’s HealtheCare, a community-based care management solution, as well as having the vendor keep hosting Advocate’s Cerner EMR through 2024. But that’s just the tip of the iceberg.

The heart of the deal is the development partnership, which if all goes well should give both parties a leg up in creating technologies that aren’t just shovelware. With the Advocate folks will bring their on-the-ground population health and process smarts to the table, and Cerner will share its population health and EMR technology.

Over the next seven years, the Physician Partners group will help Cerner develop a sophisticated set of population health tools. Meanwhile, Physician Partners gets access to HealtheRegistries, a tool which aggregates clinical, financial and operational data to offer a broad look at patient activity.

While this may seem like dressed-up vendor sales win puffery, my instinct is that it’s more than that. After all, both Cerner and Advocate stand to benefit substantially if they truly work together. Advocate gets the first look at EMR and population health tools that could shape their patient care strategy for decades, and Cerner gets vital provider input on a line of business which could prove to absorb EMR technologies in its wake.

And that, my friends, is why a vendor the size of Cerner — which could probably force its internally-designed products down the throat of health systems for quite a while — is developing real partnerships with its customers. In the emerging world of health IT, providers may very well filter their care management and documentation in ways that relegate the EMR to back-end status.

If other vendors are smart enough to see that the “we make it, you buy it” model of health IT dev isn’t aging well, the great engines that power care are likely to be robust, relevant and productive. If not, well, what’s the harm if Cerner turns a bigger profit over the next several years?

Integrating Devices, Patients, and Doctors: HealthTap Releases an App for the Apple Watch

Posted on April 16, 2015 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://radar.oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

Doesn’t HealthTap want the same thing as all the other web sites and apps crowding into the health space? Immediate and intimate connections between doctors and patients. Accurate information at your fingertips, tailored to your particular condition. Software that supports your goals where automation makes sense and gets out of the way at other times.

HealthTap pursues this common vision in its own fashion. This week, its announcement of an app for Apple Watch pulls together the foundations HealthTap has been building and cleverly uses the visceral experience that the device on your wrist offers to meet more of the goals of modern, integrated health care.
Read more..

Annual Evaluation of Health IT: Are We Stuck in a Holding Pattern? (Part 3 of 3)

Posted on April 15, 2015 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://radar.oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

The previous installments of this article covered major regulatory initiatives and standards projects. Some of the same questions have a direct impact on technological advances.

Medical Devices: Always With You, But Neither Here Nor There

One ad I saw compares a fitness device to a friend whispering in your ear wherever you go. Leaving aside control freak issues, what could be better for a modern patient with a condition that responds to behavior change than a personal device? Through such devices, we can implement a 24/7 cycle of medical care. We can also save enormous sums of money by treating the patient in his natural environment instead of a hospital or rehab facility.

The rapid spread of health devices was a foregone conclusion even before Apple thrust it into the mainstream with HealthKit. Last month’s launch of ResearchKit suggests that Apple will do the same for the big data revolution in health care championed by the Personal Genome Project, 23andMe (now back in the business after being reined in by the FDA), PatientsLikeMe, and other pioneer organizations. Apple Watch, an indulgence expected to grab the hearts of the affluent, might pull off the paradigm shift in how we interact digitally that Google Glass aimed at.

For these devices to make the leap from digital pets to real medical intervention, including a strengthening of the bond between clinicians and patients, they must satisfy stringent requirements for safety and accuracy. Current FDA regulations distinguish (in very rough terms–I am not a lawyer) between devices that make diagnoses or recommend treatments and other devices that merely measure vital signs or deliver reminders. If you make a diagnosis or recommend a treatment, you need to undergo a complex and expensive evaluation. People can also submit problems they find about your device to FDA’s medical device database.

Safety, accuracy, and transparency are goals well worth pursuing. The problem is not the cost of certification techniques, but the vast gulf between the development model assumed by certification and the one followed by modern developers of both software and hardware.

Development methods nowadays are agile. Developers incrementally release versions of software or hardware and upgrade them every few months. But certification processes require retesting every time the smallest change is made. And that’s reasonble because any tweak (even a configuration change out in the field) can cause a working device to fail. Such certifications work well for embedded systems in airplanes and nuclear facilities, and even critical medical devices that may live in patients’ bodies for decades. But they slow innovation to a crawl and raise prices precipitously.

Oddly enough, the tension between agile development and certification affects medical devices and electronic health records (EHRs) equally, and EHRs are equally prone to errors or misleading interfaces. Yet medical devices are regulated while EHRs are not. This contradiction must be resolved–but perhaps not by dropping the anvil of safety certification on all software used in medicine. The FDA can search for a more supple regulatory process that blesses certain classes of hardware and software while allowing for variation within them, backed up by guidelines for robust development and testing.

The FDA understands that it’s in an untenable situation but doesn’t know what to do. They have shaved off certain devices and marked them for lower levels of scrutiny, such as devices that transfer or display data collected elsewhere. The FDA has also led a muddled discussion over a national “test bed” for medical devices. More regulatory clarity in the area of both devices and EHRs, along with a push by regulators and users for better development practices, could help the field take off and realize the promise of personal devices.

Conclusion

I’m excited about the possibilities of health IT, but concerned that the current environment is insufficiently friendly for its deployment. On top of all the other factors I’ve cited that hold back the field, consider the urgent shortage of health IT staff. Providers and development firms have been bidding up salaries to steal each other’s employees, and attempts to increase the pool have shown disappointing results.

What I hear is that IT experts would love to get into health care, knowing that it can help the public immensely as well as pay off financially. But they have balked at the technical and working conditions in the field: hide-bound institutions, 50-year-old standards and tools, and of course the weight of standards and regulations to study.

How many of these topics will be covered at HIMSS? FHIR will be widely considered, I know, and the buzz over Meaningful Use is always strong. The question what will prod change in the system. Ultimately, it may come from a combination of consumer demand and regulatory pressure. Progress for the sake of progress has not been a prominent trait of health IT.

Annual Evaluation of Health IT: Are We Stuck in a Holding Pattern? (Part 2 of 3)

Posted on April 14, 2015 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://radar.oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

The previous installment of this article was devoted to the various controversies whirling around Meaningful Use. But there are lots of other areas of technology and regulation affecting the progress (or stasis) of health IT.

FHIR: Great Promise, But So Far Just a Promise

After a decade or so of trying to make incompatible formats based on obsolete technology serve modern needs such as seamless data exchange, the health IT industry made a sudden turn to a standard invented by a few entrepreneurial developers. With FHIR they pulled on a thread that will unravel the whole garment of current practices and standards, while forming the basis for a beautiful new tapestry. FHIR will support modern data exchange (through a RESTful API), modern security, modern health practices such as using patient-generated data, and common standards that can be extended in a structured manner by different disciplines and communities.

When it’s done, that is. FHIR is still at version 0.82. Any version number less than 1, in the computer field, signals that all sorts of unanticipated changes may still be made and that anyone coding around the standard risks having to rip out their work and starting over. Furthermore, FHIR is a garment deliberately designed with big holes to be filled by others:

  • Many fields are defined precisely, but elements of the contents are left open, such as the units in which medicine is measured. This is obviously a pretty important detail to tie down.

  • Security relies on standards in the OpenID/OAuth area, which are dependable and well known by developers through their popularity on the Web. Still, somebody has to build this security in to health IT products.

  • Because countries and medical disciplines vary so greatly, the final word on FHIR data is left to “profiles” to be worked out by those communities.

One health data expert I talked to expressed the hope that market forces would compel the vendors to cooperate and make sure these various patches are interoperable as they are pieced into the garment. I would rather design a standard with firm support for these things.

Some of the missing pieces can be supplied relatively painlessly through SMART, an open API that predates FHIR but has been ported to it. An impressive set of major vendors and provider organizations have formed the Argonaut project to carry out some tasks with quick pay-offs, like making security work and implementing some high-value profiles. Let’s hope that FHIR and its accompanying projects start to have an impact soon.

The ONC has repeatedly expressed enthusiasm for FHIR, and CMS has alerted vendors that they need to start working on implementations. Interestingly, the Meaningful Use Stage 3 recommendation from CMS announces the opinion that health care providers shouldn’t charge their patients for access to their data through an API. An end to this scandalous exploitation of patients by both vendors and health care providers might have an impact on providers’ income.

Accountable Care Organizations: Walls Still Up

CMS created ACOs as a regulatory package delivering the gifts of coordinated care and pay-for-value. This was risky. ACOs require data exchange to effect smooth transfers of care, but data exchange was a rare occurrence as late as 2013, and the technical conditions have not changed since then so I can’t imagine it’s much better.

Pay-for-value also calls for analytics so providers can stratify populations and make rational choices. Finally, the degree of risk that CMS has asked ACOs to take on is pretty low, so they are not being pushed too hard to make the necessary culture changes to benefit from pay-for-value.

All that said, ACOs aren’t doing too badly. New ones are coming on board, albeit slowly, and cost savings have been demonstrated. An article titled “Poor interoperability, exchange hinders ACOs” actually reports much more positive results than the title suggests. There may be good grounds for ONC’s pronouncement that they will push more providers to form ACOs.

Still, ACOs are making a slow tack toward interoperability and coordinated care. The walls between health care settings are gradually lowering, but providers still huddle behind the larger walls of incompatible software that has trouble handling analytics.

I’ll wrap up this look at progress and its adversaries in the next installment of this article.

Annual Evaluation of Health IT: Are We Stuck in a Holding Pattern? (Part 1 of 3)

Posted on April 13, 2015 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://radar.oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

I don’t think anyone has complained of excessive long-term thinking among health care providers. But an urgent lack of planning has worsened in the past few months as key drivers of the health IT field search for new directions. Given today’s issues with Meaningful Use Stage 3, the FHIR data exchange standard, Accountable Care Organizations, medical device regulation, and health IT staffing, I expect the next several months to be a time of waiting.

This article will look over what has happened during the past year and try to summarize large-scale trends. I used to report annually from the HIMSS conference, the largest health IT gathering in the US, but stopped going because my articles were always cynical, cantankerous, and depressed. So I figure I just write up a cynical, cantankerous, and depressed summary of what’s happening in health IT from home.

Meaningful Use Stage 3: Shoot the Moon?

There are clear indications that the Meaningful Use program has gone off the tracks. I don’t consort with those who disparaged Meaningful Use from the start and claimed that it held back progress in the IT field. What little progress has occurred can be credited to Meaningful Use, because frankly, the health care industry was totally mired before. Choose your favorite metaphor: deer in the headlights (of oncoming disruptive competitors), ostrich in the sand, even possum in the road.

And no one can challenge that Stage 1 met its (very limited) goals. Centers for Medicare & Medicaid Services (CMS) just reported that the vast majority of hospitals have attested to Stage 1 (with rural and children’s hospitals lagging significantly). In fact, while defining Stage 3, CMS could remove some of its requirements because they have “topped out,” meaning that almost everybody already does them.

All the sharper is the contrast between Stage 1 and Stage 2, which was supposed to be incremental but apparently broke the camel’s back for many EHR vendors as well as providers, a lot of whom have thrown in the towel.

Interoperability was certainly a big stumbling block. Two different EHRs can claim to support a standard (such as the C-CDA) while not actually being able to exchange data in a useful manner, for reasons ranging from outright errors to differing interpretations of a fuzzy standard.

But the most whining from providers in Stage 2 arose over a requirement that patients view, transmit, or download (VDT) data from a patient portal. Even though providers needed only 5% of their patients to take a look at the site, they complained bitterly that they were being judged for something that relied on somebody else’s behavior (their patients).

The VDT measure is indeed a responsibility that depends on the behavior of outsiders (as are the interoperability requirements). But health providers seem slow to grasp the whole idea of “pay-for-value,” which means they won’t be rewarded in the future for doing stuff–they’ll be rewarded for results. Not that patients will get healthier just by viewing or transmitting data. But we need something measurable to mark progress, and since everybody issues paeons to patient engagement, the VDT measure is a natural one.

Calls have come from around the industry to water down or otherwise “simplify” Meaningful Use for Stage 3. A common request is to eliminate clinical quality measures (such as how many patients smoke) and focus on interoperability, which I oppose.

To muddy the Meaningful Use landscape further, Congress has started weighing in with complaints that the Office of the National Coordinator (ONC) hasn’t done enough to achieve its goals. One proposed bill overrides ONC and CMS to mandate changes in health care policy. There are rumors that Congress (who of course created the Meaningful Use provision in the first place) will take it back and do some serious micromanagement, perhaps as part of a bill on a totally different topic, the “doc fix” that is supposed to regularize Medicare payments.

In the midst of this turmoil, the ONC and CMS recently released Stage 3 recommendations, and it looks like they haven’t pulled their punches on a single thing. Interoperability is central, but the clinical quality measures still appear in full force. The requirement that patients engage with the technology has been softened, but still requires patients to take some action such as using a portal or uploading their own data.

Perhaps the boldest stake that CMS put in the ground was to force all providers onto a single schedule in Stage 3, a tremendous departure from the gentle steps offered by the first two stages. This has touched off a provider frenzy. They’ve been lobbying for years to slow Meaningful Use down, and notoriously ran to Congress to delay adoption of ICD-10 disease coding. But putting everyone on the same track makes eminent sense, particularly at this stage. If you’re really serious about data exchange and coordinated care, everybody has to equally capable. Otherwise we’re back to finger-pointing and claims that technology lapses have prevented compliance.

So what are ONC and CMS up to? Are they shooting the moon–hoping to make the big leap to their maximal goals in one bold play? Are they floating an audacious wish list that they know will be cut back in the course of negotiation? Are they even taunting resistant industries to go to Congress, knowing that Congress recently has been making even more radical noise than the Administration about the drawbacks of health IT? Something along these lines seems to be in the works.

To return to the theme of this article, I’m afraid that health care providers, insurers, EHR vendors, and all their business associates will freeze up while waiting for Congress and the various branches of Health and Human Services to determine which behaviors to prescribe and which to punish. So that’s my take on meaningful use–more on other developments in health IT in the next installments.