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Who is Adopting EHRs and Why: ONC Turns up Some Surprises

Posted on December 15, 2014 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.

A high-level view of the direction being taken by electronic health records in the U.S. comes from a recent data brief released by the Office of the National Coordinator. Their survey of physician motivations for adopting EHRs turns up some puzzling and unexpected findings. I’ll look at three issues in this article: the importance of Meaningful Use incentives and penalties, the role of information exchange, and who is or is not adopting EHRs.

Incentives and Penalties
The impact of the Meaningful Use bribes–sorry, I meant incentive payments–in the HITECH act are legendary: they touched off a mad rush to adopt technology that had previously aroused only tepid interest among most physicians, because they found the EHRs outrageously expensive, saw no advantage to their use, or just didn’t want to leave the comfort zone of pen and paper. The dramatic outcome of Stage 1, for instance, can be seen in the first chart of this PDF.

This month’s data brief reconfirms that incentives and penalties played a critical role during the period that Meaningful Use has been in play. In the brief’s Figure 3, incentives and penalties topped the list of reasons for adopting records, with nothing else coming even close (although the list was oddly chosen, leaving out credible reasons such as “EHRs are useful”).

The outsized role payments play is both strange and worrisome. Strange, because the typical $15,000 paid per physician doesn’t even start to cover the costs of converting from paper to an EHR, or even from one EHR to another. Worrisome, because the escalator (a favorite metaphor of former National Coordinator David Blumenthal) on which payments put physicians is leveling off. Funding in the HITECH act ends after Stage 3, and even those payments will be scrutinized by the incoming budget-conscious Congress.

In addition, Stage 2 attestations have been dismally low. Critics throughout the industry, smelling blood, have swooped in to call for scaling back, to suggest that meaningful use provisions be eased or weakened, or just to ask for a more concentrated focus on the key goal of interoperability.

The ONC knows full well that they have to cut back expectations as payments dry up, although penalties from the Center for Medicare & Medicaid Services can still provide some leverage. Already, the recent House budget has level-funded the ONC for next year. Last summer’s reorganization of the ONC was driven by the new reality. Recent initiatives at the ONC show a stronger zeal for creating and urging the adoption of standards, which would be consistent with the need to find a role appropriate to lean times.

Health Information Exchange
I am also puzzled by the emphasis this month’s data brief puts on health information exchange. Rationally speaking, it would make perfect sense for physicians to ramp up and streamline the sharing of patient data–that’s exactly what all the health care reformers are demanding that they do. Why should somebody ask a patient to expose himself to unnecessary radiation because an X-Ray hasn’t been sent over, or try to treat someone after surgery without knowing the discharge plan?

Actually, most physicians would. That’s how they have been operating for decades. Numerous articles find that most physicians don’t see the value of information exchange, and can profit from their ignorance of previous tests and treatments the patient has received.

And that’s probably why, after taking hundreds of millions of dollars from governments, the heavy-weight institutions called Health Information Exchanges have repeatedly thrown in the towel or been left gasping for breath. At least two generations of HIEs have come and gone, and the trade press is still searching for their value.

So I’m left scratching my head and asking: if doctors adopt EHRs for information exchange, are they getting what they paid for? Redemption may have arrived through the Direct project, an ONC-sponsored standard for a low-cost, relatively frictionless form of data exchange. Although the original goal was to make HIE as simple as email, the infrastructure required to protect privacy imposes more of a technical burden. So the ONC envisioned a network of Health Information Service Provider (HISP) organizations to play the role of middleman, and a number are now operating. According to Julie Maas of EMR Direct, nearly half a million people were using Direct in July 2014, and the number is expected to double the next time statistics are collected next February.

So far, although isolated studies have shown that HIEs improve outcomes and reduce costs, we haven’t seen these effects nationwide.

What Hinders Adoption
Some of the most intriguing statistics in the data brief concern who is adopting EHRs and what holds back others from doing so. The main dividing line is simply size: most big organizations have EHRs and most small ones don’t.

I have explored earlier the pressures of health care reform on small providers and the incentives to merge. Health care technology is a factor in the consolidation we’re seeing around the country. And we should probabaly look forward to more.

Americans have trouble feeling good about consolidation in any field. We’re nostalgic for small-town proprietors like the pharmacist in the movie It’s a Wonderful Life. We forget that the pharmacist in that movie nearly killed someone by filling a prescription incorrectly. In real life, large organizations can pursue quality in a host of ways unavailable to individuals.

One interesting finding in the data brief is that rural providers are adopting EHRs at the same rate as urban ones. So we can discard any stereotypes of country hick doctors letting teenagers set up the security on their PCs.

Lack of staff and lack of support are, however, major barriers to adoption. This is the last perplexing question I take from the data brief. Certainly, it can be hard to get support for choosing an EHR in the first place. (The Meaningful Use program set up Regional Extension Centers to partially fill the gap.) But after spending millions to install an EHR, aren’t clinicians getting support from the vendors?

Support apparently is not part of the package. Reports from the field tell me that vendors install the software, provide a few hours of training, and tip their hats good-bye. This is poetic justice toward physicians, who for decades have sent patients out weak and groggy with a prescription and a discharge sheet. Smart organizations set aside a major percentage of their EHR funding to training and support–but not everybody knows how to do this or has grasped the need for ongoing support.

I certainly changed some of my opinions about the adoption of EHRs after reading the ONC data brief. But the statistics don’t quite add up. We could use some more background in order to understand how to continue making progress.

Does Meaningful Use Inspire Innovative or Mediocre Systems?

Posted on December 12, 2014 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.

I was absolutely intrigued by Dr. Webster’s tweet about the impact of meaningful use (MU) and the types of systems it inspires. I think everyone would agree that MU has done nothing to inspire innovative EHR systems to be created and I think most would agree that it’s mostly fostered the creation of mediocre systems.

I’m not saying that meaningful use has no redeeming qualities. It definitely drove adoption of EHR software. Some of the meaningful use requirements like ePrescribing and CPOE were already moving forward for many organizations and meaningful use threw gas on those fires. I think those will turn out to be really beneficial components to meaningful use.

We could talk about the overall impact of MU (good or bad), but I’m not sure how productive of a conversation that would be. Meaningful Use is the reality of today. So, instead of focusing backwards on something we can’t change, I’m interested to think about what meaningful use could become. For all intents and purposes, that’s going to be called meaningful use stage 3 (unless ONC decides to spend time on a rebranding).

The key question: Could Meaningful Use inspire innovative EHRs and other innovative health IT?

While I’m skeptical of government regulation doing much for innovation, I think there’s a chance that this could happen. The key change will be that meaningful use needs to move away from its prescriptive approach and requirements. Innovation rarely comes from prescriptive approaches to anything.

Instead of being so prescriptive, meaningful use should focus on creating frameworks for which innovation can happen. My initial analysis of FHIR is that this is directionally right when it comes to inspiring innovation in healthcare IT. I need to dig into the details a bit more, but the concepts of creating an open framework for health IT companies to innovate on top of EHR data is what things like meaningful use should incentivize. Reimbursement should help to encourage this type of innovation. HIPAA should be clarified to support this type of innovation.

RHIR is just one example and I’m sure there are many others. It’s an open approach which encourages the right things while not damaging those for which it doesn’t make any sense. To me that’s the major difference between a prescriptive requirements list versus a framework oriented approach.

Do we really care that doctors game the system to be able to meet the 5% patient engagement requirement of meaningful use? What value does that provide the healthcare system if they’re not truly engaging? That’s too prescriptive. I’m all for patient engagement. Doctors are too. However, these prescriptive MU requirements just cause doctors to game the system as opposed to truly engage.

What do you think could be done with MU so that it inspires innovative EHRs instead of mediocre systems?

Open Source Electronic Health Records: Will They Support the Clinical Data Needs of the Future? (Part 1 of 2)

Posted on November 10, 2014 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.

Open source software missed out on making a major advance into health care when it was bypassed during hospitals’ recent stampede toward electronic health records, triggered over the past few years by Meaningful Use incentives. Some people blame the neglect of open source alternatives on a lack of marketing (few open source projects are set up to woo non-technical adoptors), some on conservative thinking among clinicians and their administrators, and some on the readiness of the software. I decided to put aside the past and look toward the next stage of EHRs. As Meaningful Use ramps down and clinicians have to look for value in EHRs, can the open source options provide what they need?

The oncoming end of Meaningful Use payments (which never came close to covering the costs of proprietary EHRs, but nudged many hospitals and doctors to buy them) may open a new avenue to open source. Deanne Clark of DSS, which markets a VistA-based product called vxVistA, believes open source EHRs are already being discovered by institutions with tight budgets, and that as Meaningful Use reimbursements go away, open source will be even more appealing.

My question in this article, though, is whether open source EHRs will meet the sophisticated information needs of emerging medical institutions, such as Accountable Care Organizations (ACOs). Shahid Shah has suggested some of the EHR requirements of ACOs. To survive in an environment of shrinking reimbursement and pay-for-value, more hospitals and clinics will have to beef up their uses of patient data, leading to some very non-traditional uses for EHRs.

EHRs will be asked to identify high-risk patients, alert physicians to recommended treatments (the core of evidence-based medicine), support more efficient use of clinical resources, contribute to population health measures, support coordinated care, and generally facilitate new relationships among caretakers and with the patient. A host of tools can be demanded by users as part of the EHR role, but I find that they reduce to two basic requirements:

  • The ability to interchange data seamlessly, a requirement for coordinated care and therefore accountable care. Developers could also hook into the data to create mobile apps that enhance the value of the EHR.

  • Support for analytics, which will support all the data-rich applications modern institutions need.

Eventually, I would also hope that EHRs accept patient-generated data, which may be stored in types and formats not recognized by existing EHRs. But the clinical application of patient-generated data is far off. Fred Trotter, a big advocate for open source software, says, “I’m dubious at best about the notion that Quantified Self data (which can be very valuable to the patients themselves) is valuable to a doctor. The data doctors want will not come from popular commercial QS devices, but from FDA-approved medical devices, which are more expensive and cumbersome.”

Some health reformers also cast doubt on the value of analytics. One developer on an open source EHR labeled the whole use of analytics to drive ACO decisions as “bull” (he actually used a stronger version of the word). He aired an opinion many clinicians hold, that good medicine comes from the old-fashioned doctor/patient relationship and giving the patient plenty of attention. In this philosophy, the doctor doesn’t need analytics to tell him or her how many patients have diabetes with complications. He or she needs the time to help the diabetic with complications keep to a treatment plan.

I find this attitude short-sighted. Analytics are proving their value now that clinicians are getting serious about using them–most notably since Medicare penalizes hospital readmissions with 30 days of discharge. Open source EHRs should be the best of breed in this area so they can compete with the better-funded but clumsy proprietary offerings, and so that they can make a lasting contribution to better health care.

The next installment of this article looks at current support for interoperability and analytics in open-source EHRs.

Meaningful Use Audits and the Inconsistent Appeals Process

Posted on November 6, 2014 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.

If you haven’t had the pleasure of a meaningful use audit yet, consider yourself lucky. They are not pretty, but I’ve never met anyone who actually enjoys an audit. Turns out that meaningful use appeals are even worse than most audits. It’s likely because the meaningful use appeals process are so new and they haven’t figured out their processes. However, if you’re a clinic on the wrong side of a new process, that’s not much consolation.

Meaningful Use expert, Jim Tate, has a fascinating look into the inconsistency of meaningful use appeals. Here’s one story he shares that will kind of blow your mind (or at least annoy and scare you).

“Two Set of Rules”: You are not going to believe this one, but it is true. I was contacted last week by a large practice. Two of their physicians had failed audits. Both appealed and won with the statement from CMS: “This is the final determination notice regarding your recent appeal….Based on our review of your Appeal Filing Request, supporting documentation and the Program policies, we have accepted the documentation your provided to support your appeal. Therefore, CMS upholds your appeal.” Sounds great, doesn’t it? However, two months later they received this from CMS: “CMS has reopened the review of your appeal and supporting documentation along with others from your practice. The documentation provided….is unsufficient to support the appeal and CMS is reversing….the decision to uphold your appeal. As a result, the final CMS decision denies your appeal and upholds the adverse audit finding. This decision is not subject to further appeal.” Is it just me or it this a little bit on the crazy side? They received from CMS a “final determination” that their appeal was upheld and then two months were told the “final determination” was being undone, the appeal would now be denied and “this decision is not subject to further appeal.” Both of the letters were signed by the same CMS official. Is it just me or do we need a little sunlight on the inner workings of this process?

Jim is right that there should be a clear process for meaningful use audits and appeals. It’s interesting that Jim tried to go to DC to visit with CMS about the process. Unfortunately, his request was denied. There’s nothing worse than hitting a dead end and people aren’t willing to listen.

Hopefully CMS will hear this story and act. It’s not fair to any organization to get stuck in a bad process.

Meaningful Use #HITsm Twitter Chat

Posted on October 17, 2014 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.

I had the honor today to host the #HITsm Twitter chat. For those not familiar with the #HITsm chat, you just join every Friday at Noon ET and watch the tweets that are sent using the #HITsm hashtag. There are usually 4-5 questions that are discussed over the hour chat. Since I was the host, I created the questions this week. I chose to focus the chat on the latest happenings with meaningful use. The transcript of the chat is found here.

I just took a look at the stats for the chat on Symplur and saw that the chat had 68 participants that sent out 474 tweets which had 3,196,079 impressions. You have to be a little careful looking at impressions since that’s potential impressions, but it’s still interesting to consider the possible reach of a chat.

There were some really interesting tweets during the chat, so here are the questions and a few (ok, more than a few since I got carried away) of my favorite tweets: Read more..

Is EHR on Life Support? Short Answer…No

Posted on October 10, 2014 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.

Today, David Swink sent me a link to an article from the Washington Examiner and this quote from the article:

“A revolt is brewing among doctors and hospital administrators over electronic medical records systems mandated by one of President Obama’s early health care reforms.”

“The American Medical Association called for a “design overhaul” of the entire electronic health records system in September because, said AMA president-elect Steven Stack, electronic records “fail to support efficient and effective clinical work.”

It seems like there have been a wave of articles similar to this coming out in the national media. For some reason the national media only likes to report on things when “the sky is falling.” It’s kind of a ridiculous report though.

What’s not ridiculous is that many doctors are dissatisfied with their EHR software. That is something that is real and many are extremely frustrated with it and many of the EHR regulations that require a lot of extra work by them. Does that mean that we’re going to see an EHR “design overhaul” or that the doctors are going to revolt against EHRs and stop using them?

My answer (as the headline alludes) is that it’s not going to happen. Certainly we’re going to see some EHR switching over the next few years. In fact, we might see a lot of EHR switching. However, we’re not going to see a mass of people revolting against EHR and going back to paper. That would be a true revolt and it’s just not going to happen. Like it or not, EHR is the go forward technology that will be used by healthcare to document healthcare.

Meaningful use on the other hand is a different story. I do think that meaningful use is on life support. If the congress can somehow get the Flex-IT Act to pass, then we can take meaningful use off life support, but I’m still not planning to discharge MU from the hospital. The program has some serious health issues.

On a more optimistic note, I’m really excited to see what doctors and hospitals start doing with the data stored in EHR. Is it everything we want it to be? No, but I believe we’re still going to see a lot of good come from EHR software now that EHR’s are implemented and we’ve largely got MU behind us.

Poorly Done Report that Physicians Lose 48 minutes a Day to EHR

Posted on October 1, 2014 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.

There’s been a study that’s been pandered around making the assertion that Physicians lose 48 minutes a day to EHR. This story in Medical Economics is just one example of many. A comment on that story from Dr. Rah describes generally my feelings about the study:

I find it disappointing that such drivel is even reported. #1. A 2012 survey! Data is > 2 yrs old. #2. 411 respondents is a very small N; hardly significant in that there are at least a million users now of EMRs. #3. You can do better–why report such meaningless info??

Of course, this only begins to describe the flaws in this study. First, they were just asking physicians for their perceived views on how long something took with the EHR as opposed to actual time. As humans, we’re really bad at judging the amount of time that’s passed. Not to mention that many of the respondents were trainees who had no history with which to compare. I could go on and on, but I’ll stop there.

I’m not arguing whether EHR saves doctors time or whether it takes more time. I’ve seen places where both sides of the coin have occurred. So, I think that you could write an article that EHR saves doctors time and another article that talks about how EHR takes more time. You can find both experiences out there. There are hundreds of factors at play that influence the answer to this question.

One thing I don’t think anyone would disagree with is that meaningful use has required a lot more time from doctors. So, when you layer on a new EHR with the meaningful use requirements, then you’re probably going to be spending more time documenting in the EHR. Although, is that the EHR’s fault or meaningful use?

It would be nice for someone to do a high quality study on EHRs and the time a doctor spends. However, when you think about the factors that could influence the time spent: EHR software, specialty, location, tech skill of doctor, meaningful use, not meaningful use, etc etc etc, you can see why we haven’t seen a proper study on the impact of EHR on efficiency. There are too many variations for which you’d have to test.

Which Parts of an EHR Implementation Should Be Their Own Project?

Posted on September 29, 2014 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.

A really great discussion has been started on this post about staged patient portal implementations. Here’s one comment that really struck a chord with me:

I think that on a lot of strategic roadmaps “patient portal” is listed as a goal…a one time deadline without understanding how the patient portal works; what information flows into a fully functioning portal and to the patient; and what the system, risk, and security requirements are to consider.

This will require C level suite and decision makers to ask questions that might be getting them “into the weeds” a bit or questions that they may not know to ask. This is why a several strong consultants that are specialists in individual subject matter might be needed – instead of one project manager expected to move the project plan forward on the road map and to know everything.

This comment is right that the patient portal is often seen as a line item on a project plan that just needs to be completed. That couldn’t be farther from the truth. As one person said, sometimes you can get a grand slam, but most of the time you have to do a bunch of little things along the way. A patient portal is a great example of this. You don’t just implement a patient portal one time and then it will run forever. There’s more you can do to leverage a patient portal for your institution.

Are there other parts of an EHR implementation that exhibit similar characteristics? Maybe you implement them, but there’s always more that could be done to improve its use in your organization? Templates and workflow are one that come to mind. There should be an ongoing evaluation of your templates and workflow in order to ensure that it’s as optimized as possible.

What other pieces of your EHR project could benefit from a separate staged project plan? Of course, this assumes you’re starting to think more strategically than just trying to check off the MU check boxes.

Jonathan Bush Loves Health Data–But How Will We Get As Much As He Wants?

Posted on September 24, 2014 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 fervent hope of health care reformers is that someday we will each know as much about our bodies–our vital signs, the health of our organs, the contents of our genomes-as corporations know about our marketing habits. One of the recent expressions of this dream comes in Jonathan Bush’s engaging and readable account of the healthcare system, Where Does It Hurt?.

Bush is a tireless advocate for bottom-up, disruptive forces in healthcare, somewhat in the same camp as Vinod Khosla (whose Health Datapalooza keynote I covered) and Clayton Christensen (who wrote the forward to Bush’s book). What Bush brings to the discussion is hands-on experience at confronting the healthcare behemoth in an explicitly disruptive way (which failed) as well as fitting into the system while providing a bit more light by building athenahealth (which succeeded).

Bush’s book tours the wreckage of the conventional health care system–the waste, errors, lack of communication, and neglect of chronic conditions that readers of this blog know about–as well as some of the promising companies or non-profits that offer a way forward. His own prescription for the health care system rests on two main themes: the removal of regulations that prevent the emergence of a true market, and the use of massive data collection (on physicians and patients alike) to drive a rational approach to health care.

Both government and insurers would have a much smaller role in Bush’s ideal health care system. He recognizes that catastrophic conditions should be covered for all members of society, and that the industry will need (as all industries do) a certain minimum of regulation. (Bush even admitted that he “whined” to the ONC about the refusal of a competitor to allow data exchange.) But he wants government and insurers to leave a wide open field for the wild, new ideas of clinicians, entrepreneurs, and software developers.

Besides good old-fashioned human ingenuity, the active ingredient in this mix is data–good data (not what we have now), and lots of it. Bush’s own first healthcare business failed, as he explains, through lack of data along with the inconsistency of insurance payments. A concern for data runs through this book, and motivates his own entrance into the electronic health records market.

What’s missing from the Where Does It Hurt?, I think, is the importance of getting things in the right order: we can’t have engaged patients making free choices until an enormous infrastructure of data falls into place. I have looked at the dependencies between different aspects of health IT in my report, The Information Technology Fix for Health: Barriers and Pathways to the Use of Information Technology for Better Health Care. Let’s look at some details.

Bush wants patients to have choice–but there’s already a lot of choice in where they get surgery or other procedures performed. As he points out, some of the recent regulations (such as accountable care organizations) and trends in consolidations go in the wrong direction, removing much of this choice. (I have also written recently about limited networks.) One of Bush’s interesting suggestions is that hospitals learn to specialize and pay to fly patients long distances for procedures, a massive extension of the “medical tourism” affluent people sometimes engage in.

But even if we have full choice, we won’t be able to decide where to go unless quality measures are rigorously collected, analyzed, and published. Funny thing–quality measures are some of the major requirements for Meaningful Use, and the very things that health IT people complain about. What I hear over and over is that the ONC should have focused laser-like on interoperability and forgone supposedly minor quests like collecting quality measurements.

Well, turns out we’ll need these quality measures if we want a free market in health care. Can the industry collect these measures without being strong-armed by government? I don’t see how.

If I want a space heater, I can look in the latest Consumer Reports and see two dozen options rated for room heating, spot heating, fire safety, and many other characteristics. But comparable statistics aren’t so easy to generate in health care. Seeing what a mess the industry has made of basic reporting and data sharing in the data that matters most–patient encounters–we can’t wait for providers to give us decent quality measures.

There’s a lot more data we need besides provider data. Bush goes into some detail about the Khosla-like vision of patients collecting and sharing huge amounts of information in the search for new cures. Sites such as PatientsLikeMe suggest a disruptive movement that bypasses the conventional health care system, but most people are not going to bother collecting the data until they can use it in clinical settings.

And here we have the typical vicious cycle of inertia in health care: patients don’t collect data because their doctors won’t use it, doctors say they can’t even accept the data because their EHRs don’t have a place for it, and EHR vendors don’t make a place for it because there’s no demand. Stage 3 of Meaningful Use tries to mandate the inclusion of patient data in records, but the tremendous backward tug of industry resistance saps hope from the implementation of this stage.

So I like Bush’s vision, but have to ask: how will we get there? athenahealth seems to be doing its part to help. New developments such as Apple’s HealthKit may help as well. Perhaps Where Does It Hurt? can help forward-thinking vendors, doctors, health information exchanges, entrepreneurs, and ordinary people pull together into a movement to make a functioning system out of the pieces lying around the landscape.

The Other Talk: EHRs and Advance Medical Directives

Posted on September 11, 2014 I Written By

When Carl Bergman isn't rooting for the Washington Nationals or searching for a Steeler bar, he’s Managing Partner of EHRSelector.com, a free service for matching users and EHRs. For the last dozen years, he’s concentrated on EHR consulting and writing. He spent the 80s and 90s as an itinerant project manger doing his small part for the dot com bubble. Prior to that, Bergman served a ten year stretch in the District of Columbia government as a policy and fiscal analyst.

The Other Talk: EHRs and Advance Medical Directives

Most of us who have adult children can remember that awkward talk we had about life’s origins. We thought, whew, that’s done. Alas, there’s yet another talk. This time it’s with those adult children and it’s about you.

This one’s covered in Tim Prosch’s and AARP’s book, The Other Talk. The talk, or more accurately the process is how you want to spend the rest of your life.

The Other Talk

It’s about your money, where and how you’ll live and your medical preferences. It’s just as hard, if not harder, than the old talk because:

  • It’s hard to admit that you won’t be around forever and your independence may start to ebb away.
  • You don’t want to put your kids on the spot with difficult decisions.
  • Your children may be parents coping with their own problems. You don’t want to add to their burdens.
  • You’ve been a source of strength, often financial as well as emotional. That’s hard to give up.

Prosch and AARP want to make it easier on everyone to deal with these issues.

He covers many topics, but for those of us who live in the EHR world one is of significant importance: Medical directives.

Prosch explains directives and simply says you should give them to your doctor. Easier said, etc. Today, that means not only your PCP, but also making sure that hospitalists etc., know what you want. While the Meaningful Use program helps a bit. It’s still going to take some doing.

Medical Directives and EHRs

EHR MU1 recognizes directives’ importance requiring that they be accounted for:

More than 50% of all unique patients 65 years old or older admitted to the eligible hospital’s or CAH’s inpatient department have an indication of an advance directive status recorded.

This means that the EHR has to have the directives. However, MU 1 only goes halfway to what’s needed. It’s what the EHR does with directives that’s unsaid.

If the EHR treats a directive as a miscellaneous document, odds are it won’t be known, let alone followed when needed. To be used effectively, an EHR needs a specific place for directives and they should be readily available. For example, PracticeFusion recently added an advance directives function. That’s not always the case.

Practice Fusion: Advanced Medical Directives

Googling for Directives

To see how about twenty popular EHRs treat directives, I did a Google site search, on the term directive. I got hits for a directives function only from four EHRs:

  • Athenahealthcare
  • Cerner
  • Meditech
  • PracticeFusion

All the others, Allscripts, Amazing Charts, eClinicalWorks, eMDs, McKesson, etc., were no shows. Some listed the MU1 requirement, but didn’t show any particular implementation.

Directives: More Honored in the Breech

This quick Google search shows that the EHR industry, with a few exceptions, doesn’t treat directives with the care they deserve. It should also serve as a personal warning.

If you already have directives or do have that talk with your family, you’ll need to give the directives to your PCP. However, you should also give your family copies and ask them to go over them with your caregivers.

Some day, EHRs may handle medical directives with care, but that day is still far off. Until then, a bit of old school is advisable.