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Research Shows that Problems with Health Information Exchange Resist Cures (Part 2 of 2)

Posted on March 23, 2016 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://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 section of this paper introduced problems found in HIE by two reports: one from the Office of the National Coordinator and another from experts at the Oregon Health & Science University. Tracing the causes of these problems is necessarily somewhat speculative, but the research helps to confirm impressions I have built up over the years.

The ONC noted that developing HIE is very resource intensive, and not yet sustainable. (p. 6) I attribute these problems to the persistence of the old-fashioned, heavyweight model of bureaucratic, geographically limited organizations hooking together clinicians. (If you go to another state, better carry your medical records with you.) Evidence of their continued drag on the field appeared in the report:

Grantees found providers did not want to login to “yet another system” to access data, for example; if information was not easily accessible, providers were not willing to divert time and attention from patients. Similarly, if the system was not user friendly and easy to navigate, or if it did not effectively integrate data into existing patient records, providers abandoned attempts to obtain data through the system. (pp. 76-77)

The Oregon researchers in the AHRQ webinar also confirmed that logging in tended to be a hassle.

Hidden costs further jacked up the burden of participation (p. 72). But even though HIEs already suck up unsustainable amounts of money for little benefit, “Informants noted that it will take many years and significantly more funding and resources to fully establish HIE.” (p. 62) “The paradox of HIE activities is that they need participants but will struggle for participants until the activities demonstrate value. More evidence and examples of HIE producing value are needed to motivate continued stakeholder commitment and investment.” (p. 65)

The adoption of the Direct protocol apparently hasn’t fixed these ongoing problems; hopefully FHIR will. The ONC hopes that, “Open standards, interfaces, and protocols may help, as well as payment structures rewarding HIE.” (p. 7) Use of Direct did increase exchange (p. 56), and directory services are also important (pp. 59-60). But “Direct is used mostly for ADT notifications and similar transitional documents.” (p. 35)

One odd complaint was, “While requirements to meet Direct standards were useful for some, those standards detracted attention from the development of query-based exchange, which would have been more useful.” (p. 77) I consider this observation to be a red herring, because Direct is simply a protocol, and the choice to use it for “push” versus “pull” exchanges is a matter of policy.

But even with better protocols, we’ll still need to fix the mismatch of the data being exchanged: “…the majority of products and provider processes do not support LOINC and SNOMED CT. Instead, providers tended to use local codes, and the process of mapping these local codes to LOINC and SNOMED CT codes was beyond the capacity of most providers and their IT departments.” (p. 77) This shows that the move to FHIR won’t necessarily improve semantic interoperability, unless FHIR requires the use of standard codes.

Trust among providers remains a problem (p. 69) as does data quality (pp. 70-71). But some informants put attitude about all: “Grantees questioned whether HIE developers and HIE participants are truly ready for interoperability.” (p. 71)

It’s bad enough that core health care providers–hospitals and clinics–make little use of HIE. But a wide range of other institutions who desperately need HIE have even less of it. “Providers not eligible for MU incentives consistently lag in HIE connectivity. These setting include behavioral health, substance abuse, long-term care, home health, public health, school-based settings, corrections departments, and emergency medical services.” (p. 75) The AHRQ webinar found very limited use of HIE for facilities outside the Meaningful Use mandate, such as nursing homes (Long Term and Post Acute Care, or LTPAC). Health information exchange was used 10% to 40% of the time in those settings.

The ONC report includes numerous recommendations for continuing the growth of health information exchange. Most of these are tweaks to bureaucratic institutions responsible for promoting HIE. These are accompanied by the usual exhortations to pay for value and improve interoperability.

But six years into the implementation of HITECH–and after the huge success of its initial goal of installing electronic records, which should have served as the basis for HIE–one gets the impression that the current industries are not able to take to the dance floor together. First, ways of collecting and sharing data are based on a 1980s model of health care. And even by that standard, none of the players in the space–vendors, clinicians, and HIE organizations–are thinking systematically.

Research Shows that Problems with Health Information Exchange Resist Cures (Part 1 of 2)

Posted on March 22, 2016 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://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.

Given that Office of the National Coordinator for Health Information Technology (ONC) received 564 million dollars in the 2009 HITECH act to promote health information exchange, one has to give them credit for carrying out a thorough evaluation of progress in that area. The results? You don’t want to know.

There are certainly glass-full as well as glass-empty indications in the 98-page report that the ONC just released. But I feel that failure dominated. Basically, there has been a lot of relative growth in the use of HIE, but the starting point was so low that huge swaths of the industry remain untouched by HIE.

Furthermore, usage is enormously skewed:

In Q2 2012, for example, three states (Indiana, Colorado, and New York) accounted for over 85 percent of total directed transactions; in Q4 2013, five states (Michigan, Colorado, Indiana, New York, Michigan, and Vermont) accounted for over 85 percent of the total. Similarly, in Q2 a single state (Indiana) accounted for over 65 percent of total directed transactions; in Q4 2013, four states (California, Indiana, Texas, and New York) accounted for over 65 percent of the total. (p. 42)

This is a pretty empty glass, with the glass-full aspect being that if some states managed to achieve large numbers of participation, we should be able to do it everywhere. But we haven’t done it yet.

Why health information exchange is crucial

As readers know, health costs are eating up more and more of our income (in the US as well as elsewhere, thanks to aging populations and increasing chronic disease). Furthermore, any attempt to stem the problem requires coordinated care and long-term thinking. But the news in these areas has been disappointing as well. For instance:

  • Patient centered medical homes (PCMH) are not leading to better outcomes. One reason may be the limited use of health information exchange, because the success of treating a person in his own habitat depends on careful coordination.

  • Accountable Care Organizations are losing money and failing to attract new participants. A cynical series of articles explores their disappointing results. I suspect that two problems account for this: first, they have not made good use of health information exchange, and second, risk sharing is minimal and not extensive enough to cause a thoroughgoing change to long-term care.

  • Insurers are suffering too, because they have signed up enormous numbers of sick patients under the Affordable Care Act. The superficial adoption of fee-for-value and the failure of clinicians to achieve improvements in long-term outcomes are bankrupting the payers and pushing costs more and more onto ordinary consumers.

With these dire thoughts in mind, let’s turn to HIE.

HIE challenges and results

The rest of this article summarizes the information I find most salient in the ONC report, along with some research presented in a recent webinar by the Agency for Healthcare Research and Quality (AHRQ) on this timely topic. (The webinar itself hasn’t been put online yet.)

The ONC report covers the years 2011-2014, so possibly something momentous has happened over the past year to change the pattern. But I suspect that substantial progress will have to wait for widespread implementation of FHIR, which is too new to appear in the report.

You can read the report and parse the statistics until you get a headache, but I will cite just one more passage about the rate of HIE adoption in order to draw a broad conclusion.

As of 2015, the desire for actionable data, focus on MU 2 priorities, and exchange related to delivery system reform is in evidence. Care summary exchange rates facilitated through HIOs are high—for example, care record summaries (89%); discharge summaries (78%); and ambulatory clinical summaries (67%). Exchange rates are also high for test results (89%), ADT alerts (69%), and inpatient medication lists (68%). (p. 34)

What I find notable in the previous quote is that all the things where HIE use improved were things that clinicians have always done anyway. There is nothing new about sending out discharge summaries or reporting test results. (Nobody would take a test if the results weren’t reported–although I found it amusing to receive an email message recently from my PCP telling me to log into their portal to see results, and to find nothing on the portal but “See notes.” The notes, you might have guessed, were not on the portal.)

One hopes that using HIE instead of faxes and phone calls will lower costs and lead to faster action on urgent conditions. But a true leap in care will happen only when HIE is used for close team coordination and patient reporting–things that don’t happen routinely now. One sentence in the report hints at this: “Providers exchanged information, but they did not necessarily use it to support clinical decision-making.” (p. 77) One wonders what good the exchange is.

In the AHRQ webinar, experts from the Oregon Health & Science University reported results of a large literature review, including:

  • HIE reduces the use lab and radiology tests, as well emergency department use. This should lead to improved outcomes as well as lower costs, although the literature couldn’t confirm that.

  • Disappointingly, there was little evidence that hospital admissions were reduced, or that medication adherence improved.

  • Two studies claimed that HIE was “associated with improved quality of care” (a very vague endorsement).

In the next section of this article, I’ll return to the ONC report for some clues as to the reasons HIE isn’t working well.

The Week of Women in Healthcare

Posted on August 22, 2013 I Written By

As Social Marketing Director at Billian, Jennifer Dennard is responsible for the continuing development and implementation of the company's social media strategies for Billian's HealthDATA and Porter Research. She is a regular contributor to a number of healthcare blogs and currently manages social marketing channels for the Health IT Leadership Summit and Technology Association of Georgia’s Health Society. You can find her on Twitter @JennDennard.

#XXinHealthWeek
Twitter fans – particularly #HITchicks – may have come across the hashtag above this week as part of the larger XX in Health Week, an initiative of Rock Health to connect and empower female visionaries to drive change in healthcare. I’m all for driving change, and know from personal experience that women, whether in the home or workplace, tend to be masters of multitasking, putting out small fires as needed, and soothing bruised egos and fragile psyches. We seem well suited to the task of driving change, but not surprisingly, are not well positioned to do so.

According to a slide deck put together for the XX in Health Week, women make up just 14% of healthcare companies’ BODs, and 0% of Fortune 500 healthcare company CEOs.  The statistics are a bit more hopeful when looking strictly at hospitals, according to the recent “Women in the Hospital C-Suite” report from Billian’s HealthDATA:

bhdchart

I’m not sure when we’ll get to female leadership numbers that are acceptable, or who will make that call. It will be nice when, as mentioned in the slide deck, we recognize leaders not by their gender but by their ability to lead.

Health 2.0
Atlanta has its own Health 2.0 movement – a meetup group focused on startups in healthcare IT that is finally getting some momentum. Numbers for female leadership are good. One of three companies that pitched at the most recent event was led by a woman. Brandi March of NovitaCare – a mobile solution that helps patients and the family members who serve as their caregivers manage and coordinate care in one central location – started the company after taking on the role of caregiver for her ailing mother. She described the task of obtaining and organizing her mother’s records, sharing news with other family members, trying to stay organized and trying to make sure six or seven different providers were all on the same page as a “nightmare.” And so NovitaCare was born.

novitacareready

All in all it’s been a good week for women in healthcare. It will be interesting to see if the statistics mentioned above have changed by this time next year. I feel like there are plenty of unsung female visionaries driving healthcare change RIGHT NOW. Please share the story of someone you know via the comments below.

Interoperability vs. Coordinated Care

Posted on August 19, 2013 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.

Andy Oram asked me the following question, “Is the exchange of continuity of care documents really interoperability or coordinated care?

As it stands now, it seems like CCDs (continuity of care documents) are going to be the backbone of what healthcare information we exchange. We’ll see if something like Common Well changes this, but for now much of the interoperability of healthcare data is in CCDs (lab and radiology data are separate). The question I think Andy is asking is what can we really accomplish with CCDs?

Transferring a CCD from one doctor to the next is definitely a form of healthcare interoperability. Regardless of the form of the CCD, it would be a huge step in the right direction for all of the healthcare endpoints to by on a system that can share documents. Whether they share CCDs or start sharing other data doesn’t really matter. That will certainly evolve over time. Just having everyone so they can share will be of tremendous value.

It’s kind of like the fax machine or email. Just getting people on the system and able to communicate was the first step. What people actually send through those channels will continue to improve over time. However, until everyone was on email, it had limited value. This is the first key step to interoperable patient records.

The second step is what information is shared. In the forseeable future I don’t seeing us ever reaching a full standard for all healthcare data. Sure, we can do a pretty good job putting together a standard for Lab results, Radiology, RXs, Allergies, Past Medical History, Diagnosis, etc. I’m not sure we’ll ever get a standard for the narrative sections of the chart. However, that doesn’t mean we can’t make that information interoperable. We can, are, and will share that data between systems. It just won’t be in real granular way that many would love to see happen.

The idea of coordinated care is a much harder one. I honestly haven’t seen any systems out there that have really nailed what a coordinated care system would look like. I’ve seen very specific coordinated care elements. Maybe if we dug into Kaiser’s system we’d find some coordinated care. However, the goal of most software systems haven’t been to coordinate care and so we don’t see much on the market today that achieves this goal.

The first step in coordinating care is opening the lines of communication between care providers. Technology can really make an impact in this area. Secure text message company like docBeat (which I advise), are making good head way in opening up these lines of communications. It’s amazing the impact that a simple secure text message can have on the care a patient receives. Secure messaging will likely be the basis of all sorts of coordinated care.

The challenge is that secure messaging is just the start of care coordination. Healthcare is so far behind that secure messaging can make a big impact, but I’m certain we can create more sophisticated care coordination systems that will revolutionize healthcare. The biggest thing holding us back is that we’re missing the foundation to build out these more sophisticated models.

Let me use a simple example. My wife has been seeing a specialist recently. She’s got an appointment with her primary care doctor next week. I’ll be interested to see how much information my wife’s primary care doctor has gotten from the specialist. Have they communicated at all? Will my wife’s visit to her primary care doctor be basically my wife informing her primary care doctor about what the specialist found?

I think the answers to these questions are going to be disappointing. What’s even more disappointing is that what I described is incredibly basic care coordination. However, until the basic care coordination starts to happen we’ll never reach a more advanced level of care coordination.

Going back to Andy’s question about CCDs and care coordination. No doubt a CCD from my wife’s specialist to her primary care doctor would meet the basic care coordination I described. Although, does it provide an advanced level of care coordination? It does not. However, it does lay the foundation for advanced care coordination. What if some really powerful workflow was applied to the incoming CCD that made processing incoming CCDs easier for doctors? What if the CCD also was passed to any other doctors that might be seeing that patient based upon the results that were shared in the CCD? You can start to see how the granular data of a CCD can facilitate care coordination.

I feel like we’re on the precipice where everyone knows that we have to start sharing data. CCD is the start of that sharing, but is far from the end of how sophisticated will get at truly coordinated care.

101 Tips to Make Your EMR and EHR More Useful – EHR Tips 21-25

Posted on November 8, 2011 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.

Time for the next entry covering Shawn Riley’s list of 101 Tips to Make your EMR and EHR More Useful. I met someone at a conference who commented that they liked this series of posts. I hope you’re all enjoying the series as well.

25. Care coordination is much easier in an EMR and should be evaluated to be used
The idea of care coordination has never been more important in the history of healthcare. It’s the future of healthcare (at least in the US). Whether they end up being called ACOs or some other term, the switch to needing to coordinate care in order to improve the health of a population is happening as we speak. Luckily, EMR software is a great way to facilitate this care coordination.

24. Take advantage of E-Health tools
I actually think that this is a big call to EMR vendors to integrate their EMR software with the various e-health tools out there today. EHR vendors that think they can create every e-Health tool a doctor could want are going to be left behind by those systems which support the most popular consumer health tools on the market. However, that’s not to say that doctors can’t do their part. Start getting your patient using the e-health tools that will benefit them as a patient and then start requesting that your EMR vendor support the tools you’re using.

23. Make certain all caregivers know that logs are kept for any system overrides
Don’t hide the fact that everything is logged. Let everyone know that whatever is done on the system is logged. While some may see this as big brother watching them, most will realize that the logs are a protection for them. They log exactly what was done and said and who did it.

I remember one time there was some problem in our EMR system. I can’t remember the specific issue. Well, it was brought up in our staff meeting and the director said, whoever made this mistake is going to be providing breakfast for the whole staff. I went into the logs to see who’d accessed the patient to do the offending task. Little did the director (who was also a practicing provider a few times a week) know that she was the offending party. Everyone in the clinic enjoyed a nice breakfast that week.

22. Give caregivers the ability to override the system when necessary
Mistakes happen in documentation in an EMR. We’re all imperfect human beings (except for my wife) who make mistakes. So, you need an option and likely a process for how and who can make corrections to what was done in the EMR. Just be sure that everything that’s “overwritten” is logged and the reason for the change is well documented.

21. Develop a root cause analysis process for the EMR
I’m not that familiar with root cause analysis processes, so I’ll just share what Shawn says about it:

You very likely already have a root cause analysis model for your practice. You will need to adopt that model to the EMR. If you don’t, you will create a likelihood for the same errors to continually repeat. The EMR process is different than a usual root cause analysis. You will need to take into account interfaces, security roles, single sign on, and several other things beyond the “simple” human process.

If you want to see my analysis of the other 101 EMR and EHR tips, I’ll be updating this page with my 101 EMR and EHR tips analysis. So, click on that link to see the other EMR tips.