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Posters Flame ONC Comments

Posted on March 3, 2015 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.

Someone at ONC who has to read public comments deserves a break. They’ve been flamed.

ONC just released the public comments on its 10 year Interoperability Plan. Many of the posts are from stakeholders who provided careful, point by point comments. These often represent greatly divergent views. However, these commenters have one thing quite solidly in common. They’ve read the plan.

Not so, many others who skipped the boring reading homework. They just dumped on it with one theme: The federal government has no business getting its hands on my medical records! There are dozens upon dozens of comments on this theme. They’re irate, angry and often vituperative – to say the least. The fact that nothing like that is in the plan doesn’t stop them from believing it and roundly denouncing it.

Where did all these folks get this notion? From what I can tell, two sources made the inductive leap from practioners sharing EHR records to the feds wanting to know about your lumbago.

One was the Citizens Council for Health Freedom, which issued an August 14, 2014 press release saying:

Our government is funneling billions of dollars into systems that will dump all of our private medical records into one giant hub—accessible by many,” said CCHF president and co-founder Twila Brase. Doctors and nurses who have already started using these systems are not convinced that they are ready for use or even necessary. The government is touting these procedures as ways to streamline patient care, but they’re actually an attempt to capture and store Americans’ private medical data and share it with agencies that have nothing to do with health care.

The release then urged readers to comment on the plan.

Brase cites no sources in or out of the plan for her observations or conclusions.

The other source was Tammy Bruce. On December 14, 2014 she wrote:

Your personal healthcare information will be shared with an astounding 35 agencies (at least), offices and individuals including the Department of Defense, NASA, the Federal Trade Commission, the Department of Agriculture, the Department of Labor, the Federal Communications Commission, the HHS assistant secretary for legislation, the HHS office for civil rights, the HHS office for the general counsel, the Office of Personnel Management, the Social Security Administration, the Department of Justice and the Bureau of Prisons.

Clearly, this is meant to establish the fact that every federal agency will be participating in this scheme and will have access to your health information. Not only should this be anathema to every American on principle alone, but having all of our personal information available in the cloud also poses ridiculously obvious general security threats to our personal security.

She also urged readers to comment about the plan.

Again, no proof, no cites, just assertions and conclusions.

I don’t have anything to say about their claims, other than this. Our open political discourse means that those who read posts have to carefully sort out thoughtful, even if misinformed, opinion from dross. Pushing phony claims for whatever reason just makes it all the more difficult. Whoever at ONC has to slog through the dross in these comments has my sympathy.

Restructure and Reform Meaningful Use: Here’s a Way

Posted on February 12, 2015 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.

It’s no secret that ONC’s meaningful use program’s a mess. I’m not sure there is an easy way out. In some respects, I wish they would go back and start over, but that’s not going to happen. They could do something to see daylight, but it won’t be either easy or simple. As I‘ll outline, ONC could adopt a graduated system that keeps the MU standards, includes terribly needed interoperability and usability standards, but does not drive everyone crazy over compliance.

MU’s Misguided Approach

ONC has spent much time and money on the MU standards, but has painted itself into a corner. No one, vendors, practioners or users is happy. Vendors see ONC pushing them to add features that aren’t needed or wanted. Practioners see MU imposing costs and practices that don’t benefit them or their patients. Users see EHRs as demonic Rube Goldberg creations out to frustrate, confuse and perplex. To boot, ONC keeps expanding its reach to new areas without progress on the basics.

Most the MU criticisms I’ve seen say MU’s standards are too strict or too vague. Compliance is criticized for being too demanding or not relevant. Most suggested cures tinker with the program: Eliminate standards or delay them. I think the problems are both content and structure. What MU needs is a return to basics and a general restructuring.

Roots of the MU Program’s Problems

It’s easy to beat up on ONC’s failures. Almost everyone has a pet, so I’ll keep mine short.

MU1: Missed Opportunities. MU’s problems stem from its first days. ONC saw EHRs as little more than database systems that stored and retrieved encounters. Data sharing only this:

Capability to exchange key clinical information (for example, problem list, medication list, medication allergies, diagnostic test results), among providers of care and patient authorized entities electronically.

Compliance only required one data exchange attempt. ONC relied on state systems to achieve interoperability. Usability didn’t exist.

MU2: Punting the Problems. ONC’s approach to interoperability and usability was simple. Interoperability was synonymous with continuity of care and public health reports. Every thing else was put off for future testing criteria.

ONC’s usability approach was equally simple. Vendors defined their usability and measurement. The result? Usability’s become a dead topic.

Interoperability

ONC has many good things to say about the need for interoperability. Its recent Roadmap is thoughtful and carefully crafted. However, the roadmap points out just how poor a job ONC has done to date and it highlights, to me, how much ONC needs to rethink its entire MU approach.

Changing ONC

In one of his seminal works on organizations, C. Northcote Parkinson said it’s almost impossible to change a failing organization. His advice is to walk away and sew salt. If you must persist, then you should adopt the heart of a British Drill Sergeant, that nothing is acceptable. Alas, only Congress can do the former and I’m way too old for military service, so I will venture on knowing it’s probably foolhardy, but here goes.

New Basic Requirements

A better approach to MU’s core and menu system would allow vendors to pick and choose the features they want to support, but require that all EHRs meet four basic standards:

  1. Data Set. This first standard would spell out in a basic, medical data set. This would include, for example, vitals, demographics, meds, chief complaints, allergies, surgeries, etc.
  2. Patient ID. A patient’s demographics would include a unique patient identifier. ONC can use its new freedom in this area by asking NIST to develop a protocol with stakeholders.
  3. Interoperability. EHRs would have to transmit and receive, on demand, the basic data set using a standard protocol, for example, HL7.
  4. Usability. Vendors would have to publish the results of running their EHR against NIST’s usability standard. This would give users, for the first time, an independent way to compare EHRs’ usability.

All current EHRs would have to meet these criteria within one year. Compliance would mean certification, but EHRs that only met these criteria would not be eligible for any funding.

Cafeteria Program. For funding, vendors would have to show their EHR supported selected MU2 and MU3 features. The more features certified, the more eligible they’d be for funding.

Here is how it would work. Each MU criteria would have a one to ten score. To be eligible for funding, a product would have to score 50 or more. The higher their score, the higher their funding eligibility.

Provider Compliance. Providers would have a similar system. ONC would assign scores of one to ten for each utilization standard. As with vendors, implementing organizations would receive points for each higher utilization level. That is, unlike current practice, which is all or nothing, the more the system is used to promote MU’s goals the higher the payments. This would permit users to decide which compliance criteria they wanted to support and which they did not.

Flexibility’s Advantages

This system’s flexibility has several advantages. It ends the rigid nature of compliance. It allows ONC to add new criteria as it sees fit giving it freedom to add criteria as needed or to push the field.

It achieves a major advancement for users. It not only tells users how products perform, but it also lets them choose those that best fit their needs.

Vendors, too, benefit from this approach. They would not only know where they stood vs. the competition, but would also be free to innovate without having to include features they don’t want.

Partners Health Care Not to Expand – Can’t We All Just Get Along?

Posted on February 6, 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.

So the deal is off for the mega-medical conglomerate that dominates Boston’s health care scene. Partners Healthcare, which came so close to buying up several competitors, got slammed by a newly installed attorney general and a judge presiding over the merger decision. So big is Partners in health care–and health care in the Boston market–that this news made the lead headline in the Boston Globe on January 30.

Partners may go ahead with the mergers and face a lawsuit, but my guess is that they’ll sense the trending of the political tides and back away. Everyone understands that dominant health care providers tend to raise costs–but what might we have lost in preventing the merger?
Read more..

Assessment Released of Health Information Exchanges (Part 1 of 2)

Posted on January 6, 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.

Like my Boston-area neighbors who perennially agonize over the performance of the Red Sox, healthcare advocates spend inordinate amounts of time worrying about Health Information Exchanges (HIEs). Will the current round of exchanges work after most previous attempts failed? What results can be achieved from the 564 million dollars provided by the Office of the National Coordinator since 2009? Has the effort invested by the government and companies in the Direct project paid off, and why haven’t some providers signed up yet?

I too was consumed by such thoughts when reading a reported contracted by the ONC and released in December, “HIE Program Four Years Later: Key Findings on Grantees’ Experiences from a Six-State Review. Although I found their complicated rating system a bit arbitrary, I found several insights in the 42-page report and recommend it to readers. I won’t try to summarize it here, but will use some of the findings to illuminate–and perhaps harp on–issues that come up repeatedly in the HIE space.
Read more..

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.

FHIR is on Fire

Posted on December 5, 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.

Ever since the announcement yesterday about Project Argonaut, FHIR has been getting some widespread coverage. Although, even before this important announcement, I was hearing a lot of people talk really optimistically about the potential of FHIR for healthcare. However, with Project Argonaut, you get all of these big name organizations on board as well:

  • athenahealth
  • Beth Israel Deaconess Medical Center
  • Cerner
  • Epic
  • Intermountain Healthcare
  • Mayo Clinic
  • MEDITECH
  • McKesson
  • Partners HealthCare System
  • SMART at the Boston Children’s Hospital Informatics Program
  • The Advisory Board Company

That’s quite a list of powerhouses that are investing money behind FHIR. I’m excited that the majority of major hospital EHR are represented in that list. Although, I do wonder if this is a lot of the same people who ruined CCDA. Let’s hope I’m wrong and they learned their lesson.

FHIR was also the topic of today’s #HITsm chat. Here are some of the tweets from the chat that caught my eye.


How’s that for optimism about the future of FHIR? Keith is deep in the trenches of health IT standards so he’s got a very informed opinion on what’s happening.


A very good sign since everyone I talk to seems to hate CCDA. They say that it’s bloated and really not usable.


I agree with Donald. The real question I have is whether FHIR will get us open APIs to the data we want. I need to investigate more to know the answer to that question.


I generally think this is true also, but not if it is a limited set of data. If you limit the data and don’t provide write back function, then there’s a real limit on what you can do with that data. Of course, you can start with some functionality and then build from there.


I’m still early on in my understanding of FHIR. I’m doing a whole series of posts on EMR and HIPAA around interoperability and the challenges associated with interoperability. You can be sure that FHIR will be a major part of my research and discussion. The above links look like a good place to start.

Please add your thoughts on FHIR in the comments as well.

Treating a Patient with Partial Information

Posted on December 4, 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.

In some recent discussions, I’ve heard arguments against HIEs and healthcare interoperability which say that it’s a bad thing because “What if the HIE doesn’t provide me all the patient info I need?” This is actually a really important question and one worthy of consideration. In fact, it could be extended to say, “What if the HIE provides me the wrong information?

While these are really important challenges for HIEs to address, it returns to the common fallacy that I see over and over again in healthcare. We compare the implementation of future technology against perfection as opposed to the status quo.

The reality is that doctors have been treating patients with partial and incorrect information forever. An HIE that can only provide partial or even incorrect information sometimes is similar to the situation that doctors face every day.

Think about how many patients have chosen not to tell their doctor something because they didn’t remember to tell them that info. How many patients have told their doctors the wrong information because they couldn’t remember the right information? Millions. There are even many patients who are afraid to give their doctor their health information based on privacy concerns. Once again, the doctor is treating the patient with partial information.

I imagine the reason it feels different is that we feel like their should be a different level of trust with an HIE. Maybe there is a different level of trust in data coming from an HIE versus a patient’s memory. However, that doesn’t mean that a doctor should put 100% trust in the data that an HIE provides. There’s nothing wrong with a bit of healthy skepticism with any third party data source. No doubt there are varying degrees of trust with all third party data sources that are used by a doctor. The HIE needs to be at the high end of the trust spectrum, but its inability to be perfect shouldn’t hinder its use anymore than the imperfect EHR data hinders its use.

Over time these HIE systems will do a much better job of measuring the confidence of the data their providing. Ok, that might be pretty optimistic. Instead, it’s more likely that doctors will learn how confident they should be in the data they get from an HIE.

Doctors already have created a culture of appropriate skepticism with patient provided data. I think something similar is the right approach with HIE data. Plus, doctors are smart enough to evaluate when a medical situation requires confirmation of data and when it requires further investigation. They’re making these types of decisions all of the time.

Should Healthcare Institutes Perform “Rip-and-Replace” to Achieve Interoperability? Less Disruption, Please!

Posted on October 7, 2014 I Written By

The following is a guest blog post by Dr. Donald Voltz, MD, Aultman Hospital, Department of Anesthesiology, Medical Director of the Main Operating Room, Assistant Professor of Anesthesiology, Case Western Reserve University and Northeast Ohio Medical University.
Dr Voltz
A KLAS Research Report on the EMR buying trends of 277 hospitals with at least 200 beds has identified that almost half will be making a new EMR purchase by 2016.  Of the providers considering a change, 34 percent have already selected a vendor and another 44 percent are strongly leaning toward a specific vendor. Driving factors include concerns over outdated technology and health system consolidation.

But is the technology really outdated and health system consolidation necessary, or is the real issue lack of interoperability?  And if you are a hospital looking for a new EMR, let’s not forget the history of technology before we jump to conclusions that the greatest market share means the best of breed.

When we look at EMR adoption over the past number of years, we need to be careful with the data we use. Implementations, and now rip and replace switching to other venders, has been the only choice offices, clinics, hospitals and health systems had to address the issues with interoperability.

Most of current deployed EMRs are designed as a one-size-fits-all, leading to the situation where today out-of-the-box functionalities fit none of the care providers’ requirements. Besides that, EMR vendors have been designed with proprietary data where patient medical sharing (or exchange) becomes the biggest roadblock for patient care continuum. The reason for the rip-and-replace approach by some hospitals is to reach interoperability between inpatient and outpatient data with a single integrated and consolidated database approach.

A 50 percent turnover of EMRs is an incredibly high numbers of hospitals and clinics who have either replaced or are looking to replace their current EHR’s. Being that the majority of the initial implementations were supported by the HITECH act, one would think the government would raise issue with vendors to address this high turnover of EHR’s. There seems to be a general misperception that if our current systems do not meet the demands and needs of providers, administrators, and financial arms of a healthcare delivery system, ripping out the system and implementing a new one will solve the issues.

What is the True Total Cost of Ownership of an EMR?

Healthcare management must look beyond the actual cost paid to an EHR vendor as the only cost but they must look into the total cost, much beyond the normal Total Cost of Ownership (TCO). TCO only includes the initial license cost, maintenance cost, IT support cost, but in healthcare, there is another cost – it is the disruption of the care providers’ workflow. That disruption is directly correlated to healthcare system revenue and patient care outcomes.

Stop this disruption and let’s look for another solution where we integrate disparate systems since many of them are built upon databases that can address the needs of health. The cost to providers in time to learn a new system, the migration and loss of patient data that has been collected in the current systems, the capital expense of system software, the hardware, trainers, IT personnel, etc. all add to the burden, something that is currently being looked at as a necessary expense.

Interoperability Saves Resources

This need not be the case when platforms exist to connect systems and improve access for providers. Having a consistent display of data allows for more efficient and effective management of patients and when coupled with a robust collaborative platform, we close many of the open loopholes that exist in medicine today, even with EHR’s.

2.0 EMR connectors like Zoeticx and others have taken the medical information bus, middleware platform, to solve the challenges that current EHR’s have not.  This connection of systems and uniform display of information that physicians depend on for the management of patients is crucial if hospitals want their new EMRs to succeed. In addition, a middleware platform allows for patients to access their medical information between EMR’s in a single institution or across institutions, a major issue for Meaningful Use.

Fragmentation Prevents Some EMRs From Connecting With Their Own Software

Large EMR vendors’ lack of healthcare interoperability only reflects on how they compete against each other. Patient medical data and its proprietary structure is the tool for such competition where the outcome would not be necessarily beneficial for the hospital, medical professionals or patients. There are plenty of examples where healthcare facilities with EHRs even from the same vendor fail to interoperate with each other.

Such symptoms have little to do with the EMRs that have the same data structure, but about the fragmentation being put in place over the years of customization. We believe that the reason for this is to address fragmentation of the software product. Fragmentation is a case where deployments from the same software products have gone through significant amounts of customization, leading to its divergence from the product baseline.

To believe that ripping the whole infrastructure – inpatient and outpatient–as the method to reach interoperability would only cause a lot of disruption, yet the outcome would be very questionable down the road. Appreciating the backlash of calling the implementation of EMR’s a beta-release, we have much data to use in looking for the next solution to HIT.

As with much of medicine, we are constantly looking for the best way to take care of our patients. Like it or not, EMR’s have become a medical device and we need to start to evaluate them as we would any device used to manage health and disease. As we move forward, there will be an expansion in the openness of patient data, and in my prediction, a migration away from a single EHR solution to all of the requirements of healthcare, and into a system of interconnected applications and databases.

Once again, we have learned that massively engineered systems do not evolve into complex adaptive systems to respond to changing environmental pressures. Simple, interrelated and interdependent applications are more fluid and readily adaptable to the constantly changing healthcare environment. Currently, the only buffer for the stresses and changes to the healthcare system are the patients and the providers who depend on these systems to manage healthcare.

About Dr. Donald Voltz
By Dr. Donald Voltz, MD, Aultman Hospital, Department of Anesthesiology, Medical Director of the Main Operating Room, Assistant Professor of Anesthesiology, Case Western Reserve University and Northeast Ohio Medical University.  A board-certified anesthesiologist, researcher, medical educator, and entrepreneur. With more than 15 years of experience in healthcare, Dr. Voltz has been involved with many facets of medicine. He has performed basic science and clinical research and has experience in the translation of ideas into viable medical systems and devices.

Could Clinicians Create Better HIE Tools?

Posted on August 13, 2014 I Written By

The following is a guest blog post by Andy Oram.His post reminds me of when I asked “Is Full Healthcare Interoperability a Pipe Dream?

A tense and flustered discussion took place on Monday, August 11 during a routine meeting of the HIT Standards Committee Implementation Workgroup, a subcommittee set up by the Office of the National Coordinator (ONC), which takes responsibility for U.S. government efforts to support new IT initiatives in the health care field. The subject of their uncomfortable phone call was the interoperability of electronic health records (EHRs), the leading issue of health IT. A number of “user experience” reports from the field revealed that the situation is not good.

We have to look at the depth of the problem before hoping to shed light on a solution.

An interoperability showcase literally takes the center of the major health IT conference each year, HIMSS. When I have attended, they physically arranged their sessions around a large pavilion filled with booths and computer screens. But the material on display at the showcase is not the whiz-bang features and glossy displays found at most IT coventions (those appear on the exhibition floor at HIMSS), but just demonstrations of document exchange among EHR vendors.

The hoopla over interoperability at HIMSS suggests its importance to the health care industry. The ability to share coordination of care documents is the focus of current government incentives (Meaningful Use), anchoring Stage 2 and destined to be even more important (if Meaningful Use lasts) in Stage 3.

And for good reason: every time we see a specialist, or our parent moves from a hospital to a rehab facility, or our doctor even moves to another practice (an event that recently threw my wife’s medical records into exasperating limbo), we need record exchange. If we ever expect to track epidemics better or run analytics that can lower health case costs, interoperability will matter even more.

But take a look at extensive testing done by a team for the Journal of the American Medical Informatics Association, recently summarized in a posting by health IT expert Brian Ahier. When they dug into the documents being exchanged, researchers found that many vendors inserted the wrong codes for diagnoses or drugs, placed results in the wrong fields (leaving them inaccessible to recipients), and failed to include relevant data. You don’t have to be an XML programmer or standards expert to get the gist from a list of sample errors included with the study.

And that list covers only the problems found in the 19 organizations who showed enough politeness and concern for the public interest to submit samples–what about the many who ignored the researchers’ request?

A slightly different list of complaints came up at the HIT Standards Committee Implementation Workgroup meeting, although along similar lines. The participants in the call were concerned with errors, but also pointed out the woeful inadequacy of the EHR implementations in representing the complexities and variety of patient care. Some called for changes I find of questionable ethics (such as the ability to exclude certain information from the data exchange while leaving it in the doctor’s records) and complained that the documents exchanged were not easy for patients to read, a goal that was not part of the original requirements.

However, it’s worth pointing out that documents exchange would fall far short of true coordinated care, even if everything worked as the standards called for. Continuity of care documents, the most common format in current health information exchange, have only a superficial sliver of diagnoses, treatments, and other immediate concerns, but do not have space for patient histories. Data that patients can now collect, either through fitness devices or self-reporting, has no place to be recorded. This is why many health reformers call for adopting an entire new standard, FHIR, a suggestion recognized by the ONC as valid but postponed indefinitely because it’s such a big change. The failure to adopt current formats seems to become the justification for keeping on the same path.

Let’s take a step back. After all those standards, all those certifications, all those interoperability showcases, why does document exchange still fail?

The JAMIA article indicated that failure can be widely spread around. There are rarely villains in health care, only people pursuing business as usual when that is insufficient. Thus:

  • The Consolidated CDA standard itself could have been more precisely defined, indicating what to do for instance when values are missing from the record.

  • Certification tests can look deeper into documents, testing for instance that codes are recorded correctly. Although I don’t know why the interoperability showcase results don’t translate into real-world success, I would find it quite believable that vendors might focus on superficial goals (such as using the Direct protocols to exchange data) without determining whether that data is actually usable.

  • Meaningful Use requirements (already hundreds of pages long) could specify more details. One caller in the HIT Standards Committee session mentioned medication reconciliation as one such area.

The HIT Standards Committee agonized over whether to pursue broad goals, necessarily at a slow pace, or to seek a few achievable improvements in the process right away. In either case, what we have to look forward to is more meetings of committees, longer and more mind-numbing documents, heavier and heavier tests–infrastructure galore.

Meanwhile, the structure facilitating all this bureaucracy is crumbling. Many criticisms of Meaningful Use Stage 2 have been publicly aired–some during the HIT Standards Committee call–and Stage 3 now looks like a faint hope. Some journalists predict a doctor’s revolt. Instead of continuing on a path hated by everybody, including the people laying it out, maybe we need a new approach.

Software developers over the past couple decades have adopted a range of ways to involve the users of software in its design. Sometimes called agile or lean methodologies, these strategies roll out prototypes and even production systems for realistic testing. The strategies call for a whole retooling of the software development process, a change that would not come easily to slow-moving proprietary companies such as those dominating the EHR industry. But how would agile programming look in health care?

Instead of bringing a doctor in from time to time to explain what a clinical workflow looks like or to approve the screens put up by a product, clinicians would be actively designing the screens and the transitions between them as they work. They would discover what needs to be in front of a resident’s eyes as she enters the intensive care ward and what needs to be conveyed to the nurses’ station when an alarm goes off sixty feet away.

Clinicians can ensure that the information transferred is complete and holds value. They would not tolerate, as the products tested by the JAMIA team do, a document that reports a medication without including its dose, timing, and route of administration.

Not being software experts (for the most part), doctors can’t be expected to anticipate all problems, such as changes of data versions. They still need to work closely with standards experts and programmers.

It also should be mentioned that agile methods include rigorous testing, sometimes to the extent that programmers write tests before writing the code they are testing. So the process is by no means lax about programming errors and patient safety.

Finally, modern software teams maintain databases–often open to the users and even the general public–of reported errors. The health care field needs this kind of transparency. Clinicians need to be warned of possible problems with a software module.

What we’re talking about here is a design that creates a product intimately congruent with each site’s needs and workflow. The software is not imported into a clinical environment–much less imposed on one–but grows organically from it, as early developers of the VistA software at the Veterans Administration claimed to have done. Problems with document exchange would be caught immediately during such a process, and the programmers would work out a common format cooperatively–because that’s what the clinicians want them to do.

Rep. Phil Gingrey Comes After Healthcare Interoperability and Epic in House Subcommittee

Posted on July 30, 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.

On July 17th, the House Energy and Commerce Committee’s subcommittee on Communications and Technology and Health (that’s a mouthful) held a hearing which you can see summarized here. Brought into question were the billions of dollars that have been spent on EHR without requiring that the EHR systems be interoperable.

In the meeting Rep. Phil Gingrey offered this comment, “It may be time for this committee to take a closer look at the practices of vendor companies in this space given the possibility that fraud may be perpetrated against the American taxpayer.”

At least Rep. Gingrey is a former physician, but I think he went way too far when he used the word fraud. I don’t think the fact that many EHR vendors don’t want to share their healthcare data is fraud. I imagine Rep. Gingrey would agree if he dug into the situation as well. However, it is worth discussing if the government should be spending billions of dollars on EHR software that can’t or in more cases won’t share data. Epic was called out specifically since their users have been paid such a huge portion of the EHR incentive money and Epic is notorious for not wanting to share data with other EHR even if Judy likes to claim otherwise.

The other discussion I’ve seen coming out related to this is the idea of de-certifying EHR vendors who don’t share data. I’m not sure the legality of this since the EHR certification went through the rule making process. Although, I imagine Congress could pass something to change what’s required with EHR certification. I’ve suggested that making interoperability the focus of EHR certification and the EHR incentive money is exactly what should be done. Although, I don’t have faith that the government could make the EHR Certification meaningful and so I’d rather see it gone. Just attach the money to what you want done.

I have wondered if a third party might be the right way to get vendors on board with EHR data sharing. I’d avoid the term certification, but some sort of tool that reports and promotes those EHR vendors who share data would be really valuable. It’s a tricky tight rope to walk though with a challenging business model until you build your credibility.

Tom Giannulli, CMIO at Kareo, offers an additional insight, “The problem of data isolationism is that it’s practiced by both the vendor and the enterprise. Both need to have clear incentives and disincentives to promote sharing.” It’s a great point. The EHR vendors aren’t the only problem when it comes to not sharing health data. The healthcare organizations themselves have been part of the problem as well. Although, I see that starting to change. If they don’t change, it seems the government’s ready to step in and make them change.