In my ongoing series of Major EHR Developments from John Halamka (see my previous EHR In The Cloud, Modular EHR Software and A Network of Networks posts), his fourth major EHR development from the Technology Review article is: Engaged, Connected, E-Patients.

I think this is one of the sections that Halamka makes some of the most interesting points about the future of healthcare. You should go read this whole section. One major conclusion is that patients are going to be much more involved in their healthcare. Gone are the days that patients just come into the office largely trusting what the doctors tells them. Part of that is likely do to the changing culture of question everything and the other part of it has to do with the access to healthcare information that the internet has provided.

Halamka does mention that research shows that shared decision making between doctors and patients results in better outcomes and that an engaged patient is less likely to sue. Both great reasons for doctors to want an engaged patient. Yet, there are still many of them that don’t like this change. However, most have come to realize that they really won’t have much choice going forward.

Halamka also mentions the new reimbursement models that focus on keeping patients healthy (see all the ACO talk) as opposed to paying best on services rendered (often called fee for service). I’m not sure how much this will be a driver in the engaged, connected, e-Patients. I think the patients will actually run over the doctors with their desire for engagement and their involvement in their healthcare well before any reimbursement model changes occur.

Yes, I think patients will start to demand (in the customer demand sort of way as opposed to the arrogant demands kind of way) their doctors support new forms of engagement. Certainly this will include a number of devices that monitor a patients health. Also, the teleconsultation will become very big as technology brings your doctor back into your home.

As I’ve written about before, I’m excited by the idea that a new form of doctor will be treating “healthy” patients.

In my ongoing series of Major EHR Developments from John Halamka (see my previous EHR In The Cloud post), his second major EHR development from the Technology Review article is: Modular Software Unleashes Innovation. The following excerpt from his article sums it up well:

Until very recently, innovation in medical IT has depended upon the development schedules of a few very large vendors who sell hospital systems with $100 million price tags. In the future, electronic health records will become increasingly modular, similar to the online app stores where consumers download games or programs for their phones.

The idea of modular healthcare IT has been around for a long time. I think I first saw this concept when I learned about a group called the Clinical Groupware Collaborative. I haven’t heard much out of them recently, but every once in a while I see that they’re still working to make Halamka’s comments about modular EHR software a reality.

I’m certain that Judy from Epic would argue that such modular EHR software is a risk to the healthcare industry. She’s probably right. There are risks to modular software. However, there are even more risks and disadvantages associated with a monolithic EHR vendor that won’t interact with other modular clinical software. I believe that one day this will come back to bite Epic as new CIO’s who weren’t part of the $100 million hospital software purchase will start to embrace a more modular strategy.

Turns out that I think providers will actually be the strongest proponents of the modular strategy. They’re already buying mobile devices with money out of their own pockets and so they’re going to start using apps that will help them provide better care. Hospitals will have a hard time controlling it and they’ll eventually realize that the best way to control it is to embrace it.

The most unfortunate part of this EHR development is that it’s going to take a long time for this development to become a reality. However, little by little we’ll get there.

As most of you know, John Halamka is publishing content everywhere. In fact, maybe I should see if he’ll publish some here. Halamka is really smart and respected by many for good reason. So, I was intrigued to find an article in the Technology Review (an MIT publication) where Halamka higlights what he considers the major EHR and healthcare IT developments over the next five years.

I’ve been doing a number of series lately on EMR and EHR & EMR and HIPAA and since people seem to really like them, I decided I’d make Halamka’s major EHR developments into a series as well.

The first Major EHR Development is: EHR In the Cloud

In the article above, Halamka offers some interesting comments about doctors being doctors and not tech people, the issues of privacy in the cloud and hospitals leaning towards “private clouds.” Let’s take a look at each of these.

Doctors Don’t Want to be Tech People
While there are certainly exceptions to the rule, it’s true that most doctors just want their tech to work. They don’t want to spend a weekend installing a server. There’s little argument that a SaaS EHR requires less in office tech. This fact will end up being a major driving force behind the adoption of SaaS EHR software over the client server counterparts.

Certainly, many doctors will still feel comfortable with their local IT help doing the work for a client server install. Also, many still feel more comfortable having their EHR data stored on a server in their office. This issue will continue to fester for a long time to come. At least until the SaaS EHR vendors provide doctors a copy of their data which they can store in their office. Plus, SaaS EHR are much faster today than they were, but there’s still a few things that a client server can do that is just flat out faster than client server.

I still see the ease of implementation and “less tech” helping SaaS EHR software to continue to gain market share.

Privacy in the Cloud
The biggest problem here is likely that doctors aren’t technical enough to really understand the risks of data in the cloud or not. Plus, I think you can reasonably make an argument that both sides have privacy risks. Most people are becoming much more comfortable with data stored in the cloud. I expect this trend to continue.

Private Clouds for Hospitals
Halamka claims that he, “estimates that moving infrastructure and applications to my hospital’s private cloud has reduced the cost of implementing electronic health records by half.” Of course, we have a lot of possible definitions of “cloud” and I’m not exactly sure how Halamka defines his private cloud. However, anyone who’s managed client installs of EHR software, including client upgrades, etc knows some of the pains associated with it. I’d be interested to know what other savings Halamka and Beth Israel Deaconess Medical Center get from their “private cloud.”

Cloud and EHR
There’s one thing I can’t ever get out of me head when I think about EHR and the cloud. Someone once told me (sorry I can’t remember who), “The cloud has always won in every industry. It will win in EHR too.” I hate when people use terms like always and every, but I haven’t (yet?) found an example to prove that person wrong.

If you’re interested in reading a more personal post about 9/11, you can check out this post I did on EMR and HIPAA about teaching the new generation about 9/11.

As I’ve watched the various news stories, documentaries and memorials about 9/11, this 60 Minutes news story about a doctor caring for 9/11 survivors was incredibly fascinating. Turns out, he set up a free clinic for the survivors and also started doing interviews with these people so that their stories would be recorded for others to hear. If you didn’t see it, you should watch it below.

The opening to the 60 Minutes video had me wondering about how healthcare dealt with all the injuries in the aftermath of September 11th. It seems like so many angles of September 11th have been covered, I can’t remember ever seeing the stories of hospitals and other doctors trying to treat the influx of patients that no doubt overwhelmed their doors. If you know of some, I’d love to see them.

Maybe that’s not such a terrible thing that the focus hasn’t been on the healthcare stories. Maybe it’s better that we focus on the heroes who lost their lives that day. Although, I’m sure we’re going to hear more and more healthcare related stories about 9/11 illnesses as time passes. Too bad we don’t have an integrated EMR with HIE that could help to track all those that were exposed to the gases and dust that were found at ground zero. That might help their cause since the 9/11 First Responders bill is only for the next 5 years.

John Halamka also has a post up about the impact of 9/11 on Healthcare IT. He concludes that “Disaster recovery, security, and emergency support efforts will continue, inspired by the memories of those who perished 10 years ago.”

It’s not secret that social media continues to play an increasingly powerful role in connecting folks within the healthcare IT community. Sites such as LinkedIn, Facebook and Twitter offer easy-to-navigate platforms that enable communication with peers on any continent, in any time zone. Twitter has become a personal favorite – both for its brevity and its simplicity. (Yes, I’ve heard promising things about Google+, but haven’t yet checked it out.)

The healthcare IT community has also embraced Twitter. Follow a variety of hashtags, including personal favorite #HITsm, and you’ll encounter a variety of opinionated, educated, and often humorous industry folk who, through their activity in the social space, are either emerging as thought leaders or bolstering their credibility as one.

The hashtag #HIT100 has been popular of late thanks to the crowdsourcing efforts of Michael Planchart, aka @theEHRguy. According to his Twitter profile, he is a “Healthcare Interoperability Consultant, Enterprise Architect for Healthcare IT and Standards Specialist.” According to his LinkedIn profile, he is a chief software architect at ProKSys. One thing is for sure – he is passionate about the healthcare IT community on Twitter. So much so that just a few weeks ago he began compiling nominations from his peers on Twitter of the top 100 tweeters (personal or company accounts) in the healthcare IT space.

The resultant list, published earlier this week, can be downloaded here: Final HIT100 Nominees. It is a great resource of folks to keep up with. (Be sure to check out @billians at #78!) Anne Zieger at EHROutlook.com (@ehroutlook at #86) has helpfully distilled the list into the top EMR/EHR tweeters.

I’ve met many in person at industry events, and know even more through Twitter. Hopefully I’ll run into Michael Planchart himself at some point. In the meantime, I chatted with him via email about why he wanted to take on this project, and why the healthcare IT community has embraced social media, particularly Twitter.

Why did you decide to embark on this project?

I wanted the healthcare IT community to vote for their most valued peers. Many well-intended folks would come up with their personal list and publish it. I wanted everyone to participate to create a more objective and transparent selection. This one may not yet be perfect, but it is open and publicly created. Hopefully, for 2012 we will have greater participation from many more folks. But for now, we have this to evangelize from.

Do you think there are more influencers in the #HIT space this year than last?

I know many of the folks that I follow and those that follow me. I’ve personally met many at RSNA, HIMSS and other healthcare events. But I’ve noticed a lot of newcomers to the social media space. Many of them I know as excellent contributors to healthcare IT, since I belong to the same standards committees that they do, although many times we work on different projects. What’s new is not them being in healthcare IT, but being in social media representing healthcare IT.

But answering your question more directly, yes there are many more participants this year. To be an influencer like John Halamka, Brian Ahier, Keith Boone, Matthew Holt and Dave deBronkart, just to name a few, most have some miles to go.

And why do you think there has been such an increase?

Twitter has been an open platform to create networks from the beginning. Linkedin and Facebook are too closed to create peer-to-peer networks. So Twitter has been highly influential in creating these peer-to-peer specialized networks like our #hcsm or #HIT groups.

I encourage you to take a look at the list and start connecting, communicating and educating. Be sure to follow this blog – @ehrandhit, and myself – @SmyrnaGirl, while you’re at it!

NOTE: I had this post sitting ready to be posted back in July and never got around to it. I think it’s still pretty relevant even though we are a few months farther along. Some of the time frames might not be quite right now, but the sentiments are interesting.

DKBerry sent me a passionate email in reference to this Modern Healthcare article about the EHR subsidies unanswered questions and the possibility of EHR Stimulus money flowing in May 2011. While I don’t agree completely with DKBerry, I have to admit that it’s quite disturbing that an 800 page meaningful use final rule later and we still have lots of questions. The following is DKBerry’s reaction/summary of the article:

Trudel makes it sound like a doc could validate his meaningful use on 30 April (end of the first possible 90 day period for reimbursement) … and would get paid by CMS in May.  Wonder how long she has worked for CMS?

I especially like this line …

“John Halamka, committee co-chairman, asked whether the reimbursements paid to office-based physicians would be counted by the Internal Revenue Service as taxable income. Trudel said that question was out of her purview.”

Of course its taxable income Dr. Halmaka!  It’s based on Medicare reimbursement payments … and that’s revenue.  Had the bozzos who set up this idiotic incentive program provided tax credits instead of partial reimbursements for meaningful use adoption of a certified EHR … then maybe they would have gotten more than 15 docs to sign up.

You will love the dialog between Judith Faulkner (Epic Systems) and Doug Fridsma (ONCHIT).

“Faulkner asked whether he thought “we’re going to make” the Jan. 1, 2011, start date by having both these certification and testing organizations and vendors with tested products in place by then.

Fridsma made no promises.”

He said his hope is that having multiple testing and certifications organizations authorized will “eliminate some of the bottlenecks.” Still, he said, there will be “challenges” to get systems certified if providers “bundle” pieces of EHR systems together to achieve meaningful use, a common scenario at many hospitals.

“We are working as hard as we can to meet those timelines and get the capability in place,” Fridsma said.

I appreciate that you are working as hard as you can … but that’s not good enough.  ONC has to get it done now.  Any date after 30 September and its costing hospitals money.  They are going to be still screwing around with this in January … 2 years after they put it out in ARRA.  If I were a doc I would just say screw it … I’m closing my panel to Medicare patients.  This isn’t worth the pain and effort.

In MedCity News, John Halamka makes an effort to summarize as simply as possible the Quality Measures:

I’ve been asked to summarize the Quality Measures as simply as possible

a. The Core Measures for All Eligible Professionals, Medicare and Medicaid are in the Final Rule Table 7, page 287. The Measures are

• Hypertension: Blood Pressure Measurement
• Tobacco Use Assessment and Tobacco Cessation Intervention
• Adult Weight Screening and Follow-up

b. If the denominator for one or more of the Core Measures is zero, EPs will be required to report results for up to three Alternate Core Measures. The Alternate Core Measures for Eligible Professionals are in the Final Rule Table 7, page 287. The Measures are

• Weight Assessment and Counseling for Children and Adolescents
• Preventive Care and Screening: Influenza Immunization for Patients ? 50 Years Old
• Childhood Immunization Status

c. The Clinical Quality Measures for Submission by Medicare or Medicaid EPs for the 2011 and 2012 Payment Year (EPs must choose 3) are in the Final Rule Table 6, page 272 . Here’s a summary of the 44 quality measures that CMS posted last week.

d. The Clinical Quality Measures for Submission by Eligible Hospitals and Critical Access Hospitals for Payment Year 2011-2012 are in the Final Rule Table 10, page 303. The Measures are

• Emergency Department Throughput ’ admitted patients Median time from ED arrival to ED departure for admitted patients
• Emergency Department Throughput ’ admitted patients Admission decision time to ED departure time for admitted patients
• Ischemic stroke ’ Discharge on anti-thrombotics
• Ischemic stroke ’ Anticoagulation for A-fib/flutter
• Ischemic stroke ’ Thrombolytic therapy for patients arriving within 2 hours of symptom onset
• Ischemic or hemorrhagic stroke ’ Antithrombotic therapy by day 2
• Ischemic stroke ’ Discharge on statins
• Ischemic or hemorrhagic stroke ’ Stroke education
• Ischemic or hemorrhagic stroke ’ Rehabilitation assessment
• VTE prophylaxis within 24 hours of arrival
• Intensive Care Unit VTE prophylaxis
• Anticoagulation overlap therapy
• Platelet monitoring on unfractionated heparin
• VTE discharge instructions
• Incidence of potentially preventable VTE

Everything clear now?

Anyone that works in Healthcare IT knows who John Halamka is and so of course I was interested in his post of his top 10 impressions after HIMSS. It’s an interesting list and I think he does a pretty good job of looking at things from a very high level. Here they are as posted on his blog:

1. Meaningful Use is everywhere. Vendors are promising EHRs, modules, appliances, and services to help clinicians achieve it. I had dinner on Monday night in a small Indian vegetarian restaurant. Sitting next to me were 3 engineers from Bangalore who were arguing about the details of Meaningful Use in between bites of vegetable curry. I could not escape Meaningful Use anywhere!

2. Certification is everywhere. It’s particularly ironic that many vendors claimed their systems were certified, even though the certification NPRM was just released today, making compliance with the new certification process in time for HIMSS impossible.

3. Cloud computing, Software as a Service and ASP models are popular tactics to accelerate EHR rollouts. There are still lingering concerns about how to ensure privacy in a cloud environment.

4. Several firms such as Intersystems, Axolotol, and Medicity are offering HIE platforms that include many of the standards noted in the IFR. The marketplace for HIE products is just emerging and it’s hard to predict who will become the market leader.

5. The Continuity of Care Document is gaining traction. I found many vendors supporting CCD exports from their EHRs. A company called M*Modal , has developed natural language processing technology that captures dictated content in its original context (ontology-driven
rules) as a CDA document.

6. Consultants abound. It’s clear that Regional Extension Centers and Health Information Exchanges will require expertise and staffing from professional firms. They all had large booths at HIMSS.

7. 30,000 people attended, including 10,000 I did not recognize (just kidding). It’s clear to me that many IT professionals, even those with limited healthcare domain expertise, attended HIMSS to better understand how they could participate in the euphoria of HITECH stimulus dollars.

8. Self service kiosks for patient identification and self-registration are now mainstream. Just as we print our airline boarding passes, we can now use credit cards or biometrics to check into ambulatory care appointments and automatically settle all co-pay balances.

9. Image exchange in the cloud is being offered by several vendors. As I mentioned in Monday’s blog, Symantec announced an appliance for small clinician offices that cloud enables all imaging modalities using a facebook-like social networking invitation to share/view images.

10. PHRs and patient engagement are becoming more mainstream. Google and Microsoft continue to innovate in the non-tethered PHR marketplace.

One of my regular readers and commenters, DKBerry, sent me some extracts on an article by Modern Healthcare about HITSP. DKBerry also commented, “HITSP is still operational through 30 April. Despite the extension question to its future is going to hurt its mission IMO.” I think HITSP does face a very uncertain future. Here are the excerpts from the article:

“It appears the Healthcare Information Technology Standards Panel, or HITSP, has become yet another organization formed at the behest of the Bush administration that is being forced to reapply for its job under the federal government’s new heath IT authority.”

…
“That contract was set to expire Jan. 31, but HHS issued a “no-cost extension” to the contract through April 30, according to HITSP Chairman John Halamka, a physician who is chief information officer at 621-bed Beth Israel Deaconess Medical Center and at Harvard Medical School, Boston.”

…

“Halamka said the HHS contract extension through April will enable HITSP “to have a presence at the upcoming HIMSS conference (scheduled to run March 1-4 in Atlanta) and support the quality reporting activities being demonstrated in the Interoperability Showcase there.”

In addition, HITSP will host “informational conference calls” over the next few months and its Foundations Harmonization Subcommittee set a schedule of three meetings, the first being today at 10:30 a.m. ET, with two more Feb. 8 and Feb. 17 to wrap up its work.

“HITSP is not done; the lights are on,” said Liz Neiman, an ANSI spokeswoman. HITSP and healthcare IT interoperability are “a tremendous priority for ANSI,” Neiman said. “Absolutely, we’ll be going for any RFP that’s coming out. What’s really important for us is to keep the momentum going.”

Healthcare InformationWeek has an article that discusses the challenges of EMR security and privacy. A lot of the stuff is nothing new to those of us in the healthcare space. Although, it’s interesting to see how they summarize things like the goal to be full EMR by 2014 and the EMR stimulus money.

However, the article did include these interesting stats on the number of breaches that happen in healthcare and the focus IT managers put on privacy and data security in healthcare.

Healthcare providers and other health businesses aren’t stepping up to protect privacy, according to a recent study. Some 80% of healthcare organizations have experienced at least one incident of lost or stolen health information in the past year, according to the study, released this month from security management company LogLogic and the Ponemon Institute, which conducts privacy and information management research.

Also, some 70% of IT managers surveyed said senior management doesn’t view privacy and data security as a priority, and 53% say their organizations don’t take appropriate steps to protect patient privacy. Less than half judge their existing security measures as “effective or very effective.”

I was surprised that 80% of organizations have had an incident of lost or stolen health information. However, I honestly don’t see this ever changing. Stuff happens even with the very best efforts.

I did also like this quote of John Halamka about the challenge of balancing privacy and security with sharing the patient information to provide better patient care.

“You want to protect the patient’s preferences for confidentiality,” Halamka said. But you also need to get information where it’s needed. “If you come to the emergency department in a coma, and you have a record that includes psychiatric treatment, HIV, drug abuse, and other information, would you share part of it or all of it? My preference would be all of it, with the hope that emergency workers would use it discreetly, to save my life.” But other people may feel differently, Halamka said, and healthcare policy needs to serve all those needs.

I’m a little surprised that Halamka has had psychiatric treatment, HIV and drug abuse. He’s doing quite well considering that history. (that’s sarcasm in case you didn’t note it) His history aside, I’m totally with him on wanting that information available as well. However, he’s totally correct that many people wouldn’t want that stuff shared. Enabling the consumer to make that decision though is a hard nut to crack.