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

Posted on December 15, 2014 I Written By

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Karen DeSalvo Remains as National Coordinator of ONC Along with New Position

Posted on October 31, 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 case you missed it, last week it was announced that Karen DeSalvo had been appointed Assistant Secretary of Health focused on Ebola by HHS Secretary Burwell. In that same announcement Jacob Reider also announced his departure from ONC.

While the news was true that DeSalvo was taking on a new role at HHS as Assistant Secretary of Health, ONC also published a blog post that DeSalvo would stay on as National Coordinator of Health IT as well:

Dr. DeSalvo will serve as Acting ASH while maintaining her leadership of ONC. Importantly, she will continue to work on high level policy issues at ONC, and ONC will follow the policy direction that she has set. She will remain the chair of the Health IT Policy Committee; she will continue to lead on the development and finalization of the Interoperability Roadmap; and she will remain involved in meaningful use policymaking. She will also continue to co-chair the HHS cross-departmental work on delivery system reform.

Lisa Lewis will provide day to day leadership at ONC. Lewis served as Acting Principal Deputy National Coordinator before Dr. DeSalvo joined ONC, so she has had experience with all parts of our work. She will lead our extremely talented and very strong team during Dr. DeSalvo’s deployment to the Office of the Assistant Secretary for Health.

But most importantly, the team that is ONC is far more than one or two leaders. The team of ONC is personified in each and every individual – all part of a steady ship and a strong and important part of HHS’ path toward delivery system reform and overall health improvement.

Seems like an awkward arrangement if you ask me. DeSalvo will be providing high level leadership on policy direction, but Lisa Lewis will handle the day to day leadership. That job description for DeSalvo sounds like something an Assistant Secretary of Health might do and Lisa Lewis’ job sounds like something the National Coordinator would do.

I’m sure there’s more to this story. Maybe moving DeSalvo to Assistant Secretary was a way for ONC to save money and keep DeSalvo on board working on healthcare IT. If ONC’s budget gets cut, then HHS still has a way to pay for DeSalvo. Maybe that’s why Lisa Lewis can’t be promoted to full National Coordinator. Then again, maybe it’s like I mentioned when we first heard the DeSalvo news, DeSalvo is more of a public health person than she is a healthcare IT person.

The fact that DeSalvo is remaining as National Coordinator is interesting. However, I just came back from CHIME (healthcare CIO conference) where DeSalvo was scheduled as one of the plenary session speakers. However, she didn’t show and so the whole session was cancelled. I guess you could make the case that she’s got Ebola to deal with right now, but it also illustrates how health IT will be playing second fiddle for her going forward. Likely says something about the future of ONC.

Meaningful Use #HITsm Twitter Chat

Posted on October 17, 2014 I Written By

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

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

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

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

Do We Really Like the JASON Recommendations for Interoperable Health Data?

Posted on August 28, 2014 I Written By

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

The health IT community has been abuzz over the past few months about a report released by the Agency for Healthcare Research and Quality. Although the report mostly confirmed thoughts that reformers in the health IT space have been discussing for some time, seeing it aired in an official government capacity was galvanizing. The Office of the National Coordinator has held several forums about the report, known by the acronym JASON, and seems favorably inclined toward its recommendations.

Even though only four months have passed since its publication, we can already get some inkling of how it will fare at the ONC, which is going through major realignment of its own. And to tell the truth, I don’t see much happening with the JASON recommendations. In this article I’ll look at what I see to be its specific goals, and what I’ve heard regarding their implementation:
Read more..

Ten-year Vision from ONC for Health IT Brings in Data Gradually

Posted on August 25, 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.

This is the summer of reformulation for national U.S. health efforts. In June, the Office of the National Coordinator (ONC) released its 10-year vision for achieving interoperability. The S&I Framework, a cooperative body set up by ONC, recently announced work on the vision’s goals and set up a comment forum. A phone call by the Health IT Standards Committeem (HITSC) on August 20, 2014 also took up the vision statement.

It’s no news to readers of this blog that interoperability is central to delivering better health care, both for individual patients who move from one facility to another and for institutions trying to accumulate the data that can reduce costs and improve treatment. But the state of data exchange among providers, as reported at these meetings, is pretty abysmal. Despite notable advances such as Blue Button and the Direct Project, only a minority of transitions are accompanied by electronic documents.

One can’t entirely blame the technology, because many providers report having data exchange available but using it on only a fraction of their patients. But an intensive study of representative documents generated by EHRs show that they make an uphill climb into a struggle for Everest. A Congressional request for ideas to improve health care has turned up similar complaints about inadequate databases and data exchange.

This is also a critical turning point for government efforts at health reform. The money appropriated by Congress for Meaningful Use is time-limited, and it’s hard to tell how the ONC and CMS can keep up their reform efforts without that considerable bribe to providers. (On the HITSC call, Beth Israel CIO John Halamka advised the callers to think about moving beyond Meaningful Use.) The ONC also has a new National Coordinator, who has announced a major reorganization and “streamlining” of its offices.

Read more..

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.

Karen DeSalvo’s Sit Down Interview with Shahid Shah at the Health Privacy Summit

Posted on August 7, 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.

At the 2014 Patient Privacy Summit, Shahid Shah had a “Fireside Chat” with Karen DeSalvo. The interview was really great because it was the first time that I’ve seen Karen DeSalvo talk in a more casual and less scripted setting. In the interview you learn a lot about the leader of ONC and what’s on her mind and how her and ONC plan to approach healthcare IT in the future. Of course, since it’s at the Patient Privacy Summit, there’s a specific emphasis on privacy, but they also cover a lot of other related topics. Enjoy!

ONC’s Authority to Regulate Health IT

Posted on July 3, 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.

New National Coordinator for Health IT, Karen DeSalvo, is facing a really interesting time for ONC. The meaningful use money is close to running out and so DeSalvo has to figure out how to assure the future of the ONC organization. A part of me wonders if Farzad saw this stage of the organization coming and got out while the getting was good. Regardless, ONC has always had a challenge getting funding for its health IT efforts and with meaningful use funding close to the end it’s going to be an even bigger challenge.

I think as part of this future one option would be for ONC to become the safety and risk based regulatory body for health IT. Although, this idea has been questioned by the House Energy and Commerce Committee in a letter embedded below.

I don’t want to dive deep into the politics and regulations around this since it’s not my area of expertise. Instead, I want to discuss at a high level ONC’s future and the balance between ONC and the FDA. I’ve written about the FDA regulation of EHR before. I don’t see it happening. I don’t think it will happen and I don’t think they have the skills to make it happen.

On the other hand, should ONC start regulating it? I don’t think they have the skills or expertise either to do it effectively. Not only do they not have the funding (and that’s unlikely to change), but I don’t think they have the people who can accomplish this task. Plus, I don’t think they should regulate EHR.

I do wish that ONC would go all in on dealing with interoperability of health data. If they did this, then ONC would be an important part of healthcare’s future.

What do you think of ONC and its future? What should they be working on? What could they do to really have an impact for good on the future of health IT in the US?

Direct Messaging: The Logistics of Exchange

Posted on June 12, 2014 I Written By

Julie Maas is Founder and CEO of EMR Direct, a HISP (Health Information Service Provider) whose mission is to simplify interoperability in healthcare through the use of Direct messaging EHR integration and other applications. EMR Direct works with a large developer community to enable Direct for MU2 and other workflows using a custom, rapid-integration API that's part of the phiMail Direct Messaging platform. Julie is passionate about improving quality of care and software user experience, and manages ongoing interoperability testing within DirectTrust. Find Julie on Twitter @JulieWMaas.

Once you enable digital health data exchange via Direct instead of by fax, you’ll want to share your address with other providers, so you no longer have to deal with all those pesky scanned attachments, subtly linked to electronic patient records.

Direct directories are enabling address lookup to meet this need, and you can also let your most common business partners know your address by including it on document templates you already exchange today, so they can begin to exchange with you via Direct when they’re ready.  You can also contact your referring docs using another method you trust (such as the fax where you usually send them medical records, or their business phone number) to ask for their Direct address.

It’s wise to confirm expectations with exchange partners about the use cases/data payloads for which you intend to exchange via Direct, as Direct isn’t used just like email by everyone.  Some will use Direct solely for Transitions of Care and patient Transmit, others may use it for Secure Messaging with patients, and still other providers will be happy to conduct general professional correspondence with patients and other providers over Direct.  This service information may or may not be reflected in the first provider directories.  And even within the Transitions of Care use case, if standards aren’t implemented for optimal receiving, a sending system may generate a CCDA (Continuity of Care Document) with a subtly different structure than a receiving system is able to completely digest.  So, just a heads up as you receive your first message or two from a system with whom you haven’t exchanged before: you’ll want to carefully monitor what data is incorporated by the receiving system and what is not, and you may need to iterate slightly between sender and receiver to get the data consumption right.  You’ll still be miles ahead of the custom interfaces model.

All in all, Direct is easy to use and is working much better than the naysayers would have you believe.  Direct software follows the specification outlined in the document lovingly known in the industry as the “Applicability Statement”, crafted by consensus through a public/private collaborative effort known as the “Direct Project” and led by the Office of the National Coordinator of Health Information Technology (ONC).   Direct Project volunteers have also written reference implementations following this specification which have been used by many HISPs and EHRs as the basis for their own Direct offerings.  Other private entities have developed their own APIs and implementations of the protocol from scratch.  These different systems and varying configurations regularly test and collaborate with each other, to make Direct work as seamlessly as possible for the end users.  Because the whole system only works as well as our joint efforts, HISPs (Health Information Service Providers who provide Direct services) within the DirectTrust Network take interoperability seriously and work together to iron out any kinks.

A tremendous amount of collaboration is taking place to bring interoperability to fruition for Direct’s well-established standards and policies, and this work is producing a larger and more robust network each day.

Has EHR Become a Bad Brand?

Posted on April 25, 2014 I Written By

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

The other day, I had lunch at DC’s Soupergirl with the redoubtable Chuck Webster, workflow tool maven and evangelist. We talked a lot and discovered that both of us had a warm spot for the classic neighborhoods near Atlanta’s Piedmont Park. He as a transplant and I as a native.

More to this blog’s point, we discussed the state of EHRs and their numerous problems. Chuck wondered if EHR, per se, had become a bad brand? It’s a good question. Have we seen a once promising technology become, as has managed care, a discredited healthcare systems? It’s an easy case to make for a host of reasons, such as these:

Poor Usability. There are scads of EHRs in the marketplace, but few, if any, have a reputation as being user friendly. Whenever I first talk to an EHR user, I wait a few minutes while they vent about:

  • How they can’t put in or get out what they need to,
  • Their PCs being poorly located, inflexible or the wrong footprint,
  • Data that’s either missing, cut off or hard to find,
  • Logging in repeatedly,
  • Transcribing results from one system to put it in another,
  • Wading through piles of boilerplate, to get what they need etc., etc.
  • Having to cover PCs with sticky note workarounds.

As for patients, my friend Joe, a retired astrophysicist, is typical. He says when his doctor is on her EHR she doesn’t face him. She spends so much time keying, he feels like he’s talking to himself.

Now, it’s not completely fair to blame an EHR for how it’s implemented. The local systems folks get a lot of that blame. However, vendors really have failed to emphasize best practices for placing and using their systems.

Missing Workflows. EHRs, basically, are database systems with a dedicated front end for capturing and retrieving encounters and a back end for reporting. To carry out, their clinical role they have to be flexible enough to adapt to varying circumstances with a minimum of intervention.

For example, when you make an appointment for a colonoscopy, the system should schedule you and the doctor. It should then follow rules that automatically schedule the exam room, equipment, assign an anesthetist, and other necessary personnel, etc.

When you come in, it should bring up your history, give your doctor the right screens for your procedure, and have the correct post op material waiting. General business software workflow engines have done this sort of thing for years, but such functions elude many an EHR. EHRs without needed workflow abilities increase staff times and labor costs. They also mean users miss important opportunities and potential errors increase.

Data Sharing. Moving from paper to electronic records promised to end patient information isolation. Paper and faxed records can only be searched manually. However, with a structured electronic record, redundant entry would be reduced and information retrieval enhanced. Or so the argument went, but it hasn’t worked out that way.

While there are systems, such as the VA, Kaiser and various HIEs that fulfill much of the promise, it is still a potential rather than a reality for most of us. There are two basic reasons for this state of affairs: ONC’s mishandling of interchange requirements and one member of Congress’ misplaced suspicions.

ONC’s Role. ONC’s Meaningful Use program is meant to set basic EHR standards and promote data interchangeability.

When it comes to these goals, MU fell down from the start. MU1 could have been concise requiring an EHR to capture a patient’s demographics, vitals, chief complaint and meds.

Most importantly, MU could have made this information sharable by adopting one of HL7’s data exchange protocols. This would have given us a basic, national EHR system. Instead, MU focused on too many nice to have features, leaving data exchange way down the list.

ONC has tried to correct its data interchange a failing in MU2 to a degree, but it’s not there yet. Here’s what GAO, has to say about ONC’s efforts:

HHS, including CMS and ONC, developed and issued a strategy document in August 2013 that describes how it expects to advance electronic health information exchange. The strategy identifies principles intended to guide future actions to address the key challenges that providers and stakeholders have identified. However, the HHS strategy does not specify any such actions, how any actions should be prioritized, what milestones the actions need to achieve, or when these milestones need to be accomplished. GAO Report-14-242, March 24, 2014. Emphasis added.

Ron Paul. The other important obstacle to interchange came from Congress. When Congress passed HIPAA in 1996, it mandated that HHS develop a national, patient ID. However, in 1998 Ron Paul, (R-TX) deduced that since HHS wanted the ID system, it therefore wanted to put everyone’s medical records in a government database. He saw this as a threat to privacy. He got a rider added to HHS’s budget forbidding it to implement the ID system or even discuss one.

The ban’s remained in succeeding budgets. The rider has created a national medical data firewall for each of us, which hinders all of us. Paul’s gone from Congress, but Congress continues the ban. As Forbes’ Dan Munroe wrote about Paul’s ban:

The health data chaos we have today doesn’t allow for interoperability, portability or mobility. It’s why fax machines remain the ‘lingua franca” of U.S. healthcare. Every healthcare entity in the U.S. sees each patient, event and location as unique to them. For lack of a single identifier, there’s no easy or cost-effective way to coordinate patient care. Emphasis added.

While the lack of a patient ID is not EHRs fault, it noticeably reduces their ability to interchange information. State or other HIE’s are, in effect, workarounds for lack of a uniform ID. This situation adds to the perception of EHRs as unresponsive technology.

Onerous Agreements. As many an EHR buyer has found, vendors see EHRs as a sellers’ market. They use this to write onerous license agreements exempting their products from adhering to standards such as MU or from responsibility for costly errors or omissions.

These agreements not only limit liability, but often silence a buyer’s adverse comments. The effect is to cut buyers from any meaningful recourse. This shortsighted practice adds one more layer to the EHR industry’s image as unresponsive, self serving and defensive.

Whither the Brand?

The question then is are things so bad that EHR needs rebranding? If so, how should this be done by calling EHRs something else, advocating for a different technology, or yet another alternative?

For some brands, a new name along with some smart PR will do. That’s how Coca Cola reversed its New Coke fiasco. EHRs have a tougher problem. EHRs are not a one vendor product. They are a program class. Reforming EHR’s brand will take more than effective PR. It will take pervasive technical and policy changes.

Change From Where?

Change in a major technical field, as in public policy, requires either overcoming or going around inertia, habit, and complacency. EHRs are no exception. Here are some ways change could happen.

External Events. The most likely source of change is a crisis that brings public pressure on both the industry and government. There is noting like a tragedy to grab public attention and move decision makers off the dime. I don’t want it to occur this way, but nothing like a tragedy makes events go into fast forward and move issues from obscure to inevitable. Given EHRs many patient safety problems, this is all too likely an outcome.

ONC Initiative. ONC could step in and help right matters. For example, as I have advocated, ONC could run NIST’s usability protocols for all systems seeking MU certification. It could then publish the test results giving users a needed, common benchmark. This, in turn, could be a major push to get vendors to regard usability, etc., as an important feature.

ONC is not inclined to do this. Instead, it asks vendors to pick one of several versions of user centric technology. As Bennett Lauber, Chief Experience officer of The Usability People recently told HIEWatch:

“Usability certification for meaningful use really isn’t a test the way the rest of the certification process is. (Testers) go out and observe users, and report back to the certifiers,” Lauber reports. “There seem to be different sets of evaluation criteria because ONC has not really defined usability yet….” Emphasis Added.

Recently appointed ONC Coordinator, Dr. Karen Desalvo, unlike her predecessors, has been frank about changing ONC’s course. She’s revamped her advisory committee structure and spoken about going beyond meaningful use to big data.Notably, she understands the need for and the problems of interoperability. However, she’s not offered any changes in standards. ONC is in the best position to implement real standards, but for both political reasons; it’s unlikely to do so.

To chill things politically, vendors only have to find a few Congressmen who’ll, for a well placed contribution, will send ONC vendor drafted letters threatening its appropriation, committee reviews, etc. It can happen otherwise, but as Damon Runyon has said, “The race is not always to the swift, nor the battle to the strong, but that’s the way to bet.”

User Revolt. The most notable user push back to the status quo has involved unilateral EHR vendor agreements.

As Katie Bo Williams of Healthcare Drive (edited by Hospital EMR and EHR’s Anne Zieger) has notably described, major lawsuits are costing some vendors dearly. The industry, however, has yet to set buyer agreement standards that could aid its and EHRs’ reputation.

These lawsuits might chastise vendors, but users will need to become bolder if they want change. EHR vendors have an association to protect their interests. So do hospitals, physicians, practice managers, etc. Users are the one group that’s not represented.

You may belong to this or that product’s user group, but there is no one group that looks after EHR user’s interest. If there were a well organized and led EHR user group that lobbied for better usability, workflow tools and universal data exchange etc., then these issues would become more visible. More importantly, users would be able to demand a place at the table when ONC, etc., makes policy.

Those interested in patient safety, too, are taking some new directions. Recently, ECRI convened the Partnership for Promoting Health IT Patient Safety to promote changes, within “a non punitive environment,” that is, in a collaborative setting among vendors, practioners, safety organizations, etc. While the group has not issued any reports, it offers two hopeful signs.

The group’s advisory panel includes experts, such as, MIT’s Dr. Nancy Leveson, who works in aeronautic and ballistic missile safety systems. The other factor is that the group has consciously sought to give vendors a place where they see the impact their products have on patient safety without the threat of litigation. Whether the group can bring this off and influence the market remains to be seen.

Technical Fix. It’s possible users may decide to fix EHR’s problems themselves. For example, the University of Pittsburgh Medical Center  (UPMC) uses a combination of EPIC, Cerner and its own clinical systems. It wanted to pull patient information into one, comprehensive, easily used profile. To do this, the Center developed a new, tablet front end that overcomes a variety of common EHR problems.

Once a major actor, such as Pitt, shows there is a market, others will explore it. You’ll know it’s a real trend, when a major vendor buys a front end start up and brands it as its own.

Natural Turnover. Finally, John recently raised the question of EHRs’ future in What Software Will Replace EHR? He thinks that change will come organically as more technically robust software pushes out the old.

Slowly replacing current EHRs with new tools is the most likely path. However, a slow path may be the worst outcome. Slow turnover would give us a mixture of even more incompatible systems. This would make the XP installed base problem look simple.

The EHR brand reminds me of a politician with both high positives and negatives. It may be liked by many, however, it also has a lot of baggage. As with a candidate in that position, something will have to change those negatives or it will find itself just an also ran.