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The Case For Dumping EMR Interoperability Goals

Posted on December 22, 2015 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

The new year is upon us, and maybe we should consider some new approaches, or even throw out accepted wisdom. Why not consider some major pain points and reconsider how we’re handling them?

In that spirit, my question is this: Should we give up on the idea that EMR vendors will ever allow their data will be interoperable? While this conclusion isn’t exactly a no-brainer, many of us have certainly toyed with the idea. So let’s take ‘er out for a spin.

One major consideration is that EMR vendors have some very compelling reasons for keeping things as they are. Perhaps most notably, interoperability would mean that providers wouldn’t be trapped in deals with a single vendor, as they could just shift the data over to a new platform if the need arose. If I sold EMRs I’d fight tooth and nail to prevent my product from being dumped too easily.

As if that weren’t enough of a disincentive, EMR vendors would need to spend big bucks to achieve interoperability, with no direct reward in sight. Somehow, I doubt that they’re ever going to make such an investment to win some “nice guy” award from the industry.

And even if they could somehow achieve interoperability without breaking a sweat, we’ve got to contend with inertia. Making changes on that scale takes a great deal of effort, and EMR vendors have very little reason to do so.

Maybe the federal government could achieve interoperability through some kind of epic power play, like refusing to issue Medicare reimbursement to providers whose EMRs didn’t meet some ONC interoperability standard.

But even that kind of brute force wouldn’t solve the interoperability problem with one stroke. Such an approach would come with a raft of serious concerns. What interoperability standard would ONC use, and how long would it take to choose? Then, how long would vendors have to meet the standard?  How long would providers have to decommission their existing EMR — and let’s not forget, quite possibly interlocking HIT systems — and where would they get the money for the new/upgraded systems?

Not only that, it would it cost billions of dollars, without a doubt, to make this transition. It could take a decade before the transition was complete. A lot can happen to derail such an initiative over that amount of time, and market forces could render the premises of such an effort obsolete.

On top of that, any effort which encouraged providers to dump their existing EMR platform would greatly diminish, if not erase, the value of the billions of dollars invested in Meaningful Use incentives. A lot of effort has gone into workflow and interface designs that support MU compliance, and starting from scratch on a new platform would NOT be a walk in the park.  So meeting MU goals might be possible over time, but could fall by the wayside for the short term.

All told, it seems that we may be chasing our tails trying to push through interoperability. In theory it sounds good, but when you look at the details it seems unlikely to happen. That being said, the need to share patient data isn’t going to go away, so what alternatives might work? I’ll follow up with some additional thoughts.

Significant Articles in the Health IT Community in 2015

Posted on December 15, 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.

Have you kept current with changes in device connectivity, Meaningful Use, analytics in healthcare, and other health IT topics during 2015? Here are some of the articles I find significant that came out over the past year.

The year kicked off with an ominous poll about Stage 2 Meaningful Use, with implications that came to a head later with the release of Stage 3 requirements. Out of 1800 physicians polled around the beginning of the year, more than half were throwing in the towel–they were not even going to try to qualify for Stage 2 payments. Negotiations over Stage 3 of Meaningful Use were intense and fierce. A January 2015 letter from medical associations to ONC asked for more certainty around testing and certification, and mentioned the need for better data exchange (which the health field likes to call interoperability) in the C-CDA, the most popular document exchange format.

A number of expert panels asked ONC to cut back on some requirements, including public health measures and patient view-download-transmit. One major industry group asked for a delay of Stage 3 till 2019, essentially tolerating a lack of communication among EHRs. The final rules, absurdly described as a simplification, backed down on nothing from patient data access to quality measure reporting. Beth Israel CIO John Halamka–who has shuttled back and forth between his Massachusetts home and Washington, DC to advise ONC on how to achieve health IT reform–took aim at Meaningful Use and several other federal initiatives.

Another harbinger of emerging issues in health IT came in January with a speech about privacy risks in connected devices by the head of the Federal Trade Commission (not an organization we hear from often in the health IT space). The FTC is concerned about the security of recent trends in what industry analysts like to call the Internet of Things, and medical devices rank high in these risks. The speech was a lead-up to a major report issued by the FTC on protecting devices in the Internet of Things. Articles in WIRED and Bloomberg described serious security flaws. In August, John Halamka wrote own warning about medical devices, which have not yet started taking security really seriously. Smart watches are just as vulnerable as other devices.

Because so much medical innovation is happening in fast-moving software, and low-budget developers are hankering for quick and cheap ways to release their applications, in February, the FDA started to chip away at its bureaucratic gamut by releasing guidelines releasing developers from FDA regulation medical apps without impacts on treatment and apps used just to transfer data or do similarly non-transformative operations. They also released a rule for unique IDs on medical devices, a long-overdue measure that helps hospitals and researchers integrate devices into monitoring systems. Without clear and unambiguous IDs, one cannot trace which safety problems are associated with which devices. Other forms of automation may also now become possible. In September, the FDA announced a public advisory committee on devices.

Another FDA decision with a potential long-range impact was allowing 23andMe to market its genetic testing to consumers.

The Department of Health and Human Services has taken on exceedingly ambitious goals during 2015. In addition to the daunting Stage 3 of Meaningful Use, they announced a substantial increase in the use of fee-for-value, although they would still leave half of providers on the old system of doling out individual payments for individual procedures. In December, National Coordinator Karen DeSalvo announced that Health Information Exchanges (which limit themselves only to a small geographic area, or sometimes one state) would be able to exchange data throughout the country within one year. Observers immediately pointed out that the state of interoperability is not ready for this transition (and they could well have added the need for better analytics as well). HHS’s five-year plan includes the use of patient-generated and non-clinical data.

The poor state of interoperability was highlighted in an article about fees charged by EHR vendors just for setting up a connection and for each data transfer.

In the perennial search for why doctors are not exchanging patient information, attention has turned to rumors of deliberate information blocking. It’s a difficult accusation to pin down. Is information blocked by health care providers or by vendors? Does charging a fee, refusing to support a particular form of information exchange, or using a unique data format constitute information blocking? On the positive side, unnecessary imaging procedures can be reduced through information exchange.

Accountable Care Organizations are also having trouble, both because they are information-poor and because the CMS version of fee-for-value is too timid, along with other financial blows and perhaps an inability to retain patients. An August article analyzed the positives and negatives in a CMS announcement. On a large scale, fee-for-value may work. But a key component of improvement in chronic conditions is behavioral health which EHRs are also unsuited for.

Pricing and consumer choice have become a major battleground in the current health insurance business. The steep rise in health insurance deductibles and copays has been justified (somewhat retroactively) by claiming that patients should have more responsibility to control health care costs. But the reality of health care shopping points in the other direction. A report card on state price transparency laws found the situation “bleak.” Another article shows that efforts to list prices are hampered by interoperability and other problems. One personal account of a billing disaster shows the state of price transparency today, and may be dangerous to read because it could trigger traumatic memories of your own interactions with health providers and insurers. Narrow and confusing insurance networks as well as fragmented delivery of services hamper doctor shopping. You may go to a doctor who your insurance plan assures you is in their network, only to be charged outrageous out-of-network costs. Tools are often out of date overly simplistic.

In regard to the quality ratings that are supposed to allow intelligent choices to patients, A study found that four hospital rating sites have very different ratings for the same hospitals. The criteria used to rate them is inconsistent. Quality measures provided by government databases are marred by incorrect data. The American Medical Association, always disturbed by public ratings of doctors for obvious reasons, recently complained of incorrect numbers from the Centers for Medicare & Medicaid Services. In July, the ProPublica site offered a search service called the Surgeon Scorecard. One article summarized the many positive and negative reactions. The New England Journal of Medicine has called ratings of surgeons unreliable.

2015 was the year of the intensely watched Department of Defense upgrade to its health care system. One long article offered an in-depth examination of DoD options and their implications for the evolution of health care. Another article promoted the advantages of open-source VistA, an argument that was not persuasive enough for the DoD. Still, openness was one of the criteria sought by the DoD.

The remote delivery of information, monitoring, and treatment (which goes by the quaint term “telemedicine”) has been the subject of much discussion. Those concerned with this development can follow the links in a summary article to see the various positions of major industry players. One advocate of patient empowerment interviewed doctors to find that, contrary to common fears, they can offer email access to patients without becoming overwhelmed. In fact, they think it leads to better outcomes. (However, it still isn’t reimbursed.)

Laws permitting reimbursement for telemedicine continued to spread among the states. But a major battle shaped up around a ruling in Texas that doctors have a pre-existing face-to-face meeting with any patient whom they want to treat remotely. The spread of telemedicine depends also on reform of state licensing laws to permit practices across state lines.

Much wailing and tears welled up over the required transition from ICD-9 to ICD-10. The AMA, with some good arguments, suggested just waiting for ICD-11. But the transition cost much less than anticipated, making ICD-10 much less of a hot button, although it may be harmful to diagnosis.

Formal studies of EHR strengths and weaknesses are rare, so I’ll mention this survey finding that EHRs aid with public health but are ungainly for the sophisticated uses required for long-term, accountable patient care. Meanwhile, half of hospitals surveyed are unhappy with their EHRs’ usability and functionality and doctors are increasingly frustrated with EHRs. Nurses complained about technologies’s time demands and the eternal lack of interoperability. A HIMSS survey turned up somewhat more postive feelings.

EHRs are also expensive enough to hurt hospital balance sheets and force them to forgo other important expenditures.

Electronic health records also took a hit from ONC’s Sentinel Events program. To err, it seems, is not only human but now computer-aided. A Sentinel Event Alert indicated that more errors in health IT products should be reported, claiming that many go unreported because patient harm was avoided. The FDA started checking self-reported problems on PatientsLikeMe for adverse drug events.

The ONC reported gains in patient ability to view, download, and transmit their health information online, but found patient portals still limited. Although one article praised patient portals by Epic, Allscripts, and NextGen, an overview of studies found that patient portals are disappointing, partly because elderly patients have trouble with them. A literature review highlighted where patient portals fall short. In contrast, giving patients full access to doctors’ notes increases compliance and reduces errors. HHS’s Office of Civil Rights released rules underlining patients’ rights to access their data.

While we’re wallowing in downers, review a study questioning the value of patient-centered medical homes.

Reuters published a warning about employee wellness programs, which are nowhere near as fair or accurate as they claim to be. They are turning into just another expression of unequal power between employer and employee, with tendencies to punish sick people.

An interesting article questioned the industry narrative about the medical device tax in the Affordable Care Act, saying that the industry is expanding robustly in the face of the tax. However, this tax is still a hot political issue.

Does anyone remember that Republican congressmen published an alternative health care reform plan to replace the ACA? An analysis finds both good and bad points in its approach to mandates, malpractice, and insurance coverage.

Early reports on use of Apple’s open ResearchKit suggested problems with selection bias and diversity.

An in-depth look at the use of devices to enhance mental activity examined where they might be useful or harmful.

A major genetic data mining effort by pharma companies and Britain’s National Health Service was announced. The FDA announced a site called precisionFDA for sharing resources related to genetic testing. A recent site invites people to upload health and fitness data to support research.

As data becomes more liquid and is collected by more entities, patient privacy suffers. An analysis of web sites turned up shocking practices in , even at supposedly reputable sites like WebMD. Lax security in health care networks was addressed in a Forbes article.

Of minor interest to health IT workers, but eagerly awaited by doctors, was Congress’s “doc fix” to Medicare’s sustainable growth rate formula. The bill did contain additional clauses that were called significant by a number of observers, including former National Coordinator Farzad Mostashari no less, for opening up new initiatives in interoperability, telehealth, patient monitoring, and especially fee-for-value.

Connected health took a step forward when CMS issued reimbursement guidelines for patient monitoring in the community.

A wonky but important dispute concerned whether self-insured employers should be required to report public health measures, because public health by definition needs to draw information from as wide a population as possible.

Data breaches always make lurid news, sometimes under surprising circumstances, and not always caused by health care providers. The 2015 security news was dominated by a massive breach at the Anthem health insurer.

Along with great fanfare in Scientific American for “precision medicine,” another Scientific American article covered its privacy risks.

A blog posting promoted early and intensive interactions with end users during app design.

A study found that HIT implementations hamper clinicians, but could not identify the reasons.

Natural language processing was praised for its potential for simplifying data entry, and to discover useful side effects and treatment issues.

CVS’s refusal to stock tobacco products was called “a major sea-change for public health” and part of a general trend of pharmacies toward whole care of the patient.

A long interview with FHIR leader Grahame Grieve described the progress of the project, and its the need for clinicians to take data exchange seriously. A quiet milestone was reached in October with a a production version from Cerner.

Given the frequent invocation of Uber (even more than the Cheesecake Factory) as a model for health IT innovation, it’s worth seeing the reasons that model is inapplicable.

A number of hot new sensors and devices were announced, including a tiny sensor from Intel, a device from Google to measure blood sugar and another for multiple vital signs, enhancements to Microsoft products, a temperature monitor for babies, a headset for detecting epilepsy, cheap cameras from New Zealand and MIT for doing retinal scans, a smart phone app for recognizing respiratory illnesses, a smart-phone connected device for detecting brain injuries and one for detecting cancer, a sleep-tracking ring, bed sensors, ultrasound-guided needle placement, a device for detecting pneumonia, and a pill that can track heartbeats.

The medical field isn’t making extensive use yet of data collection and analysis–or uses analytics for financial gain rather than patient care–the potential is demonstrated by many isolated success stories, including one from Johns Hopkins study using 25 patient measures to study sepsis and another from an Ontario hospital. In an intriguing peek at our possible future, IBM Watson has started to integrate patient data with its base of clinical research studies.

Frustrated enough with 2015? To end on an upbeat note, envision a future made bright by predictive analytics.

EHR Certification Termination – What’s It Mean?

Posted on September 10, 2015 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.

The news recently came out that ONC had terminated the SkyCare EHR developed by Platinum Health Information System, Inc. It sounds like those that were using the SkyCare EHR were likely aware of the issues with their EHR. From reports I read, many customers had already reported that SkyCare EHR was no longer responding to them and the company had basically disappeared.

It’s always sad when this happens even when there are only a handful of doctors using this EHR. You’d think that the founders of the company would have enough integrity to provide their users as soft a landing place as possible. Plus, if they didn’t have enough respect for their users, how about respect for the patients that could be put in harms way without a soft landing. Even with the help of an EHR vendor, switching EHR software is tough. Without them it can be brutal and have all sorts of ugly consequences for a practice.

ONC certainly did the right thing to terminate the company’s EHR certification. If they hadn’t done it, then the doctors would be in an even worse situation. With the EHR certification terminated, the doctors can now apply for the exception which will allow them to avoid the EHR penalties. Of course, that doesn’t help them when it comes to the EHR incentive money which they’ll no longer receive.

I hope this is a lesson for other EHR vendors (and many more will fail). Don’t leave your EHR users high and dry. Do the right thing and help them move to a new EHR system. I’m sure there’s more to the story of why SkyCare EHR was shutdown, but I can’t imagine wanting to ever work with the Founders of that EHR in any other capacity.

Providers Still Have Hope For HIEs

Posted on July 10, 2015 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Sometimes, interoperability alone doesn’t cut it.  Increasingly, providers are expecting HIEs to go beyond linking up different organizations to delivering “actionable” data, according to a new report from NORC at the University of Chicago. The intriguing follow-on to the researchers’ conclusions is that HIEs aren’t obsolete, though their obsolescence seemed all but certain in the past.

The study, which was written up by Healthcare Informatics, conducted a series of site visits and 37 discussions with providers in Iowa, Mississippi, New Hampshire, Vermont, Utah and Wyoming. The researchers, who conducted their study in early 2014, hoped to understand how providers looked at HIEs generally and their state HIE program specifically. (The research was funded by ONC.)

One major lesson for the health IT types reading this article is that providers want data sharing models to reflect new care realities.  With Meaningful Use requirements and changes in payment models bearing down on providers, and triggering changes in how care is delivered, health IT-enabled data exchange needs to support new models of care.

According to the study, providers are intent on having HIEs deliver admission, discharge, and transfer alerts, interstate data exchange and data services that assist in coordinating care. While I don’t have comprehensive HIE services research to hand, maybe you do, readers. Are HIEs typically meeting these criteria? I doubt it, though I could be wrong.

That being said, providers seem to be willing to pay for HIE services if the vendor can meet their more stringent criteria.  While this may be tough to swallow for existing HIE technology sellers, it’s good news for the HIE model generally, as getting providers to pay for any form of community data exchange has been somewhat difficult historically.

Some of the biggest challenges in managing HIE connectivity identified by the study include getting good support from both HIE and EMR vendors, as well as a lack of internal staff qualified to manage data exchange, competing priorities and problems managing multiple funding streams. But vendors can work to overcome at least some of these problems.

As I noted previously, hospitals in particular have had many beliefs which have discouraged them from participating in HIEs. As one HIE leader quoted in my previous post noted, many have assumed that HIE connection costs would be in the same range as EMR adoption expenses; they’re been afraid that HIEs would not put strong enough data security in place to meet HIPAA obligations; and they assumed that HIE participation wasn’t that important.

Today, given the growing importance of sophisticated data management has come to the forefront, and most providers know that they need to have the big picture widespread data sharing can provide. Without the comprehensive data set cutting across the patient care environment — something few organizations are integrated enough to develop on their own — they’re unlikely to mount a successful population health management initiative or control costs sufficiently. So it’s interesting to see providers see a future for HIEs.

Annual Evaluation of Health IT: Are We Stuck in a Holding Pattern? (Part 1 of 3)

Posted on April 13, 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.

I don’t think anyone has complained of excessive long-term thinking among health care providers. But an urgent lack of planning has worsened in the past few months as key drivers of the health IT field search for new directions. Given today’s issues with Meaningful Use Stage 3, the FHIR data exchange standard, Accountable Care Organizations, medical device regulation, and health IT staffing, I expect the next several months to be a time of waiting.

This article will look over what has happened during the past year and try to summarize large-scale trends. I used to report annually from the HIMSS conference, the largest health IT gathering in the US, but stopped going because my articles were always cynical, cantankerous, and depressed. So I figure I just write up a cynical, cantankerous, and depressed summary of what’s happening in health IT from home.

Meaningful Use Stage 3: Shoot the Moon?

There are clear indications that the Meaningful Use program has gone off the tracks. I don’t consort with those who disparaged Meaningful Use from the start and claimed that it held back progress in the IT field. What little progress has occurred can be credited to Meaningful Use, because frankly, the health care industry was totally mired before. Choose your favorite metaphor: deer in the headlights (of oncoming disruptive competitors), ostrich in the sand, even possum in the road.

And no one can challenge that Stage 1 met its (very limited) goals. Centers for Medicare & Medicaid Services (CMS) just reported that the vast majority of hospitals have attested to Stage 1 (with rural and children’s hospitals lagging significantly). In fact, while defining Stage 3, CMS could remove some of its requirements because they have “topped out,” meaning that almost everybody already does them.

All the sharper is the contrast between Stage 1 and Stage 2, which was supposed to be incremental but apparently broke the camel’s back for many EHR vendors as well as providers, a lot of whom have thrown in the towel.

Interoperability was certainly a big stumbling block. Two different EHRs can claim to support a standard (such as the C-CDA) while not actually being able to exchange data in a useful manner, for reasons ranging from outright errors to differing interpretations of a fuzzy standard.

But the most whining from providers in Stage 2 arose over a requirement that patients view, transmit, or download (VDT) data from a patient portal. Even though providers needed only 5% of their patients to take a look at the site, they complained bitterly that they were being judged for something that relied on somebody else’s behavior (their patients).

The VDT measure is indeed a responsibility that depends on the behavior of outsiders (as are the interoperability requirements). But health providers seem slow to grasp the whole idea of “pay-for-value,” which means they won’t be rewarded in the future for doing stuff–they’ll be rewarded for results. Not that patients will get healthier just by viewing or transmitting data. But we need something measurable to mark progress, and since everybody issues paeons to patient engagement, the VDT measure is a natural one.

Calls have come from around the industry to water down or otherwise “simplify” Meaningful Use for Stage 3. A common request is to eliminate clinical quality measures (such as how many patients smoke) and focus on interoperability, which I oppose.

To muddy the Meaningful Use landscape further, Congress has started weighing in with complaints that the Office of the National Coordinator (ONC) hasn’t done enough to achieve its goals. One proposed bill overrides ONC and CMS to mandate changes in health care policy. There are rumors that Congress (who of course created the Meaningful Use provision in the first place) will take it back and do some serious micromanagement, perhaps as part of a bill on a totally different topic, the “doc fix” that is supposed to regularize Medicare payments.

In the midst of this turmoil, the ONC and CMS recently released Stage 3 recommendations, and it looks like they haven’t pulled their punches on a single thing. Interoperability is central, but the clinical quality measures still appear in full force. The requirement that patients engage with the technology has been softened, but still requires patients to take some action such as using a portal or uploading their own data.

Perhaps the boldest stake that CMS put in the ground was to force all providers onto a single schedule in Stage 3, a tremendous departure from the gentle steps offered by the first two stages. This has touched off a provider frenzy. They’ve been lobbying for years to slow Meaningful Use down, and notoriously ran to Congress to delay adoption of ICD-10 disease coding. But putting everyone on the same track makes eminent sense, particularly at this stage. If you’re really serious about data exchange and coordinated care, everybody has to equally capable. Otherwise we’re back to finger-pointing and claims that technology lapses have prevented compliance.

So what are ONC and CMS up to? Are they shooting the moon–hoping to make the big leap to their maximal goals in one bold play? Are they floating an audacious wish list that they know will be cut back in the course of negotiation? Are they even taunting resistant industries to go to Congress, knowing that Congress recently has been making even more radical noise than the Administration about the drawbacks of health IT? Something along these lines seems to be in the works.

To return to the theme of this article, I’m afraid that health care providers, insurers, EHR vendors, and all their business associates will freeze up while waiting for Congress and the various branches of Health and Human Services to determine which behaviors to prescribe and which to punish. So that’s my take on meaningful use–more on other developments in health IT in the next installments.

Why Meaningful Use Should Balance Interoperability With More Immediate Concerns

Posted on March 12, 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.

Frustration over the stubborn blockage of patient data sharing is spreading throughout the health care field; I hear it all the time. Many reformers have told me independently that the Office of the National Coordinator should refocus their Meaningful Use incentives totally on interoperability and give up on all the other nice stuff in the current requirements. Complaints have risen so high up that the ONC is now concentrating on interoperability, while a new Congressional bill proposes taking the job out of their hands.
Read more..

Should the Interoperability of Health Care Records Be the Law of the Land?

Posted on March 10, 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.

The upcoming three days may be critical to health care in the US. Representative Michael C. Burgess (R-Texas) has introduced a bill to promote the interoperability of health care records, and is accepting comments to his office only through March 13. This bill states valuable goals, but also embodies implications we should be wary of–and some real dangers.
Read more..

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.

ONC Healthcare Interoperability Roadmap Infographic

Posted on February 5, 2015 I Written By

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

There’s been a lot of talk around the 10 year ONC Healthcare Interoperability Roadmap. I think it’s a really great thing that they’re helping to drive a lot more discussion around interoperability. I’m very interested in doing the same.

For those who want the cliff notes version of the interoperability roadmap, I think this infographic does a pretty good job summarizing it:
ONC Healthcare Interoperability Roadmap Infographic

What do you think of the roadmap? Is it all conjecture and not much substance or will it make a big difference?