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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://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.

All I Want for Christmas is a Doctor’s Appointment

Posted on December 20, 2013 I Written By

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

A friend of mine had a very timely – and telling – prayer request at church the other day. She asked the Lord to help those in need of doctor’s appointments make them in a timely manner, both in terms of receiving care soon, and getting face time with a doctor before insurance deductibles roll over or cancelled policies end. It’s a prayer I’m sure many patients have been uttering just before they pick up the phone to see when their doctor’s next available appointment is; one that is all the more urgent for those with chronic conditions.

I have based past decisions on which new doctor to use based on their window of open appointments. Can’t see me for three weeks? Then you don’t get my business. Time is of the essence in healthcare these days. Patients want doctors’ time, and doctors don’t seem to have enough to go around. (Nor do they feel adequately compensated for it.)  Healthcare IT – patient portals, CPOE, natural-language processing systems, etc. – is certainly playing a role in helping doctors and ancillary staff get back some of that time. (Though many doctors contend entering data into EMRs is eating up a lot of that time savings.)

Some have postulated that healthcare IT, particularly digital health tools, will actually cause us to need doctors less. This counters the notion that we will soon see (if we aren’t already) a physician shortage, and an even greater lack of appointment availability thanks to the 27 million newly insured who will take advantage of their new policies in 2014. I’m not quite convinced that digital health devices and apps will cause me to go to the doctor any less. They may make the waiting in between my appointments less anxiety inducing, but I know myself too well to think I’d ever scale back on face time with my doctor. Perhaps those with chronic conditions feel differently. I’d be open to telemedicine and virtual visits, but those don’t seem to be on the radar of providers in my area.

Healthcare IT can certainly save time and improve access to care, but I don’t see how it can convince people to enter the healthcare field, which is where the true appointment availability problem seems to stem from. As a recent article at HealthcareFinanceNews.com points out, “retirement age physicians outnumber young members entering the ranks; over-worked physicians want to reduce their hours and care for fewer patients; and [there is a] general disenchantment with the state of healthcare.”

It’s a sad state of affairs when put that way. So what’s the answer? How can the healthcare industry – healthcare IT in particular –  work to ensure that prayers for timely appointment availability are no longer routine? Feel free to share your ideas in the comments below.

More Patient Portals

Posted on July 3, 2012 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 a LinkedIn response to my post about multiple patient portal logins I got this insightful commentary from Stuart Jarvis on the challenges of patient portals that I think will help to expand the conversation about patient portals:

The patient portal is a nice idea but the complications of hippa rules and penalties makes it not worth the effort.

I would be nice if digital devices linked directly into EMR’s but here are the reasons that it will probably never happen;

1. Most digital devices that are not made/developed by the EMR vendor (like
Philips or GE) will not interface cleanly

2. Most of the digital devices are islands unto themselves related to both hardware
and software

3. Many of the devices that you are probably talking about generate meaningful
data, but are so old in terms of technology and software, that getting the
data would be very painful

4. The last item is that these devices generate so much data and reports, most
of which are not what the doctor wants to see that the doctor will not use
them because it takes to long to get to the small amounts of information that
they do want.

I think it’s great to expand the discussion of patient portals to include integration with the data to a device. The other integration that we’ll have to consider is integration between a patient portal and a health information exchange. Yes, I know that’s farther down the road, but visions of the cloud are so much more exciting than carrying a device around with your information.

I think the last point is the one that resonates the most with me. We’re on the precipice where physicians are going to be inundated with data. In some ways we’re already there. We need smart systems that can transform that data into something useful for the doctor. We need technology to filter through the mass of data to get the “small amounts of information” that the physician does want. I think that’s a major part of the challenge of the next five years.

Multiple Patient Portal Logins

Posted on June 29, 2012 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.

A long time reader, first time e-mailer recently emailed me some really interesting questions and comments about meaningful use. One thing that they pointed out in that email is the issue of multiple patient portal logins. It was a good point that I think is worth discussing.

When you look at the market for patient portals, you quickly realize that at least in the current environment we’re not going to get close to having one patient portal for all the doctors. Think about an elderly patient that goes to 5 different doctors. This would likely mean that this one patient will have 5 different patient portal logins. That’s a lot of logins just to manage your healthcare. Not to mention, you have to learn 5 different portals. Some you can schedule an appointment online. Some you can pay online. Others you can get refills. Others you can’t. Yep, it’s going to get really confusing really fast.

I’m sure many reading this are thinking, we’re already juggling multiple logins in our life so why does it matter if we have a few more. While annoying, I actually agree with this statement for the younger generation. I probably have a few hundred logins that I use regularly (I’m probably at the high end) and I’m able to manage without too much trouble. In fact, lately I’ve learned how to reset my password quickly on those that I’ve forgotten and/or don’t use regularly. It’s rarely been an issue for me.

However, remember that many of those that are patients aren’t part of this younger, tech savvy generation. I think about my mom and the fear she has of trying something new on the computer. If she’s never done it before, she’s literally afraid to screw something up. As much as we try to convince her otherwise, you can sense the fear and trepidation she has when she’s never used a website before. I should also add, that my mother isn’t even that old. I think you can see the challenge that these patient portals are going to face with the not so tech savvy patient population (which is the majority of the patient population).

I think most of us agree that the meaningful use stage 2 measure that requires patients to interact with the patient portal is going to be taken out or modified. Everyone I’ve talked to agrees that it would be a huge mistake for ONC to hinge meaningful use dollars on something the physician doesn’t control: patient actions. I expect and hope that it will be modified appropriately.

With that said, I still think there will be a push by ONC towards patient portals. The idea of one login per doctor has me a little concerned. I wonder if more patient portals shouldn’t start more fully embracing Facebook logins or other unified logins like OpenID for their portals. Although, I’m sure many of the patients don’t have Facebook logins either so that won’t solve all the problems.

Am I overstating the challenge? Is there a solution out there? Am I wrong about their being so many portals that patients will have to log into? I’d love to hear your thoughts.