Health System Ed

I would like to welcome Health System Ed’s first guest blogger for the occasion of HIMSS15. John Lynn of Healthcare Scene and EMR & HIPAA has been blogging on health IT for 10 years and is a regular at the annual HIMSS conference. He provided daily insight from the conference at his website. He has the gift of both the history and the long view of electronic patient records. Thank you, John, for sharing your HIMSS15 wrapup post with us.

As I fly home from HIMSS15 (literally), I’ve been thinking how to summarize my annual visit to the mecca of healthcare IT conferences we know as HIMSS. I’ve seen a bunch of numbers around attendance and exhibitors and I believe they’re somewhere around 43,000 attendees and 1300 exhibitors. It definitely felt that massive. The interest in using technology to improve healthcare has never been higher. This shouldn’t be a surprise for anyone. When I look at the path forward for healthcare, every single scenario has technology playing a massive role.

With that in mind, I think that the healthcare IT world is experiencing a massive war between a large number of competing interests. Many of those interests are deeply entrenched in what they’ve been doing for seemingly ever. Some of these companies are really trying to dig in and continue to enjoy the high ground that they’ve enjoyed for many years. This includes vendors at HIMSS, but also many large and small healthcare organizations (the small entrenched healthcare organizations weren’t likely at HIMSS though) who enjoyed the status quo.

The problem with this battlefield is that they’re battling against a massive shift in reimbursement model. They can try and stay entrenched, but the shift in healthcare business model is going to absolutely force them to change. This is not a question of if, but when. This doesn’t keep these organizations from bombing away as they resist the changes.

If you’re a healthcare startup company entering the battlefield (to continue the analogy), you’re out in the open and absolutely vulnerable. You’re very rarely the target of this major entrenched players, but sometimes you get impacted by collateral damage. As the various organizations throw bombs at each other you have to work hard to avoid getting in their way. This is a tricky challenge.

Even more challenging to these startup companies is they don’t have a way to access many of the entrenched companies so they can work together around a common vision. Most of the startups would love to work with the entrenched healthcare companies, but they don’t even have a way to start the conversation.

The mid size healthcare IT companies are even more interesting. They’ve started to carve a space for them in the battle and many of the entrenched healthcare IT vendors are scared at what this means for them. They’re using every means possible to disrupt the competition. At HIMSS I saw the scars from many of these battles.

Certainly this description is true of many industries. Welcome to economic competition and capitalism. Although, this year at HIMSS I found the battle to be much more intense. In the past couple years meaningful use opened up new territories to be “conquered.” There was enough “land” to go around that companies were often working to capture new territories as opposed to battling their competitors for the same opportunities. That’s why I think we’re in a very different market today versus the past couple years.

The great thing is that in periods of turmoil often comes the most amazing innovations. I believe that’s what we’re going to see over the next couple years. Although, I predict that most of these innovations are going to come from places we don’t expect. It’s just too hard for companies to innovate themselves out of business. There are a few exceptions in history and we might see a few exceptions in healthcare. However, my bet is on the most successful companies being those that choose to obliterate as opposed to automate.

What’s most exciting to me is that healthcare organizations and patients seem to be ready for change. There are varying degrees of readiness, but I believe I’ve seen a groundswell of change that’s coming for healthcare. As a blogger this of course has me excited, but as a patient it has me excited as well.

What were your thoughts of HIMSS 2015? What do you think of the analogy?

While the battle is on in healthcare IT, the best part of HIMSS is always the people. Every industry has some bad apples, but for the most part I’m always deeply impacted by the good nature of so many people I meet at HIMSS. They are sincere in their efforts to try and improve healthcare for good. We certainly have our challenges in healthcare, but similar to what George Bush said in his keynote, I’m optimistic that the good people in healthcare will be able to produce amazing results. The best days of healthcare are not behind us, but are ahead of us.

By Peggy Salvatore

Two items caught my attention last week that underlined the importance of thinking more expansively and inclusively about health IT as we thunder ahead with Meaningful Use 3 requirements and HHS’s health IT Roadmap.

Over the past few months, the onrush of incredible health technology appears to be overwhelming and outpacing the original national blueprints for the uptake and implementation of electronic health records as designed by Health and Human Services. HHS’s more flexible approach to next stages recognizes that reality. But as a system with entrenched interests, HHS’s challenge is to move that approach along a continuum toward embracing the rapid onset of tomorrow’s needs.

So, about those two items that underline the importance of widening our lens as we create our vision and plans for the future of the health IT infrastructure.

FDA’s Hamburg Points To Global Regulation

First, in her retirement speech to the National Press Club last week, FDA Commissioner Margaret Hamburg emphasized the importance of emerging global standards for drugs and devices under the newly organized International Coalitions of Medicines Regulatory Authorities (ICMRA), a sort of umbrella agency to harmonize standards among the FDA and its companion organizations around the world.

Hamburg said, “Globalization has multiplied the scale of our responsibility and heightened the need for us to work together to ensure safety, efficacy of the medical products that we oversee, and to promote the needed research in innovation in medical science.”

As a global agency that oversees tracking of approved drugs and devices, the ICMRA will look to individual countries and regions to participate using internationally interoperable standards.

IOM Report Looks to Globalize Clinical Trial Data Standards

Hamburg’s speech comes on the heels of a report released in January from the Institute of Medicine, Sharing Clinical Trial Data: Maximizing Benefits, Minimizing Risks, that discusses a pathway for sharing clinical trial data globally including overcoming privacy concerns, creating equitable funding mechanisms and protecting intellectual property.

If you’ve got a few hours, a great interest in this topic and an insatiable appetite for detail, you can download a free pdf of the report here.

The preface to the IOM report acknowledges that the landscape of electronic health records and the input of personal monitoring devices is changing the nature of data collection and so it makes its recommendations tentatively considering these uncertainties. The report states specifically that the future shape of clinical trial data cannot rely on familiar structures.

In a presentation last week, Deven McGraw a partner in Manatt, Phelps and Philip’s Healthcare Practice and one of the committee members who drafted the report, said in an online seminar sponsored by Manatt that the presumptions underlying the report included steps to protect patients’ data, that the data would be used for the benefit of patients, and that the data would be shared equitably among participants. The details about database funding, data sharing and privacy are beyond the scope of this brief blog, but for the discussion here the most important detail is the recommendation that the a global multi-stakeholder body be convened for the purpose of addressing the key infrastructure and technological challenges that sharing of clinical data will require.

Clearly, the promise of a fully realized health information infrastructure is that data can be shared for research (which treatments work best in whom, when and why) which can then applied at the point of care for the benefit of the individual (decision support), all done while protecting private patient information.

Pivot, Flex, Refocus

Margaret Hamburg’s parting words and the IOM’s report on sharing clinical trial data both point to taking a wide and long view as we forge forward in crafting national requirements for standards and interoperability by realizing we are leading into a global community.

If you consider these items in context of the HIMSS report  that only 3.6% of hospitals in the U.S. meet its highest level (Stage 7) of interoperability and usability as of Q42014, the good news is that we have not run too far or too fast in one direction as the situation is still unfolding. Our tentative start allows for flexibility and pivots that may not have been immediately obvious when Meaningful Use was first conceived.

Pivot. Flex. Refocus. Remain open to a rapidly changing reality.

By Peggy Salvatore

The U.S. Senate Health, Education, Labor and Pensions Committee’s hearing last week on the electronic health records trained its sights on interoperability of EHR systems, or lack thereof. And the Senate, like much of the rest of the medical world, wondered out loud whether we’re getting our money’s worth .

If you are wondering the same thing, this is a great time to speak up. After all, the government has plowed billions of dollars into implementing electronic patient record systems over the last five years that still don’t capture all relevant patient information or even talk to each other.

HHS put out a Notice of Proposed Rule Making (NPRM) for Meaningful Use Stage 3 on March 20. Anyone with an interest in the issue can submit comments to HHS. Your comments are considered before the final rules are written. This is an opportunity for patient and provider advocates to pull together a team and submit a detailed comment. Responding to proposed Federal Regulations can be tedious, but I recommend it as an exercise for interested parties. The comment deadline is May 29 at 5 p.m.

If you want to start right now, here is the link to all 301 pages.

Why Patients and Providers Need to Respond

Large stakeholders like software vendor Epic and hospital systems like Kaiser will submit detailed comments. Their voices will be heard and their interests protected. The regulations will be written to preserve the status quo.

Patients and providers who are affected daily by these decisions need to be represented as strongly. After all, what good is it to a patient retiree whose main residence is in DesMoines if the hospital where they vacation in Florida can’t see their records? Imagine if that same person put their money in a bank in DesMoines and couldn’t retrieve it at an ATM in Fort Lauderdale.  The bank that couldn’t play nicely with the other banks wouldn’t be in business too long. Customers wouldn’t stand for it.

At some point, all the Senate hearings, Interoperability Roadmaps and Meaningful Use penalties don’t amount to a hill of beans if the electronic patient record system doesn’t catalog all the patients critical data, make it available at any possible point of use and keep it secure enough that patients feel free to hold all their personal, confidential health information online.

Having watched this debate since 1998, it baffles me that the same issues, debates and problems keep circling around this system, only the names change.  The same huge gaps remain in the system, interoperability seems to be a pipe dream and the security of patient data is the smoke wafting from the pipe. Meanwhile, I can download an app on my phone that takes a picture of my rash and sends it in a HIPAA-compliant fashion to my electronic record. My phone couldn’t even take a picture in 1998. The market for using technology to advance human health is surging ahead leaving the feds in the dust.

Remind Me, What is the Goal?

The promise is universal access to full patient data to better serve the patient and reduce the cost treatment due to pricey duplication and error. The reality is a tug of war among competing interests including proprietary software and government control. The most important interest groups in this discussion, the patients themselves and the providers who care for them,  have squeaky little voices.

Admittedly, Meaningful Use can be a somewhat arcane discussion as much of it revolves around software and hardware standards that facilitate interoperability and ensure data security.  Even if discussions around electronic patient data make your eyes glaze over, the substance of what is at stake is as sexy as the latest season of Grey’s Anatomy.

The motivation for getting patient data online is strongest when the interest groups with the most to gain or lose are the focus of the effort. Those groups are patients whose health is at stake and the individual providers who care for them.

As long as the loudest interest groups at the table are big software companies whose stock hangs in the balance and government entities that can make revenue by taxing and penalizing large health systems, the real motive for getting to goal is too far removed from the vision to ever achieve success.

Here  are some early stakeholder reactions to the Meaningful Use rules.

By Peggy Salvatore

My grandmother was born in 1896. The ice man delivered big blocks of ice through a little ice door in the kitchen where my great-grandfather moved the ice into the family icebox. My great-grandmother, fresh from birthing my grandmother upstairs in a quiet room attended by the family physician and a neighbor, heard the clopping of horse hooves pull away from her back door as the ice man dragged his freight to the next home while she held her infant daughter.

My grandmother was the first born of 13; she was the last of the 13 to die in 2002 surrounded by electronic, beeping equipment confirming that her heart had stopped after 105 years of continuous beating. No matter what else ailed her throughout the years, old Doc Hahn who visited her in the big living room and sat next to her on the “couch” told her, “Mamie, you’ve got a strong heart.”

Her three remaining children, 7 grandchildren and 8 great-grandchildren arrived for her funeral in motorized transportation. After her funeral, we gathered at a restaurant where food was prepared in kitchens with large, walk-in refrigerators holding fresh fish caught days before in places as far away as Maine and Vancouver.

After that same baby was laid in her final resting place two centuries later, her grandchildren pulled out their cell phones to tell their employers they’d be back at their desks later that day.

Only 105 Years Later

My grandmother lived only 105 years. In that span, she went from gas lighted fixtures to the computer age. Never in the history of man had huge leaps in technology taken our species that far in so short a period of time. Read Alvin Toffler’s 1970 bestseller Future Shock to get a sense of the compression of history. Today, scientists tell us the first human who will live to be 500 years old is already born. When I view history through my grandmother’s eyes, it doesn’t seem impossible.

In fact, when I think about the pace of progress, it doesn’t seem that surreal. It’s almost a yawn.

What was sci-fi in the late 1960s is merely everyday life today.  So, why not a lifespan of 500 years?

What Does All This Have to Do with Health IT?

For my readers of Health System Ed blog, more importantly, why do I mention it here in the place where we talk about health information technology policy and related issues?

This blog began as a place where I could think out loud to explore the promise of health information technology as a way to make healthcare equal, accessible and affordable for all. I have believed since the mid-90s, and continue to believe, that technology is the great equalizer.

As I (re) start writing a book on the topic of health IT that has been growing mold in my computer, it is becoming increasingly clear that already we have partially arrived where I originally envisioned the future to be five years ago. The real story of health and technology is beyond that near horizon of universal, secure electronic patient records. Now, it reaches as far as the eye can see.

Increasingly, it is the interface of wearable and assistive technology with the electronic patient record systems where real vitality begins.

Disc brakes on a space shuttle

We still need to build and repair the technology that runs the system today. Electronic patient record systems still go down and leave health care practitioners working “blind”. It is still nearly impossible for your dentist to know anything about the rest of your physical health without personally asking you for your history, getting permission, and faxing your medical records across town. Your psychiatrist or psychologist who is treating you and possibly prescribing drugs faces the same limitation as your dentist.

From the perspective of what is possible with state of the art medicine circa 2015, the electronic patient record system seems almost barbaric. But our legal and regulatory systems, the limits of budgets and patient engagement and much, much more all figure into the system we are locked into today.

At the same time, we are beginning to build those large vessels – both literally and figuratively – fit for grand adventures that will take us to far horizons. Here, in my little corner of the world, I am expanding the definition of health information technology to include all the technology that informs leaps in human health and wellbeing.

To get anywhere meaningful, we need the full picture from a high level.  Spending time, money and resources on health-related technology requires that view expand to take in all the current advances that will impact what we think of today as the interface of man and machine. When we think of the interface of man and machine under the rubric of “health information technology,”  our imagination is  limited to the computer on the desk of your primary caregiver’s receptionist.

On one hand, it seems superfluous and even careless to think about the leaps in genetic medicine, as well as the potential of assistive and wearable technology, when most healthcare providers can’t meet Stage 2 Meaningful Use attestation requirements. But in reality, without considering the state of the art, we will spend money foolishly as the technology leaps out ahead of our plodding efforts at putting a laptop in the lap of every HCP.

I don’t pretend to have any answers. But it is becoming increasingly clear as we reflect on the way the health information infrastructure is being constructed, that we start asking some bigger questions so we stop throwing money at projects that can’t do what they are intended to do.

The danger in controlling and regulating the details of the implementation of health IT is that we end up planning for disc brakes on a space shuttle. Our society and its component businesses are financing an infrastructure that serves the needs of people who live to be 100 in a time when babies are born who will live to see 2515.