David Harlow at HealthBlawg talks turkey about Gruber and other things health policy related in his fine hosting of this week’s Health Wonk Review.
Roadmap to replace MU? MY, MY!
By Peggy Salvatore
Last week, the eHealth Initiative officially launched its 2020 Roadmap initiative to “enable coordinated efforts by public and private sector organizations to transform care delivery through data exchange and health information technology,” its website states.
Its foci: interoperability, clinical motivators and incentives and data access and use. Sound familiar?
The forces behind it are formidable. It includes players like Booz Allen Hamilton, Siemens, Accenture and United Healthcare, PriceWaterhouseCoopers and the Mayo Clinic. And its stated purpose:
“Since the passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act and the Affordable Care Act (ACA), a tremendous amount of money, time and resources has been invested into optimizing the healthcare system in the U.S. However, many stakeholder groups are questioning the direction in which the public and private sectors are currently heading and raising concerns about the slow pace of improving the quality of care and achieving reductions. As we look ahead to the next five years, it is critical to reexamine the recent polity, innovation and technology efforts and identify the best path forward toward health system delivery transformation.”
Dismantling of Meaningful Use
The introduction of the Roadmap coincides with the apparent, but not declared, dismantling of the Meaningful Use efforts of the Office of the National Coordinator of Health IT. What the eHealth Inititaive people seem to be saying in fairly bold and obvious language, is that what the government under the auspices of HHS been doing to coordinate and encourage the uptake and implementation of a national electronic patient record system has not been working. The system is still fragmented, and it cost us a fortune to go down a thousand different roads at varying rates of speed, not all headed toward the goal.
My read on the Roadmap initiative is that it is an attempt by powerful and frustrated forces to reassess what has been put in place, find a common language and path to move forward, untangle the harried, put the emerged leaders at the head of the pack, and carry on.
ONCHIT has already declared that it is putting together a 10-year plan, and it appears to coordinate with the Roadmap. I’m not a betting woman, but I’ll wager that the eHealth Initiative will be a major player in refocusing the national efforts toward putting in place a workable, affordable plan that allows all the players to achieve mastery of the technology in a way that is meaningful to patients and the people who care for them.
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The Best Laid Plans…Laid Waste? ONC and CCHIT and the future of health IT
Reading the Tea Leaves
With some fanfare, in 2004, President George W. Bush (Bush, the younger) made the national rollout of health information technology a federal government priority when he established the Office of the National Coordinator of Health IT. Dr. David Brailer was tapped to be our first “health IT czar” at ONC. He had a stellar resume and did a commensurate job. He went on to lead a private equity fund that invests in health technology.
When Dr. David Blumenthal, a Harvard Med School prof, took over the post of Coordinator in 2011, he implemented the Meaningful Use plan. It was well-thought-out, stepwise. It had carrots and sticks, and a timeline for implementation. Given the state of electronic patient records in all 50 states, more than 5,500 hospitals and hundreds of thousands of individual practices at mostly the paper-and-file-folder stage of recordkeeping in 2004, it was a gargantuan undertaking. Dr. Blumenthal also was a serious intellectual powerhouse, which is redundant with Harvard Med School prof.
Dr. Blumenthal’s successor, the bow-tied Dr. Farzad Mostashari who stepped down last fall to lead his own company focused on the future of healthcare, was instrumental in the creation of the Certification Commission for Healthcare Information Technology (CCHIT), a certification and accreditation body. That was a huge step forward, as it required anybody building patient record software in their mom’s basement to make sure it could play nicely with all the other software and perform as advertised.
On some level, Meaningful Use has achieved some meaningful change. First, the carrots and sticks worked and people sat up and paid attention. Providers bought electronic patient record systems, some out of fear or greed, but they bought them. (Hey, fear and greed are powerful motivators!) They tried to use them, some successfully, some very successfully, and some not so much. But certainly, the Meaningful Use initiative moved the needle. Where we had about 9% of doctors using electronic prescribing at the start of this effort, I saw a statistic last week that puts it over 50%.
Dr. Karen DeSalvo was called into service as our latest “health IT czar” in January 2014. Dr. DeSalvo is yet another powerhouse in her own right, who was down in the streets putting New Orleans’ healthcare system back together after Hurricane Katrina. That will get you known around town as somebody who gets things done. So Obama tapped her to take over ONC when Dr. Mostashari resigned to lead his own company focused on the future of healthcare.
Which leads us to Dr. DeSalvo’s current task. ONC is a big job; the czar appellation makes it clear that it is important. When the Ebola panic struck, the Secretary of HHS Sylvia Burwell “snagged Karen DeSalvo to help in the Ebola fight,” according to an article titled DeSalvo to Juggle ONC, Ebola Work by Tom Sullivan in Healthcare IT news on October 28. The article went on to say:
Dr. DeSalvo will serve as Acting Assistant Secretary of health ‘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.‘ (Sullivan quotes HealthITBuzz here)
Moving such a git ‘er done woman to this other post might lead some people to conclude either:
A. The country’s health system emphasis has shifted from electronic patient records to fighting Ebola
B. The Dallas hospital where Patient Zero Duncan died originally blamed the electronic patient record system for the failure to treat Duncan promptly so someone decided we need a “health IT czar” to lead the Ebola fight
OR
C. It is clear the future of health IT is headed in a different direction than ONC, so it’s time to quietly dismantle an outdated idea.
My tea leaves are soaked in sweat as I carefully cast my vote with Option C. Another little news item last week tipped the scales for me.
In the wake of moving Dr. DeSalvo directly under Burwell as Acting Assistant Secretary of Health, that accrediting body CCHIT that Dr. Mostashari initiated during tenure as “health IT czar” was dismantled the next day. They were told to go home, we don’t need you anymore.
An article in HealthData Management on October 28 titled CCHIT Announces It Will End Operations by November 14 by Greg Slabodkin contained this statement from CCHIT’s executive director:
[The] slowing of the pace of the ONC 2014 Edition certification and the unreliable timing of future federal health IT program requirements made program and business planning for new services uncertain.
Maybe those former czars who’ve gone on to fund the future of healthcare sent back a memo saying the techies in the trenches got this covered. They are way ahead of you out here in the field.
Now I’ll dry out my tea leaves to be reconstituted another day.
Peggy Salvatore writes on healthcare and business issues as Health Business Communications. She has recently published an Amazon ebook Working with SMEs: An Instructional Designers Guide to Gathering and Organizing Content from Subject Matter Experts.
Health Wonk Review: The Falling Leaves Edition
Falling Leaves Edition
Thank you to Louise Norris of Colorado Health Insurance Insider for hosting this beautiful fall collection of wonkiness.
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Ebola and The Chicken Little Syndrome
Ebola is real. No doubt about it. So was 9-11. And so was the anthrax attack. In each case, a real event set off a national wave of panic.
After 9-11, the U.S. was locked down, citizens worried about another airplane attack on our vital infrastructure. The World Trade Center tragedy begat the anthrax scare. Who can forget that one? A few public officials got some white powder in the mail and all mail was held for anthrax screening after that. I lost a copyright application to the Library of Congress due to the mail being opened and destroyed in Washington D.C. My mother wore latex gloves to get her mail for weeks. No, really.
I’m not suggesting the Ebola threat isn’t real or isn’t serious. I am questioning our reaction to it. Some reactions are valid, helpful and reasonable. Some reactions are political, hysterical and accusatory.
I’m all for the first. I am suggesting the second are counter-productive especially in an emergency.
Dontcha just hate it when I get all analytical and stuff?
Valid, helpful and reasonable
What is a valid, helpful and reasonable response to Ebola?
I’m not an infectious disease specialist. Can’t you tell? But here are some responses that seem pretty reasonable.
HHS held a conference call today to help healthcare facilities craft a response. A one-hour webinar hosted by the HHS Assistant Secretary for Preparedness and Response including people from the CDC, DHS and HHS Intergovernmental and External Affairs are also on the call. You can get an audio and transcript by going to www.phe.gov/Preparedness/responders/ebola.
Also, Modern Healthcare sponsored an Ebola Preparedness Session streamed live and organized by the Greater New York Hospital Association, the Service Employees International Union and the Partnership for Quality Care. It was a three and a half hour telethon. I listened to some of it, and it lays out some very common sense approaches including good gowning procedures.
Also, in the non-hysterical, analytical corner is Ron Shinkman of FierceHealthFinance. His column puts Ebola in the context of other deadly things that are going around, like the flu and other medical errors. Here’s an excerpt:
Were there serious medical errors that occurred at Texas Health Presbyterian involving patients other than Duncan during his treatment? Almost certainly. And if they didn’t occur at Texas Health Presbyterian, they occurred at other U.S. hospitals at exactly the same time the Ebola story has been unfolding. Surgical patients were discharged with a sponge or an instrument in their body that may not be detected for months, if at all. Patients died because they received the wrong dosage of medication, or because they acquired an infection when a staffer forgot to wash their hands.
The difference has been in the response: Little light is shed on these errors, even though they routinely kill 100 patients or more a day nationwide and cost the healthcare system billions of dollars annually. Meanwhile, the two Texas Health Presbyterian nurses are receiving such attentive care that despite Ebola’s high mortality rate they have as good a chance as anyone of making a full recovery.
This would have been an opportune time to focus the spotlight on serious medical errors in U.S. hospitals. The media has blown it.
Thanks, Ron.
Political, Hysterical and Accusatory
As for political reactions, an Ebola czar? Really? An Ebola czar who is a lawyer from Joe Biden’s and Al Gore’s staffs? My first reaction was wondering whether the White House thinks it has a health emergency or a political opportunity to leverage a tragedy. Like I said, just wondering. My second reaction is wondering how many czars we have now. Like I said, again, just wondering.
Hysterical and accusatory reactions are running rampant. Because I am usually focused on electronic patient records, I’ll restrict my comments to that.
We all know that hospitals and doctors are in the middle of trying to implement electronic records systems as a requirement of getting government funding – or losing government funding if they fail to get it right in the next few years. They are already having to cope with the fact that the systems don’t meet interoperability standards and that just about nobody can meet Meaningful Use requirements, and those that meet MU only have to reach something like 5% patient uptake.
Providers already have their hands full trying to meet MU, and now they have to implement some special electronic patient record protocol to make sure they capture Ebola, specifically. This is where we get very myopic at a cost of time and money that will never be recovered.
Dr. David Blumenthal, from the Office of the National Coordinator for Health IT twice removed, wrote an excellent article putting this in perspective in his blog with Commonwealth Fund. You can catch it at http://www.commonwealthfund.org/publications/blog/2014/oct/ehrs-the-new-lightening-rod-in-health-care
Electronic patient records, done well, will have enough specific fields built in to capture travel histories, infectious disease alerts, and other relevant data that Ebola and son-of-Ebola and all other threats will be captured and made available to the providers who need that information.
Until then, the government is just chasing squirrels in a reactive, political, hysterical and accusatory fashion. Which get us…exactly…nowhere. In a very expensive vehicle.
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This Week’s Health Wonk Review http://www.joepaduda.com/2014/10/the-election-coming/
Special thanks to Joe Paduda for hosting this week’s wonkery.
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Ebola: Patient Notes on Travel History
by Peggy Salvatore
The story about Ebola has been dominating the news, and I didn’t feel any particular need to weigh in on it since there is plenty of information out there. Then a few little bits of information hit my inbox and I feel compelled to discuss the seriousness of it because the electronic patient record system has been implicated.
According to a story in HealthLeaders Media on the morning of October 3 by Cheryl Clark (who writes accurately and prolifically for HealthLeaders), Patient Duncan’s travel itinerary was tucked into a note in the nurse’s record which was not connected to the physician’s workflow. The way the unnamed electronic patient record software is set up, different caregivers can enter notes that are not cross-posted to other caregivers.
You can read the full article at: http://www.healthleadersmedia.com/page-3/TEC-309001/Hospital-EHR-Flaw-Obscured-Ebola-Patients-Travel-Note
If we stop and digest this for even half a New York minute, the flaw in this design is obvious and egregious.
That night, this tidbit hit my email alert by Joseph Goedert (also an accurate and prolific reporter) 10:25 p.m. October 3 in HealthData Management, “Friday evening, the hospital issued another statement:
“We would like to clarify a point made in the statement released earlier in the week. As a standard part of the nursing process, the patient’s travel history was documented and available to the full care team in the electronic patient record (EHR), including within the physician’s workflow.
“There was no flaw in the EHR in the way the physician and nursing portions interacted related to this event. [end of statement]
“Emails to two Texas Health Resources spokespersons late Friday asking what changed so that the hospital now believes there was no fault in the workflow of the EHR, or if the attending physician simply missed the travel history, were not quickly answered.”
Huh?
You might imagine for a minute the panic at the up-until-then unnamed software vendor. Since then, I have seen the name, and I choose not to mention it here. But there are only a few biggies in hospital systems today, and it is one of them.
The truth is important. It really is.
Where You’ve Been Matters
At first, I was moved to put keyboard to screen when I read this story because I had an experience before the proliferation of electronic patient records that further supports the fact that our travel is a critical piece of information when we present with symptoms. About 20 years ago, I began to have serious gastrointestinal problems. I couldn’t keep anything inside me – solid or liquid. When it was clear that no matter how much I put into my body, I was losing it all immediately and starting to slip away, my primary doc sent me to a gastrointestinal doc. The gastro guy asked me a few questions and within 10 minutes knew exactly what I had and where I got it: after hearing the symptoms, he asked specific questions about my vacation the previous summer. He knew the lake, he knew the bug. He prescribed a heavy duty antibiotic and within 10 days I was recovered. He probably saved my life.
Doctors are human, too. They don’t all know everything; they can’t. That’s why we have specialists. And that is why all the information in an electronic patient record needs to be accessible to every provider who touches the patient. You never know what little gems in there may really be the golden key in the hands of the right physician.
A thorough history shared with providers all along the caregiving continuum is not a luxury. It is essential to providing efficient and effective care, as quickly as possible, at all points along the healthcare spectrum. And travel histories, especially when a patient presents with a mysterious illness, is critical information. Travel histories are critical information today, especially with the proliferation of bizarre viruses and flu epidemics popping up all over the country and the globe. Where you’ve been matters.
That is the beauty of the potential of electronic patient records. The case of Patient Duncan in Dallas highlights the importance of designing the record systems so we can extract the value they could provide when done right.
Points to ponder:
1. Electronic patient records need to be comprehensive and include travel histories, especially when the patient presents with a mysterious disease.
2. All providers need access to all patient information across all sites of care.
3. As to the disparate reports, it is worth repeating that the truth matters or the record is pointless.
Billy Wynne has posted the “Thank God It’s Recess” edition of Health Wonk Review at Healthcare Lighthouse
Here’s the link to this week’s Health Wonk Review post from Billy Wynne’s Healthcare Lighthouse:
http://www.healthcarelighthouse.com/blog/health-wonk-review-t-g-i-r-edition/
Enjoy!
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Apple Hints At Putting The “Meaningful” Into Meaningful Use
What’s so “meaningful” about Meaningful Use anyway?
The short answer is, “Today, very little. Tomorrow, everything.”
And that is the problem with the meaningful use requirements as they exist.
By its very definition, patient data is information that should have meaning. To be useful, information needs to be in context for the patient and the physicians caring for the patient. It needs to be complete, address the issues relevant to the patient at hand, and be available at the point of care no matter where that might be.
The goal of the meaningful use guidelines as constructed by the Office of the National Coordinator of Health IT under Dr. David Blumenthal addressed these issues in a very well-thought-out way. When Dr. Blumenthal unveiled MU guidelines and deadlines to the University of Pennsylvania medical and health policy community, I was fortunate enough to be in attendance. It made, and to this day makes, sense.
The U.S. operates in a complicated, multi-tiered clinical environment (read: uncoordinated and fragmented). To suggest otherwise, or to create rational pathways that imply point-A-to-point-B symmetries, ignores the realities. Not that the theoreticians do not know this. It’s just that if somebody suggests we better come up with a plan, somebody else is going to respond with a plan.
It may be a very rational plan that makes a lot of sense. In a perfectly rational world.
Crystal-Clear Crystal Ball
The very best minds, by definition, understand the complexities far better than I do. To this day, I believe that the need to come up with a good plan, any plan, soon, to accelerate uptake and interoperability of electronic patient records drove the Meaningful Use guidelines and deadlines the industry is dancing to today. And, I reiterate, it was a good plan. I reviewed the detail of the original proposal the other day. If you want a copy, email me (peggysalvatore@healthsystemed.com) and I’ll send it to you.
Even the best minds, with crystal-clear crystal balls, will miscalculate trends – even by a smidgen. The costs are always more than expected; the technical glitches are greater than anticipated; the human factors can never be completely predicted; and the trajectory of technology is usually surprising. We know what happens to a trajectory when it deviates just a smidgen from its expected path somewhere past the point of origin.
Organizations have spent many dollars doing much implementation, often putting into place systems that are already in need of replacement even before the MU guidelines could be met.
The guidelines themselves will certainly be met over time. It’s just that the human factors will change the pace of uptake because younger workers are sympatico and even ahead of where the applications are. Tech is in their DNA. Most notably, with the excitement last week around Apple’s announcement of the iPhone6 and the company’s healthcare strategy, the effect of mobile health on personal responsibility and patient involvement will gallop ahead of the central control model assumed by large implementations of gargantuan software applications within the tentacles of burgeoning healthcare systems.
The Health Information Management Systems Society (HIMSS) is thinking along these lines as it goes to Congress asking it for a change in direction.
In the best of all worlds, the healthcare system will be running to catch up to patients’ demands for interoperability in a few years. And you know how the market responds to consumer demand.
