A Harmonious HIT Thanksgiving

Since I’m traveling to visit family over Thanksgiving, I’ll take this opportunity to wish everyone a great holiday week. There’s always time to comment on what could be better! But now’s a good time to reflect on things for which I’m thankful in the HIT industry and my professional career. I won’t lengthen this post with all the personal reasons I have to be thankful, but they are many.

1. I’ve worked in HIT for 34 years at one employer (SMS/Siemens Healthcare). Having a job at all is not to be taken for granted these days, and it’s much more than “a job” because I truly believe HIT, properly applied, can help people.
2. I’ve had so many opportunities to interact with great people from healthcare providers, other vendors, the federal government, states, payers, pharmacies, labs, consumer advocates, certifying bodies, standards developers, and more, who have greatly enriched my understanding and competence.
3. I live in a country where people are free to debate and disagree, but still work together, without fear of reprisal from the government. In fact, we have a government that wants to listen, as evidenced by ONC S&I Framework and public hearings and comment processes.
4. My family and I have received excellent healthcare from many professionals assisted by HIT, and our lives are better (or some are still alive at all) as a result.
5. My colleagues include many healthcare professionals, some of whom have given me high quality medical care, and who use the EHRs that we and other vendors develop, so they understand firsthand what works and what needs to be improved.
6. There are increasing opportunities for me to be engaged, as a patient, in HIT.
7. No one I know is satisfied with the status quo of HIT. We all want it to do more and better in terms of interoperability, usability, efficiency, and promotion of patient safety.
8. There’s much exciting work ahead, so life in HIT is anything but rote and boring!

Have a wonderful Thanksgiving, filled with harmony among those with whom you spend it.

"Six Months of Strategery?"

I read a story in Modern Healthcare about a discussion with HHS CTO Todd Park at a recent conference in Nashville. He talked about unleashing innovation. I applaud Todd for his bravery in giving out his email address publicly seeking input on innovations, and for his goal of “unlocking the mojo” of HHS staff, rather than having good ideas doomed by “six months of strategery.” I liked that!

There has been plenty of recent discussion, and guidance from NIST about improving EHR Usability (for patient safety, efficiency, and many other reasons). There has also been similar discussion in the HIT Standards Committee implementation workgroup about improving the usability of specifications and standards to remove barriers to adoption so the “little guy” isn’t left behind, and so that everyone doesn’t waste time navigating specs that point to other specs that point to other specs (called “the indirection problem”). Some recent standards efforts, such as the HL7 Consolidated CDA implementation guide, are trying to improve usability of specs in this way.

I plan to write Todd speaking as an individual citizen (remember this blog doesn’t speak for my company though my writing is influenced by working in the Health IT industry). Usability is important for both a positive and a negative reason. Lack of usability (of specs, or software, or anything) tends to waste people’s time and “raise their blood pressure” due to frustration. Wasted a few hours per person multiplied by thousands or millions of people, and you have some serious non-productivity! Worse, it can lead to mistakes (like clinical errors jeopardizing patients) or people throwing up their hands and just not doing things that are too complicated (like refusing to use an EHR). On the positive side, when something is usable, like I consider my search engine, Word processing, email, and blog editing software to be, then people can get amazingly more productive, and can do great things.

What about the usability of the specifications that hover over all of us in the EHR industry, Meaningful Use and Certification regulations? Or for that matter, all Federal regulations published in the Federal Register with its three columns and small print, no index and poor searchability? It’s so “1950’s” and paper-oriented. You can’t just scroll down the page like any normal document or web page, because you have to keep backing up for the next column. Try fitting a page on a screen and you can’t read the tiny font. You can’t search it to find a referenced section number, because the numbers are not a sensible scheme like 178.25.3.2.7, where you always know your context: instead section numbers aren’t even contiguous and searchable. For example, the ONC Standards and Certification Final Rule has text like “The standard specified in § 170.207(a)(2)”  OK, if I want to find that paragraph in the document, it’s easily done in the Acrobat search box, right? Nope, can’t be done! It only finds is the references to the paragraph, but not the paragraph itself. The only way to get to § 170.207(b)(2) is by scrolling around and finally locating 170.207 near the end, then finding subparagraph (b) dangling by itself, and finally finding subsubparagraph (2), hopefully still inside of (b) unless I missed a changed letter in between. And when I finally get there, I still can’t see what the standard is, because it says “the code set specified in 45 CFR 162.1002(a)(2)” which isn’t defined in the document. I have to go out to Google. Those like me who have been doing this for a while know some tricks and short cuts and contacts to ask, but a lot of people don’t have that luxury.

So my suggestion to Todd is very low-tech and has nothing to do with HIT, but a lot to do with usability, productivity, and helping folks actually do what the regulations want them to do! First of all, they need to be able to understand the regs in a reasonable amount of time. I’ve spent hundreds of hours reading regulations affecting HIT. I estimate that just their formatting and numbering alone causes me to spend 50-100% more time to digest them than it should. And I probably also miss important information in the process. Multiply that by thousands of others who have the same problem. While it helps that others have created “Readers Digest versions” to simplify and explain the regulations, but why did they have to create them in the first place?

Could this problem be solved by reformatting new regulations for usability, using a few smart people including human factors engineers, armed with common sense and putting themselves in the “consumer’s” shoes? Could this be done without “six months of strategery?” Hopefully yes, if Todd’s right and “mojo gets unlocked” in this area. I admit that I and probably most people and companies have similar entrenched traditions and rules that get in the way of us doing what we ought to do. I just blogged about this today because I read the interview with Todd and connected his ideas with my reading of the regulations. But the Federal Government’s regulations affect thousands of providers, vendors, and others. There’s a real opportunity for a simple low-tech innovation in the government regulation writing and formatting to help many people avoid wasting time, so they can direct more of their energies to creating innovative solutions that will really help people!

ONC Care TransITions Convocation – What Happened?

I blogged about the meeting that was to be held on October 14^th. Now that it has occurred, with approximately 160 persons attending in person and 300 via webcast, here are first impressions. Some slides from the meeting are posted, with the main conclusions on 13-17 and 24-26.  

KEY POINTS FROM THE MEETING

• ONC's purpose in convening this meeting. Farzad Mostashari (ONC) and Todd Park (HHS CTO) said ONC's role was to "unite the tribes" and "let others help” solve a major problem in today’s health care system.
• Transition between hospitals and post-hospital (PCP, Long-Term Care, Home) was the focus. The consensus was that the current state of affairs is unacceptable. Much of the time there is zero transfer of information from hospital to other providers, particularly public health clinics.
• Plan of Care. Based on findings from four parallel workgroups, there was much mindshare in support of a shared Plan of Care (PoC). "Shared" doesn’t mean just "exchanged" as in passed along from one provider to another. They meant a collaborative mutually-developed Plan of Care that has input from multiple providers (care team) as well as the patient and his caregivers. This comes with challenges of governance and access control, though I didn’t hear those issues discussed.
• Are transitions of care more like a "relay race" (hand off the baton linearly) or like a "football game" which is much more interactive all along the way? Some felt that the best we could expect was to improve the handoffs in a relay (vs. dropping the baton by not exchanging at all), whereas others wanted to move more toward a collaborative care model like a football team. Harmonious collaboration requires much clearer definition of roles and responsibilities across many organizations.
• Some said that the care plan should be approved by the patient, and co-developed, like two people redlining a contract together, rather than thrown over the wall.
• CDA Consolidation Standard. Doug Fridsma and Jitin Asnaani affirmed ONC's support for the new "single standard" CDA Consolidation. This builds upon but also simplifies the standards that many have worked hard to support, and is convergence rather than divergence. I favor this direction, though the standard is still being balloted, and it will take work to migrate to it.
• Dr. Holly Miller of MedAllies gave a good example of the clinical need for standards and information exchange which could not only help care transitions, but change the course of the patient's health. She used the example of repeat visits to the ER involving patient falls treated in isolation, vs. the alternative where the PCP is notified, detects a pattern and underlying cause, and intervenes to prevent future falling incidents.
• Jitin said that 10 HIT/HIE vendors (not named) have committed thus far to the ONC ToC pilots. He said one or two of them would test Consolidated CDA in conjunction with Direct Project. (My editorial comment: Consolidated CDA in its entirety (over 50 sections) is unlikely to be tested in the pilots, but a constrained subset that still needs to be clearly defined should be tested).
• Jitin also announced the coordination of the S&I Framework, Beacon Communities, EHR/HIE Interoperability Workgroup (the multi-state effort led by New York), and the State HIE Programs. The EHR/HIE workgroup is outside of ONC, but is cooperating with them.
• While the focus of much of the discussion was on needs rather than how to do it technically, there was a strong agreement on the need for tight, specific standards.
• Timeliness and Relevance of Information. The theme of "the right information, when I need it, where I need it" was emphasized often. Not just for providers but for patients. Dr. Scott Young of Kaiser Permanente said that typical Discharge Instructions are not given/explained at the right time and place (which should be where the patient spends most of their time, e.g., at home). Similarly, patient education is often deferred until the end of the hospitalization and are generic, whereas it can and should be started while the patient is in the hospital. Several said that PCP and other providers needed to be notified at the time of admission not just at discharge, because they need to be aware of the situation and given the opportunity to contribute to the care process.
• Taking Follow-Up Actions. Others said that Patients should not just be told to do things like make appointments: the hospital should actually make them (or help the patient make them) while the patient is still there. Similarly, don't just tell the patient to get prescriptions filled or buy medical equipment: send them home with them! The highest risk to a patient occurs within the 1st 72 hours after discharge, when the patient is most vulnerable physically but also is distracted by other things needing social support (childcare, finances, cleaning the house, taking care of the yard, etc.).
• Medication Reconciliation. One suggested that the reconciliation process should start with what the patient is actually taking, and then build from there, rather than other people's lists that the patient is asked to verify (because they will tend to say "yes" when asked "Are you taking ____X?" even if they really aren't taking it.
• Feedback loops were often emphasized. While not defined precisely, I gather that it means feedback to the care team and caregiver about how well the care plan is working, whether desired outcomes/goals are being achieved.
• Disintermediation. Dr. Bo-Linn, a physician who has practiced for 50 years, said that there must be "disintermediation" because the system can't afford to be so hierarchical and provider-dependent, but that patients must be able to do more for themselves to remove cost from the system. He pointed to examples like ATMs (no tellers), pumping and paying for gas. Making travel reservations is another example.
• Spread of existing technology rather than new technology. While new technology was encouraged, most felt that the technology exists to do nearly everything that was discussed, and that successes exist in pockets, but are exceptional and seldom replicated. So one of the challenges is disseminating successes and scaling out the solutions that already exist.
• Getting the Word Out. Health Affairs, one of the leading health policy journals, wants to chronicle innovation as its happening, and encourages submissions. ONC is now funding Health 2.0, an innovative group highly focused on patient engagement. It has sponsored an innovation competition, "Ensuring Safe Transitions from Hospital to Home" which ends on November 16th.

So it was a thought-provoking day that I’m glad I attended. While its intent was to stimulate urgency and innovation, rather than to define standards or regulations, I think it was a preview of priorities that HHS will be focusing on in the future. Speaking of Care Transitions, I’m at the ONC S&I Face-to-Face right now. I plan to blog about the S&I Framework projects that I’m involved in.

Would You Like to be Engaged to Multiple EHRs?

There’s strong agreement that for meaningful use of Healthcare IT, patients and families need to be “engaged.” The question is, how? In Stage One, patients are to be given an electronic or paper copy of clinical summary information from office visits and hospitalizations, as well as discharge instructions from hospitals. This is good and a step beyond mere paper. But that raises the question of how this information can be used by the patient, other than viewed as if it were paper. What’s the “Quicken” equivalent of a “killer app” for patients to manage their health? (Oops, maybe “killer” app is not so good for healthcare…). The Stage 2 Meaningful Use Request for Comment proposes that patients be able to view and download their information from a “web based portal” that is a module of an EHR (considering that the incentive program is about “certified EHR technology”).

The best tool for any given patient depends on the individual, so speaking in statistical terms may gloss over some things. But let’s suppose that all EHRs were to offer such a portal. How many of them would a patient need to access? For myself last year, that would have been five (four EP and one hospital). According to an article by Peter Bach of Memorial Sloan Kettering Cancer Center, the typical Medicare patient sees seven doctors in four practices in one year, and those with multiple chronic conditions saw 11 docs in seven practices in one year. If you then throw in a hospital, that means eight healthcare organizations possibly with eight EHRs for one patient in a year. If you’re a family member caring for your children or aging relatives, multiply all that. You might have to interact with more than 20 web portal accounts, ending up with over 40 separate downloaded files (you’d probably need more than one per organization per year). Even if they’re in a standardized format, who or what will reconcile or pull them together? Will you be the one, using copy & paste with a spreadsheet or word processor? I don’t think so… If you use a web-based tool specifically designed to deal with those files, well then you’re probably using a Personal Health Record (PHR).

The problem with the current MU proposal for downloading from individual EHRs is that it implicitly endorses a “tethered PHR” model – a PHR extension of an EHR. But that PHR is not really patient-centric, because it contains the patient’s data from the organization using the EHR. Over time, the data will broaden as EHRs import and reconcile data from other sources such as EHRs or Healthcare Information Exchanges, but most EHRs aren’t there yet. And “tethered” is only one of several approaches to patient-centric health records. Other flavors include independent personally-controlled PHRs such as Microsoft’s and Google’s; health record banks; payer-based PHRs such as Blue Cross; employer-based PHRs such as Walmart’s using Dossia. They all have their strengths and weaknesses, but the personally controlled PHR has recently made some significant headway, associated in part with the Direct Project announcement re Dr. Paolo Andre’s EHR and Beth Israel’s Direct Push to Healthvault. If independent PHRs can be updated through a standard transport protocol (Direct secure SMTP), that securely pushes standardized content (e.g., CCD or CCR) into the PHR in a way that is structured and codified, as already required in Stage 1 MU, then the potential for a comprehensive, patient-centered record (not tied to any one provider) has increased. Now this isn’t magic – the patient or family member still needs to decide which data from the CCD are relevant and should be added to their master problem list, medication list, etc., as I’ve done with my own PHR. An ecosystem of innovative products (trackers, monitors) can then flourish around the PHR, given the influx of more robust data to operate on.

In preparing comments to the HIT Policy Committee’s Meaningful Use workgroup, I’ve recommended that MU should focus on the goal: getting the information to the patient or caregiver’s hands in a way that they can use, not on inadvertently favoring an EHR-centric “tethered PHR” flavor. Let the EHRs do the behind the scenes work of transmitting the patient’s info into PHRs of the patient’s choice (which might be any of the flavors I mentioned), enabling patients to interact productively with a tool they like, rather than making them “polygamously engaged” to multiple EHRs/portals and encumbered with lots of files to manually import into PHRs. For patients who don’t want to use a PHR, they can still get their electronic copies (as in MU Stage 1). But for those who want the opportunity to have their electronic information together in one place, there’s a great opportunity for MU, defined in a way that allows flexibility and innovation, to leverage the Direct Project and the existing and emerging clinical content standards like harmonized (I like that word) CDA Consolidation Project templates building upon CCD/C32.  

So, patient and family engagement: yes! Let this relationship between patients and HIT be productive, patient-centered, simple-to-use and... engaging, please!

“Quickening” the Flow of Health Information – Part Two

Sometimes you just have to be quick. And I wasn’t, so Part Two is later than I planned. Here are some more analogies between Quicken (which I use for my “Electronic Financial Record”) and an Electronic Health Record inasmuch as both require information exchange. Of course, “money” and a relatively small data set are exchanged in financial transactions, rather than the vast array of health information. So with that caveat, here I go.

• Making payments is analogous to Direct Project “push” messages. I enter payments that are pushed to payees in a format that they can accept (some electronic, some paper checks). I can enter these payees’ addresses or have Quicken look some up in a directory. My interaction is simple, but Quicken and the financial network (like a healthcare HISP) securely route the transaction behind the scenes.
• Quicken updates my register pulling relevant data from my bank. To me, the bank is analogous to a Healthcare Information Exchange in that it received and aggregated transactions from many payees, so I don’t have to connect to all the payees. I can download from the bank as needed. Of course, the bank has security and privacy protections for my data, similar to how health data must be protected.
• Balancing my register, which occurs automatically, is comparable to data reconciliation in an EHR (though it is much much simpler for money than for health data!)
• I can set up automatic actions such as reminders and payments, which is analogous to workflow automation features in healthcare, where events (like signing a letter or discharging a patient) can trigger data to be transmitted to others.
• Quicken interfaces to tax preparation software such as Turbo Tax, which then files taxes with the IRS and state. This is analogous to healthcare transmissions to public health and quality reporting agencies.

The bottom line is that I use Quicken because it saves time and money and helps me do things that would be hard to do on my own. Just avoiding the late fee on one credit card bill pays for the software investment. I’ll surmise that healthcare providers would insist on those kinds of benefits and more. If a provider can have an EHR that can do more than just the electronic equivalent of FAX -- like quickly match and autofile incoming messages to the right patient, help reconcile the data, notify the user that new information is available, provide clinical decision support, improve efficiency  – that EHR would ultimately pay for itself with or without incentives. All of us who work on EHRs need to keep that in mind: if my professional livelihood depended on using this EHR, would I use it? Personal Health Records (PHRs) are an even closer analogy to Quicken, and I believe that they too need interoperability and Quicken-like value to deliver on their potential (rather than being something that most consumers don’t have time for).

Interestingly, Dr. Clem McDonald (an HIT pioneer) recently  wrote a similar analogy, that ideally healthcare data import ought to be as easy as importing bank statements to Quicken, in his commentary Clinical Decision Support and Rich Clinical Repositories in the Archives of Internal Medicine (sorry, the link used to be public but now requires membership).

To wrap up… securely pushing information, as simply as e-mail, is good progress. Liquidity of information, whether health or financial, enables value to be realized when software acts upon it. Financial software has progressed far beyond just moving information. Healthcare isn’t nearly as far, but it’s advancing and more options are becoming available. Not all EHRs are right for everyone, but I believe that they’re on the road to being as if they were “healthcare Quickens.”

Finale: Drinking Safely and Healthily from Liquid Information

Happy New Year! If you must drink, do it responsibly and safely. Which brings us to the subject of this Finale to a blog series that started here. How can Health IT systems help clinicians to consume/drink the liquid information that will increasingly flow to them? How can these systems help users protect both patient safety and clinician productivity?

The faucet has been opened. It’s fairly easy to tell developers to send clinical information to others. It’s harder to know what to tell providers to do with what they receive. The trickle of information exchange hasn’t become a flood yet, but let’s be prepared! Clinicians want the information to be usable, not a hindrance. They want to do the right thing, but they can’t afford to reduce their capacity to see patients, and they don’t want to be liable for negligence if they can’t read every word of every available electronic record for the patient. Policies and guidelines for realistic expectations and duties of clinicians to retrieve and read electronic information would be very helpful coming from medical, legal, and health information management professional associations.

Patient safety is impacted both if there’s inadequate information flow but also if there’s too much. We’ve heard of “alert fatigue” in clinical systems, and could face “information overload fatigue” too, where important information is obscured by “noise” that could lead to errors or duplication as occur in the absence of information flow. While the PCAST report on health information technology proposes applying search technology (good idea), that may be helpful but insufficient. I can “Google” anything, but how often do you or I look beyond the first page of results, even when there are thousands of hits? I implicitly rely upon the search engine to display the most relevant links first, since my time is limited. While a patient’s medical records are much less voluminous than data in web searches, even dealing with only 24 clinical documents per my personal health example requires indicators of relevance to aid decision making. If I don’t look at Google search results page 2, it’s probably not a big deal, but the stakes are much higher for patient care: who can decide what’s most important to show for a clinical encounter, especially since that varies depending on the encounter’s purpose?

Thankfully, healthcare and academic organizations realize the need to tackle this challenge. I was fascinated by the findings from this medication reconciliation project at Partners Healthcare: “design of a novel application and the associated services that aggregate medication data from EMR and CPOE systems so that clinicians can efficiently generate an accurate pre-admission medication list.” It was pioneering work at the time, and was a springboard for further research, such as refined aggregation algorithms based on more standardized data, and clinician-vetted UI techniques to reduce cognitive burden and add value.

In 2008 when I helped interoperability and ambulatory workgroups (including physicians, nurses, pharmacists, engineers, and others) write the CCHIT certification criteria and roadmap through 2011, we proposed 2009 as a first step in consumption of discrete data such as medications and allergies from C32 CCDs, but concluded that we shouldn’t be prescriptive about EHR functionality or workflow to handle such data.

Medications are just one example of data that needs to be reconciled after being exchanged. A new clinical data Reconciliation project at IHE offers promise to advance the cause of clinical decision support for reconciling problems, allergies, medications, and more. It’s humbling to acknowledge that HIT isn’t so sophisticated or trusted to make clinical decisions, any more than web search can buy your next car automatically. Instead, we should share the results of research to inform and stimulate innovations that are then tested in multiple care settings, before even thinking about regulating and standardizing functionality. But I’m all for specifying how standardized information exchanges can be inputs to these innovative algorithms and UIs.

To return to my musical analogy, music isn’t just playing the notes in a score: but rather how the score is brought to life to touch the heart through the genius of great performers. We shouldn’t try to turn musicians into robots where every nuance is pre-programmed. Similarly, in HIT MUsic, there’s room for the art as well as the science!

If anyone reading this can point to interesting research and experiences regarding consuming health information that’s exchanged, I’d love to hear about them. The results would benefit providers and developers EHRs and HIEs as well.

Making HIT MUsic

This post assumes that you have a general understanding of ARRA HITECH legislation and the concepts of Certification and Meaningful Use (MU) of Electronic Health Records (EHRs).

So what would make HIT successful? Let’s keep our eye on the nationally stated goals of quality, safety and efficiency, i.e., better and safer health for consumers at a reasonable cost. As my first blog article compared interoperability specifications to musical scores, I’ll recommend where detailed specifications are necessary, and where they aren’t, so that we end up with a HIT MUsical, not an expensive flop/bomb. (I warned you about my puns in the first article!)

As people wonder what MU should be in the future, some alternative approaches are being considered by groups such as the HIT Policy Committee Meaningful Use Workgroup. One approach is to focus on outcomes achieved more than specific functional requirements. The HIT Policy Committee’s Certification and Adoption Workgroup made recommendations in August, 2009, that “Criteria on functions/features should be high level; however, criteria on interoperability should be more explicit.”

Interoperability: yes, be very specific! As one who has pored over many committee recommendations, interoperability specifications, CCHIT criteria, HHS regulations, NIST test scripts, certification handbooks, and HHS FAQs, I agree that interoperability criteria need to be explicit. I enjoy the opportunity to listen to various performances and recordings of masterpieces such as Beethoven’s Symphony #7. They allow some innovation in tempo, dynamics, and expressivity, but they’re all still the same symphony, because they conform to Beethoven’s musical notation “spec.” I don’t think anyone would suggest that the symphony be performed without all musicians following the same score. Because many players’ efforts need to fit together, it wouldn’t work to let musicians make up their own parts. Interoperability likewise requires many systems to fit together. But let's not skimp on quality: specs need to be implemented successfully in the real world before requiring their use. Also, evaluating return on investment is also key to avoid going overboard: the more frequently information is exchanged, the more people who need the info, and the higher the impact, the more it is worth standardizing. But for something on the other end of the spectrum (infrequent exchange, few people, little impact), is standardization worth the effort and cost?

Functionality: don’t be too prescriptive! In contrast, “functions/features” criteria, excluding interoperability, can be stated at a high (non-prescriptive) level, because they’re within a single system. Other organizations’ systems don’t interact directly with them. There’s the dilemma of wanting to ensure success without “micromanaging” and stifling innovation. Everyone “doing their own thing” re interoperability might be innovative but counterproductive. But when it comes to clinical functionality and workflows, won’t providers have enough information from other providers, market reports, professional associations, user groups, Regional Extension Centers, and test-drive opportunities to figure out what will work for them? Bear in mind that an EHR’s customers already have a starting base, and will lean towards whatever adds value to what they have, rather than something that conforms to generic criteria but doesn’t fit their environment.

We all want a health system that produces the best possible health outcomes for us. I’d rather see our policies, and the efforts of EHR developers, focused on achieving those outcomes, rather than meeting the “letter of the law” of detailed functionality criteria. Such criteria can lead to developers diverting time from features their customers really want, in order to “check the box” and deliver features to meet certification criteria and test scripts that won’t ever be used. So for functionality, excessive specificity of criteria produces distraction and waste! But in contrast, lack of precision and clarity of interoperability specs has produced waste, resulting from people being confused and the same question being asked over and over again.

So I think the original recommendations of the Certification and Adoption Workgroup regarding high-level functionality criteria and explicit interoperability criteria, and the MU Workgroup’s thoughts of more outcome-oriented objectives, are excellent paths to follow as we proceed into MU Stages 2 and beyond.