"All the World's a Stage"...Two

”All the world's a stage,

And all the men and women merely players:

They have their exits and their entrances;

And one man in his time plays many parts,

His acts being seven ages…”

[As You Like It, William Shakespeare]

Oh no, as if music analogies weren’t enough, now I’m quoting Shakespeare? Actually, I’ll confess that I’ve never read As You Like It but I thought of these lines in the context of Healthcare IT and Meaningful Use (MU) Stages. The monologue quoted above goes on to list seven “ages” (which we would call “stages”) of life: infancy, childhood, the lover, the soldier, the justice, old age, dementia/death. I think HIT has gotten beyond infancy, probably into “childhood” and wants to grow more mature with each Stage (stopping well before dementia and death, of course).

The eyes of the HIT world are watching the “players” from the HIT Policy Committee, who are proposing Stage 2 MU which will start in FY2013. When it’s defined, will it be “as we like it” and will we believe it is taking us on the right path? What’s the vision and strategy to which Stage Two is a stepping stone?

Most of us indeed play many parts (roles). For instance, with respect to HIT, I ‘m a public citizen commenting on regulations, standards developer, interoperability champion, product developer, PHR user, patient, and caregiver. The dedicated people on the HIT PC also play many parts  simultaneously, which may include clinician, developer, researcher, business executive, standards developer, and of course policy maker and patient.

Before submitting detailed comments, I want to share some themes and associated issues that I gleaned from my initial reading of the 19-page HIT Policy Committee Meaningful Use workgroup’s Stage 2 recommendations.

• There’s more recognition of the need for evidence to support objectives. A little over three pages of references are given, though I wish that there were more explicit connections between each objective and the citations. Consider that regulations that affect thousands of providers, hundreds of vendors, and millions of patients have high stakes. So it’s reasonable to expect evidence not only of benefits but of associated costs including impacts upon workflows. The public comment period will undoubtedly cause more evidence to surface (and I encourage everyone who comments to include evidence as to why you agree or disagree, not just assertions or emotions).
• There’s a broader view of the clinical team. I see progress towards a balanced perspective with the focus on medication administration, assessments, longitudinal care plan, and care team members, though there’s a lot of room for interpretation as to what the last two mean. There’s also more clarity of clinical/discharge instructions in Stage 2. It’s good to see the acknowledgement of other professionals such as nurses, pharmacists, and therapists, in addition to physicians.
• Patients are increasingly considered part of the team. I’m all for “engaged” patients and consider myself one. The most challenging Stage 2 objective for patient engagement may be the patient download-upon-demand feature for all EHRs. What do patients want out of the data and how does it improve their health? I’d like to see this addressed in the Evidence Base/Rationale section.
• More and more information will be exchanged. That’s no surprise, and can be a good thing for patients and providers, if…it’s usable and relevant, as I wrote in my three part December series starting with Information Liquidity. As stated by Dr. Lyle Berkowitz who gave testimony to the HIT Standards Committee: “Data sharing alone is never enough. Dr. Reid Coleman from Lifespan had the quote of the day when he said,   ‘Data is like salt water… you need a filter to drink it’. I’d also add that it helps to have good plumbing to connect it to the right facilities, and then also to have plenty of glasses available to make it easy for people to get it to the ‘final foot.’”

The Policy Committee has a tough tightrope to walk – on the one hand they’d like to wait for more early returns, evidence of how the industry is doing adopting Stage 1; they could then incorporate those experiences before finalizing Stage 2. On the other hand, they have heard that everyone need lots of lead time to work Stage 2 into their roadmaps, and needs its requirements finalized “yesterday” or at least 18 months beforehand. So they’re trying to send a “signal to the market” but they can’t guarantee that the signal won’t change. They’ll probably receive hundreds of comments. Interesting times lie ahead!

Philosophizing

Now that the HIT Policy Committee Meaningful Use workgroup’s Stage 2 recommendations have been released for public comment (due February 25^th), I and probably hundreds of others will give it a careful review and offer public comments. I know that a lot of thought and balancing of considerations from public testimony has already gone into it. The “philosophical basis” – the “why” not just the “what” -- of MU is fundamental to what is included and how it is specified. I hope to look for what lies behind the objectives. Some of this comes out in the workgroup’s meetings (which, along with the HIT Policy Committee meetings, are open to the public, so I encourage you to participate). However, the “intent” behind proposals is not always evident in the documents themselves, and readers who didn’t listen to the meetings might not be able to read between the lines to understand what outcomes the workgroup is striving for. Presentations from prior meetings can help explain the guiding principles more than just reading the proposed objectives. I believe it really is about better health outcomes for all of us, including the currently disadvantaged. 

In the meantime before I’ve analyzed the recommendations, what should I blog about? I’m humbled by the consistency with which other bloggers manage to write daily (I wish…!) since it’s hard for me to find time, let alone good ideas, to share daily. In that regard, my son Dan sets a high bar for consistency as he writes his blog, The Philosopher Developer, almost daily. Similar to my combining thoughts on HIT and music, he combines his vocation (programming) and his avocation (philosophy/thinking). While it’s tempting for me to say “like father, like son,” Dan started his blog a year before I did, so I should say “like son, like father!” His January 15^th post on “Resolution: the need for a terminating condition” is sound advice to us all as we engage in discussion and debate about the right path forward in HIT, health reform, family issues, or anything else, such as the Arizona Tragedy. Hopefully, there can be a harmonious environment and humble attitude framing our discussions, even when we disagree.

Back to Health IT. It’s clear that increasing patient engagement in health is one of the main drivers for Stage 2 and 3. I look forward to the day, not too far away, when I’ll ask each of my healthcare providers, as meaningful users, to share information with me as a patient or possibly a caregiver, per the regulations (electronic copy, access, download, secure messaging) or beyond that if they can. My HIT work won’t be a compartment that I leave behind at the office, but a reality every time my family or I interact with the healthcare system. Like it not, that’s likely to be more and more often for me for the rest of my life.

An Aid to Survey the River of Clinical Information

Recently, I’ve had discussions with many people in the HIT industry about the future direction for Meaningful Use (MU), especially about exchanging clinical information. It’s clear that Stage 1 is only the start of a journey, and that increasingly robust sets of clinical information will need to be exchanged. However, such exchanges need to be helpful rather than burdensome, and much work needs to occur to figure out how to display what’s significant, accurate, reconciled, and usable for clinicians and patients (see my recent blog series Part 1, Part 2, Finale).

I’m sharing a spreadsheet (a work in progress) showing a library of standardized reusable data sections and comparing many types of electronic clinical documents/records, including the two most “famous” that are required in Meaningful Use Stage 1, CCD and CCR. This spreadsheet may eventually be published in a more final form from an organization, but even now it may be useful to you if you have any of these questions:

• What must be shared in Stage 1 as a clinical summary with providers and/or patients? (See spreadsheet columns B and D green cells)
• Are certification and MU clinical summaries the same? There are some interesting differences that can be found between the standards for certification and the language for meaningful use (See column A and the CMS FR – Clinical Summary tab).
• What’s the difference between a full C32 and what’s required in Stage 1 certification? Quite a bit, actually! (See column D, white check marks)
• What data are not included in CCR and CCD but might be desirable to share in the future? (See all rows and columns). Stage 1 requires only the most commonly requested clinical summary data (meds, allergies, problems, results, etc.).
• How much reusability exists among today’s electronic clinical documents? (See column Q, which also indicates which sections are most often used). There are worthy efforts afoot to improve commonality and reduce divergence, such as the ONC sponsored CDA Consolidation Project. 

Here’s my compulsory “liquid” or “music” analogy of the day. A mighty rushing river is growing, of clinical information and the standards thereof. I hope my high-level spreadsheet serves as an aid, a “Bridge Over Troubled Water” where you can safely survey the river before you plunge in. Although I created this spreadsheet, with plenty of review from Health Story and EHRA members, I’m far from being the authority on clinical documents. Robin Raiford did wonderful work on a similar spreadsheet in 2009, which was actually more detailed, but was limited to HITSP CDA documents and preceded the ONC Final Rules. I recommend that you read the original specs, and follow Keith Boone’s blog and his upcoming CDA book.

The Arizona Tragedy and Harmonious HIT

I was shocked, saddened, and angered by the news of the recent assassination attempt on Arizona congresswoman Gabrielle Giffords and the killing or wounding of 18 other innocent bystanders.

What does this have to do with healthcare IT? A little. I am very grateful that it looks as though Representative Giffords will survive. Undoubtedly, an amazing amount of medical technology as well as skilled and compassionate healthcare professionals were involved in the surgery. Without both the technology and the  people, she certainly would not have survived. And both will be needed continuously if, as expected, she faces a lengthy and arduous recovery, long after the headlines have faded from our memories.

What does this have to do with "harmonious?" A lot, actually. Jared Loughner is not talking at present, and it's too soon to know what really motivated him to commit such a horrendous crime. Still, I'm reminded that words as well as bullets can wound deeply. It's ironic and sad that a subject such as Healthcare Reform, and to some extent Healthcare IT -- both intended to improve people's lives -- are sometimes debated with such rancor and acrimony in public forums, e.g., on the Internet.

I hope that the discussion of legislation, meaningful use, certification, standards, and all other subjects related to healthcare, and HIT, will be conducted in a rational civil manner. When we feel strongly about the rightness of our cause, that's great: we should exercise our privilege of free speech. But with privilege come responsibility, and we don't need to fire off verbal bullets or grenades with shrapnel, as if others are merely "targets" and not real people. Rep. Giffords, the other victims, and all of us deserve no less as we try to work together, harmoniously rather than dissonantly, to improve the health of our nation and our people.

This may be too "preachy" a blog post, but the Arizona tragedy affected me and made me think again about the reasons I got into the HIT industry in the first place. How can I and each of us contribute to making things better?