Patient Engagement Needs to be a Two-Way Street

The “patient and family engagement” objectives within the federal Meaningful Use (MU) incentive program Stages 1 and (proposed) Stage 2 have been well-intended steps forward. But they have mostly regarded patients as receivers of information (education materials, clinical summaries after each visit, view/download/transmit their information, receive patient reminders). This is pretty much a “one way street.”  Sure, there is “secure messaging” where a patient can send essentially an email to a provider. But most requirements assume that providers control the keys to information that they (figuratively) “dispense” to the patient.

I recently read a fascinating book called “Cognitive Surplus: Creativity and Generosity in a Connected Age” by Clay Shirky, whose premise is that the digital age offers “thrilling changes” as society is transformed from a passive consumer culture (e.g., watching TV/movies and reading publications, all controlled by large media companies), to a more networked culture where technology enables people to create, publish, share, connect, and collaborate in innovative ways, without dependence on established authorities. While the “free for all” can produce huge volumes of frivolous or low-quality content, it can also engender truly original and breakthrough ideas, which otherwise would not have happened, by relying on the goodwill and “cognitive surplus” (hitherto untapped creative energies) of millions of people. Examples include Wikipedia, kiva (microfinancing to help individuals start small businesses and alleviate poverty) and Grobanites for Charity fans of a singer who banded together to help charitable causes in places such as Africa. Shirky’s cognitive surplus thesis has strong parallels to the Health 2.0 movement and patient engagement. How can patients be full partners and contributors to their health information and their health, rather than merely passive consumers whose information is controlled by providers? Or, to use a music analogy as I like to do, is the patient just listening to solo performances by each provider, or are they playing harmoniously as an ensemble?

Patients are partial contributors already. After all, didn’t lots of the patient’s history and information about symptoms, contraindications, outcomes, and treatment that’s in paper charts or EHRs come from patients and their families, through interviews, assessments, and clipboards? Who knows better than patients what they are really doing (not what someone else thinks they ought to be doing)? So it’s good that there has been recent testimony and requests for public comment from the HIT Policy and Standards Committees about patient-generated health data (PGHD). If you have any interest in this subject (and, as a patient, you should), you can respond too. There’s no stated deadline, though commenting sooner rather than later you’d be more likely to be heard.

Admittedly, it’s easier when discussing EHR certification and MU to discuss outputs from the provider’s EHR to patients, because those are easier to understand, quantify, and control (from a provider’s or EHR vendor’s perspective). When accepting information from patients, things are much more unpredictable. The request for comment asks 10 good questions, such as how “structured” PGHD should be, where are patients “the authoritative source,” and what degree of incorporating PGHD into EHRs should be expected of providers.

I have many thoughts on these questions. More to come next week…

That Harmonious Spring Break Happened

Well, my big piano recital event for which I had been practicing for a year occurred last weekend. I was happy to play, and now I'll be a little less intense for a while, before I start preparing for the MusicAppassionata piano festival in West Chester, PA August 1-6.

I've uploaded most of my recital performances to YouTube. To find them, search in YouTube for David Tao piano recital and they'll show up. The camcorder sound was compressed, meaning that the soft parts were made louder and the loud parts were softened, so there appears to be very little dynamic variation. Trust me, I actually can play soft, sometimes!

I've related music and its performance to interoperability several times in this blog. One thing that a recital teaches you is that things go awry that you totally didn't expect, but you move on. You can't anticipate everything about some keys making unwanted noises, wheel locks not preventing the piano from rolling away, slight movements in the audience causing a brief distraction and memory lapse, etc. Despite avoidance of sugar and caffeine, and conscious intent to stay under control (knowing adrenaline would amp me up anyway), I still played faster than planned. Similarly, implementing interoperability in the real world seldom goes as you envisioned it or as cleanly as what's written in the standards or even developed in a product, because each participant doesn't have control over the other participants' systems or the environment. But every time you do it, you learn and improve the next time.

Happy Memorial Day Holiday Weekend to everyone!

David

A Harmonious Musical Spring Break

I expect to conclude my three-part certification retrospective within the week. Since it will end with a discussion of lessons learned as well as some tough controversies, it will need some thoughtful review before I just fire it off. In the meantime, I’m going to take a brief break to return to my non-HIT passion, music, which has many parallels with Health IT as I introduced in my first blog post in December.  One of my physician colleagues recently shared with me an article from the March 15^th edition of the Annals of Internal Medicine, entitled What Musicians Can Teach Doctors. No, I’m not going to use this post to teach doctors, but I recommend the article, as it compares musical training and performance to medical training and practice. Furthermore the aspects of teamwork, rehearsal, and specialization are key to HIT interoperability. Both music and interoperability must be performed by collaborating participants, not just specified in theory, and there’s no substitute for doing it over and over, refining it, and continuously improving.

I’ve been applying the principle of “practice” (musical, not medical) for the past year preparing for an upcoming solo piano recital. For too long, I didn’t make time for it, as the demands of family, work, and “life” kept getting in the way, but now on May 20^th and 21^st I’ll perform two concerts. Information is available on the web about the recital program, Youtube video preview “trailer” and location at Immaculata University. So if any blog readers happen to be in the Philadelphia PA area on those dates and would like to come by, you’re most welcome! I realize that solo piano doesn’t illustrate very well the “teamwork” principle that ensemble music would. But I’d like to convey a faithful and yet personal interpretation of the composers’ musical “specifications” to connect with my audience so that they realize the genius and beauty of what Bach, Beethoven, Liszt, et al created. So even though it’s a solo recital, I’m trying to be the “interface” between the composers and my audience. Hopefully, not too much will be lost in translation!

Anyway, after this “break,” next time I’ll return to conclude the CCHIT Certification Retrospective.

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.

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.

Harmonious What?

Hi, I'm David Tao. This initiates my new blog. I'm not going to dive into anything deep, heavy, political, or technical today. But I'll briefly introduce myself and my blog's purpose. I expect that anyone who takes the time to read this is interested in healthcare, information technology (that's what "IT" is), or else is my mom or wife.

I'm married, a father of four, and a grandfather of two. My family is blessed with good health and has generally avoided serious illnesses. But if there's one thing I know for sure, there are no sure things as far as health, so I want the health care system to work as well as it possibly can when we inevitably need it.

I've been employed since 1977 by Siemens Healthcare (and Shared Medical Systems, which Siemens acquired). Siemens is a large global company with major presence in many technology/engineering fields. Its products are everywhere, some visible to the eye (like windmills, high-speed railroads, solar panels, light bulbs, and MRI machines) and some behind the scenes (like electrical power distribution, broadband networks, and the software that runs healthcare organizations). I'm a "senior key expert" in the Solutions Development organization of a business unit known as Siemens Health Services, located near Philadelphia, PA, which provides Healthcare Information Technology ("HIT") software and services for healthcare organizations like hospitals and physicians. My specific focus is on interoperability (which means exchange of information). Patients receive health care in many physician offices, hospitals, clinics, labs, pharmacies, long term care, and their own homes, so their information should be exchanged with everyone who needs it, including the patients themselves and their families.

Why did I name my blog "Harmonious Health IT?" It's really a play on words expressing my professional desire for HIT systems to share information and work together "harmoniously" for the good of patients, and my personal love for music (and harmony in particular). I enjoy singing in a cappella vocal groups, church choirs, and harmony-driven pop like Beach Boys/Eagles/Beatles. I also love playing classical piano (one of the few instruments that can create its own harmony as well as melody and rhythm).

There are lots of parallels between music and interoperability. Consider an orchestra where all the parts need to fit together. Similar to the specifications for HIT interoperability, orchestral scores are both a "standard and implementation guide" to the musicians. Individual musicians have some flexibility in how they perform their parts, but they're guided by well-defined specs for what instruments like the cello, french horn, timpani, and clarinet should play. If everyone made up their own part, there wouldn't be harmony, but rather disharmony or even cacophony. Unfortunately, HIT hasn't always been harmonious over the years if systems made up their own parts. But with billions of taxpayer dollars stimulating increased use of HIT, it better become harmonious quickly!

Never mind my age, but when I quote the song "I'd like to teach the world to sing in perfect harmony..." that may give you a clue as to my generation. Many of you won't know what I'm talking about (but for those who do, yes I prefer Coke over Pepsi). If I were to call that a "HIT song" that would also tell you about my unfortunate propensity for puns (from which you can only hope I spare you in upcoming blog posts).

In the coming weeks, I'll share my thoughts on what's happening or on the horizon in HIT, and my suggestions for how all of us (who share a common bond as consumers and patients of the healthcare system) can help ourselves move forward to more harmony in health and ultimately to more harmony in our lives.

Thanks for joining me.

David