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June 21 2012

The state of Health Information Exchange in Massachusetts

I recently attended the Massachusetts Health Data Consortium's (MHDC) conference on Health Information Exchange (HIE), modestly titled "The Key to Integration and Accountability." Although I'm a health IT geek, I felt I needed help understanding life outside the electronic health record (EHR) world. So, I roped in Char Kasprzak, statistical data analyst at Massachusetts Health Quality Partners, to give me a better picture of the quality implications of HIE (and to help me write this post).

John Halamka, CIO of Caregroup/Beth Israel Deaconess Medical Center, took the stage first and blasted through all the progress being made establishing the necessary frameworks for HIE to occur in Massachusetts. The takeaway message from John's talk was that there have been many changes since September 2011 in the financial, technical, and legal structures involved in building health information exchange. The lessons learned from the initial pilot should enable Massachusetts to be ready for the first stage of statewide HIE.

HIE development in Massachusetts

Health care providers historically thought of HIE as a large institution run by a state or a major EHR vendor. It carried out the exchange of patient records in the crudest and most heavyweight way, by setting up one-to-one relationships with local hospitals and storing the records. (Some of the more sophisticated HIEs could link together hospitals instead, rather like Napster linked together end-users for file exchange.) These institutions still dominate, but HIE is now being used in a much broader sense, referring to the ability of institutions to share data with each other and even with patients over a variety of channels.

Despite the push for the health IT industry to use "HIE" as a verb rather than a noun, there was quite a lot of discussion at the event surrounding the structures and applications involved. Although HIE should be conceptually identified as a process (verb), having the structures and organizations (nouns) necessary to facilitate exchange is a challenge facing health care entities across the country. This conference did a good job of articulating these organizational challenges, and it presented clear plans on how Massachusetts is addressing them.

In Massachusetts, the model moving forward for phase one of HIE will be based on the Direct Project, with one central Health Information Service Provider (HISP) that will focus on PKI and S/MIME certificate management, maintaining a provider/entity directory, creating a web portal for those not ready for Direct, and maintaining an audit log of transactions. The concept of HISP was created in the Direct Project Implementation and Best Practices workgroups, and was designed to be an organizational and functional framework for the management of directed exchange between health care providers. The statewide HISP will consist of several existing HISP organizations, including Berkshire Health, Partners, Athena Health, and the New England Health Exchange Network. No small task, but not insurmountable.

I remain skeptical about the ability of providers and even hospitals to install EHRs capable of sending Direct-compliant messages conforming to the XDR/XDM IHE Profile for Direct Messaging. Not that it doesn't work or because it's some Herculean task, but essentially because it hasn't been mandated. That may change, though, with the inclusion of Direct Messaging in the transport standards for Meaningful Use Stage 2. In Massachusetts, the creation of a health information highway (phase 1) is set to go live on October 15, 2012. Phase 2 will include analytics and population health, and Phase 3 is set to have search and retrieve, which will include a governance model for an Electronic Master Patient Index (EMPI) and Record Locator Service (RLS). Phase 2 and 3 will set a framework for querying patient data across entities, which is one of the biggest technical barriers to HIE. Currently, one of the best methods for this process is the Patient Identifier Cross-Referencing (PIX) profile, but few organizations are using this tool to its full potential.

What are the challenges?

When experts talk about exchanging health information, they tend to focus on the technology. Micky Tripathi, CEO and executive director of the Massachusetts eHealth Collaborative, pointed out at the event that the problem isn't the aggregation or analysis of data, but the recording of data during the documentation process. In my experience, this is quite accurate: Having exchange standards and the ability to analyze big data is useless if you don't capture the data in the first place, or capture it in a non-standard way. This was highlighted when the Massachusetts eHealth Collaborative ran the same reports on 44 quality measures, first using popHealth data, then again with Massachusetts eHealth Collaborative data, and received conflicting results for each measure. There are certainly lessons to be learned from this pilot about the importance of specifying numerators, denominators, vocabularies, and transmission templates.

Determining what to capture can be as important as how the data is captured. Natasha Khouri elaborated on the challenges of accurate data capture during her presentation on "Implementing Race and Ethnicity Data Collection in Massachusetts Hospitals — Not as Easy as It Sounds." In 2006, Massachusetts added three new fields and 33 categories to more accurately record race and ethnicity information. The purpose of this is to address health disparities, which is something I'm very excited to see discussed at a health IT conference.

With accurate data in hand, direct interventions in communities can be more targeted and effective. However, the largest barrier to this seems to have been getting providers to ask questions about race and ethnicity. This was due to high training costs, staff resistance, and workflow changes necessary for collecting the demographic data. This problem was particularly interesting to me, having worked with the Fenway Health Institute to craft their Meaningful Use Stage 2 comments regarding the inclusion of gender identity and sexual orientation in the demographics criteria. Recording accurate data on vulnerable populations is vital to improving public health campaigns.

What about patients?

For a conference with no patient speakers, there was a surprising amount of discussion about how patients will be involved in HIE and the impact EHRs have on patients. Dr. Lawrence Garber,who serves as the medical informatics director for Reliant Medical Group, examined issues of patient consent. The research he discussed showed that when given the choice, about 5% of patients will opt out of HIE, while 95% will opt in. When patients opt in at the entity/organizational level, this enables automated exchange between providers, entities, care teams, and patients. Organizations utilize a Data Use and Reciprocal Support Agreement (DURSA) to establish a trust framework for authenticating entities that exchange data (presumably for the benefit of patients). DURSAs will likely play an important role as organizations move toward Accountable Care Organization models of care.

Information exchange should also lead to more patient satisfaction with their medical visits, where they will be able to spend more time talking to their doctors about current concerns instead of wasting time reviewing medical history from records that may be incomplete or inaccessible.

Dana Safran, VP of performance measurement and improvement at Blue Cross Blue Shield, explained at the conference that patients can expect better quality of care because quality improvement efforts start with being able to measure processes and outcomes. With HIE, it will be possible to get actual clinical data with which to enhance patient-reported outcome measures (PROMs) and really make them more reliable. Another topic that can be better measured with HIE is provider practice pattern variation. For example, identifying which providers are "outliers" in the number of tests they order, and showing them where they stand compared to their peers, can motivate them to more carefully consider whether each test is needed. Fewer unnecessary tests means cost savings for the whole system, including patients.

Toward the end of the conference, Dr. Nakhle A. Tarazi gave a presentation on his Elliot M. Stone Intern Project on the impact of EHRs on patient experience and satisfaction. The results were quite interesting, including:

  • 59% of patients noticed no change in time spent with their provider.
  • 65% of patients noticed no change in eye contact with their provider.
  • 67% of patients noticed no change in wait time in the office.

The sample size was small, interviewing only 50 patients, but the results certainly warrant a larger, more in-depth study.

In Massachusetts, it seems like the state of the HIE is strong. The next year should be quite exciting. By this time in 2013, we should have a statewide HISP and a web portal service that enables exchange between providers. Halamka has promised that on October 15 the walls between Massachusetts health care orgs will begin to come down. If it is successful in Massachusetts, it could be a valuable model for other states. We also have the opportunity to involve patients in the process, and I hope organizations such as The Society for Participatory Medicine and Direct Trust will be involved in making patients active partners in the exchange of health data.

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February 24 2012

The Direct Project in action

The Direct ProjectThe Direct Project is all over HIMSS12, and really all over the country now. But it still carries controversy. When I found out that one of the Houston Health Information Exchange efforts had successfully launched a Direct Pilot, I simply had to do an interview. After all, here was software that I had contributed to as an open source project that was being deployed in my own backyard.

Jim Langabeer is the CEO of the newly renamed Greater Houston Healthconnect. I caught up with Jim at Starbucks and peppered him with questions about where Health Information Exchange (HIE) is going and what HIE looks like in Houston.

What's your background?

Jim Langabeer: I have been in healthcare for a long time in the Texas Medical Center.  I started as a hospital administrator at UTMB, where my first project was to work on an IT project team developing a Human Resources Management System. It was a collaborative effort between three hospitals.

I recently led a software company in the business intelligence space, which was later acquired by Oracle. After that, I decided I wanted to come back to Houston and continue to work in healthcare, so I returned to work for MD Anderson leading project and performance management. I eventually worked with the CIO Lynn Vogel to assess the business value of information systems. I most recently taught healthcare administration at the UT School of Public Health.

Throughout my healthcare career, I have been using data to drive healthcare decisions. My PhD is in decision sciences — quantitative modeling of data for decision-making — and my research grants have all involved analyzing large datasets to make healthcare decisions better. I have also worked between organizations in a collaborative manner. Health Information Exchange was an obvious next step for me.

Where are you in the process of creating a health information exchange?

Jim Langabeer: We are in the middle stage of operations. We are finalizing our architectural vision and choosing vendors. Most importantly, we have strong community support: 41% of the doctors in the region have committed to the exchange with letters of support as well as 61 of the 117 local hospitals.

We are meeting with all of the doctors we can. We are calling them and faxing them and visiting them, with one simple message: Health IT is coming and we want you to participate.

You mentioned an "architectural vision." Can you expand on that?

Jim Langabeer: We really cannot have just one architecture, so our architectural vision really means choosing several protocols and architectures to support the various needs of our stakeholders in parallel. We need to accommodate the entire range of transactions that our physicians and hospitals perform. The numbers say that 50% of Houston docs work in small practices with only one or two doctors, and they typically do not have electronic health records (EHR). Hooking these doctors into a central hub model does not make sense, so a different model where they can use browser/view capabilities and direct connections between providers must be part of our architectural vision.

Houston also has several large hospitals using EPIC or other mature EHR systems. That means we need a range of solutions. Some docs just want to be able to share records. Some are more sophisticated and want to do full EHR linking. Some doctors just want to be able to view data on the exchange using a web portal.

We want to accommodate all of these requests. That means we want a portfolio of products and a flexible overall architectural vision. Practically, that means we will be supporting Direct, IHE and also older Hl7 v2.

Some people are saying Direct is all we want. We do not want a solution that is way over what small providers can handle and then it never gets used. We are architecture- and vendor-neutral, which can be difficult because EPIC is so prevalent in Houston.

We have practices that are still on paper on one hand and very sophisticated hospitals on the other, and that is just in the central Houston area. Immediately outside of Houston, lots of rural hospitals that we plan to support have older EHR systems or home-grown systems. That means we have to work with just about every potential health IT situation and still provide value.

Recently, a JAMIA perspectives article criticized Direct as a threat to non-profit HIE efforts like yours. Do you feel that Direct is a threat?

Jim Langabeer: I do not see Direct as a threat. I hear that from lots of sources, that Direct is a distraction for health information exchanges. I disagree.

I see it as another offering. The market is obviously responding to Direct. The price point on the software for Direct is definitely a benefit to smaller docs. We see it as a parallel path.

We do not see Surescripts (which is offering Direct email addresses to doctors with the AAFP) as a threat because we see them as a collaborator. We want them, and similar companies, to be part of our network. We are also having conversations with insurance companies and others who are not typically involved in health information exchanges because we are looking for partners.

The problem in healthcare is that it has always been very fragmented; no single solution gets much penetration. So, as we consider different protocols, we have to go with what people are asking for and what is already being adopted. We have to get to a point were these technologies have a very high penetration rate.

How are you narrowing your health IT vendors?

Jim Langabeer: What we want is a vendor that is going to be with us long term, sharing our risks and making sure we are successful. The sustainability of the vendor is connected to the sustainability of our exchange, so that is really important. Our 20-county region represents 6.4 million people, and that population is larger than most states that are pursing exchanges. Not many vendors have experience on that scale.

How important is the software licensing? Do open source vendors have an advantage?

Jim Langabeer: I am not sure they have an advantage. Of course, open source is ideal, but often proprietary vendors are ahead in terms of features. A mix in the long-term solution would be really cool.

How will you work with outside EHR vendors?

Jim Langabeer: We are trying to engage at the CIO level. We're trying to understand what solutions standards and data they want to share. There is a core set of things everyone needs to do. Beyond that core, some people want to go with SOA; other people really want IHE or Direct. There is not much data sharing between hospitals. That is why industry standards are so important to us. It helps us shorten those discussions and make a more narrow offering. So, we are focusing on protocols as a means to work with the various EHR vendors.

One CIO told us, "We do not want to exchange data at all; we just want our doctors to be able to open a browser and see your data." We may not like to hear that, but that is the reality for many organizations in Houston.

The other thing that is unique about Houston is that you are not going to see the state of Texas taking a dictatorial role. In other large exchanges, you often have a state-level government dictating HIE. In that environment, it is easier to insist on specific standards. That is not our situation in Houston, so we have to meet our constituents where they are.

I have been frustrated that the Direct Project reference implementations only come in Java and .NET at this point. I would like to see implementations in PHP, Python, Ruby, etc. — languages that are more popular with entrepreneurs. Are you concerned with issues like that?

Jim Langabeer: We're definitely thinking about things like that. We do not want to be merely business-to-business — we want to offer services to consumers. So, we care about the technology becoming accessible to consumers, which means getting to iPhones. We want to be able to offer consumers tools that will bring them value, so we certainly care about issues like implementation language because we see those issues as connected.

If I let you dictate which Houston clinic or hospital I go to, when can I go see a doctor and get my patient data sent to my HealthVault or other PHR Direct account?

Jim Langabeer: I would hope that the technology would be ready by the end of year. What I envision is a core group of early adopters. We already have several hospitals and some physician groups that are interested in taking that role.

This interview was edited and condensed.

Meaningful Use and Beyond: A Guide for IT Staff in Health Care — Meaningful Use underlies a major federal incentives program for medical offices and hospitals that pays doctors and clinicians to move to electronic health records (EHR). This book is a rosetta stone for the IT implementer who wants to help organizations harness EHR systems.


February 23 2012

Direct Project will be required in the next version of Meaningful Use

The Direct ProjectThe Office of the National Coordinator for Health Information Technology (ONC) announced that the Direct Project would be required in stage 2 of Meaningful Use.

As usual the outside world knew almost instantly because of Twitter. Nearly simultaneous posts from @ahier (Brain Ahier) and @techydoc (Steven Waldren MD). More information followed shortly after from @amalec Arien Malec a former leader for the Direct Project.

There are some other important announcements ahead of the official release, such as the end of support for CCD, but this requirement element has the deepest implications. This is jaw-dropping news! Meaningful Use is the standard by which all doctors and hospitals receive money for Electronic Health Record (EHR) systems from the federal government. In fact, the term "Electronic Health Record" is really just a synonym for "meaningful use software" (at least in the U.S. market). Meaningful Use is at the heart of what health IT will look like in the United States over the coming decades.

The Direct Project has a simple but ambitious goal: to replace the fax machine as the point-to-point communications tool for healthcare. That goal depends on adoption and nothing spurs adoption like a mandate. Every Health Information Exchange (HIE) in the country is going to be retooling as the result of this news. Some of them will be totally changing directions.

This mandate will make the Direct Project into the first Health Internet platform. Every doctor in the country will eventually use this technology to communicate. Given the way that healthcare is financed in the U.S., it is reasonable to say that doctors will either have a Direct email address to communicate with other doctors and their patients in a few years, or they will probably retire from the practice of medicine.

It was this potential, to be the first reliable communications platform for healthcare information, that has caused me to invest so heavily in this project. This is why I contributed so much time to the Direct Project Security and Trust Working Group when the Direct Protocol was just forming. This is an Open Source project that can still use your help.

The Direct Project is extensively covered in "Meaningful Use and Beyond" (chapter 11 is on interoperability). I wrote about the advantages of the Direct Project architecture. I helped arrange talks about about Direct at OSCON in 2010, and in 2011, I gave an OSCON keynote about the Health Internet , which featured Direct. I wrote a commentary for the Journal of Participatory Medicine, about how accuracy is more important than privacy for healthcare records and how to use the Direct Project to achieve that accuracy. I pointed out that the last significant impact from Google Health would be to make Direct more important. I am certainly not the only person at O'Reilly who has recognized the significance of the Direct Project, but I am one of the most vocal and consistent advocates of the Direct Project technology approach. So you can see why I think this a big announcement.

Of course, we will not know for sure exactly what has been mandated by the new revisions of Meaningful Use, but it is apparent that this is a huge victory for those of us who have really invested in this effort. My hat is off to Sean Nolan and Umesh Madan from Microsoft, to Brian Behlendorf and Arien Malec, who were both at at ONC during the birth of Direct, to Dr. David Kibbe, Brett Peterson and to John Moehrke. There are countless others who have contributed to the Direct Project, but these few are the ones who had to tolerate contributing with me, which I can assure you, is above and beyond the call of duty.

Obviously, we will be updating "Meaningful Use and Beyond" to include this new requirement as well as the other changes to the next version of Meaningful Use (which apparently will no longer be called "stage 2"). Most of the book will not change however, since it focuses on covering what you need to know in order to understand the requirements at all. While the requirements will be more stringent as time goes on, the core health IT concepts that are needed to understand them will not change that much. However, I recommend that you get a digital copy of the book directly through O'Reilly, because doing so entitles you to future versions of the book for free. You can get today's version and know we will update your digital edition with the arrival of subsequent versions of the Meaningful Use standard.

I wonder what other changes will be in store in the new requirements? ONC keeps promising to release the new rule "tomorrow." Once the new rules emerge, they will be devoured instantly, and you can expect to read more about the new standards here. The new rule will be subject to a 60-day commentary period. It will be interesting to see if the most dramatic aspects of the rule will survive this commentary. Supporters of CCR will be deeply upset and there are many entrenched EHR players who would rather not support Direct. Time will tell if this is truly a mandate, or merely a strong suggestion.

Meaningful Use and Beyond: A Guide for IT Staff in Health Care — Meaningful Use underlies a major federal incentives program for medical offices and hospitals that pays doctors and clinicians to move to electronic health records (EHR). This book is a rosetta stone for the IT implementer who wants to help organizations harness EHR systems.


March 23 2011

SMART challenge and P4: open source projects look toward the broader use of health records

In a country where doctors are still struggling to transfer basic
patient information (such as continuity of care records) from one
clinic to another, it may seem premature to think about seamless data
exchange between a patient and multiple care organizations to support
such things as real-time interventions in patient behavior and better
clinical decision support. But this is precisely what medicine will
need for the next breakthrough in making patients better and reducing
costs. And many of the building blocks have recently fallen into

Two recent open source developments have noticed these opportunities
and hope to create new ones from them. One is the href="">SMART Apps for Health
contest at, based on the href="">SMART Platform that is one
of the darlings of href="">Federal
CTO Aneesh Chopra and other advocates for health care innovation.
The other development is href="">P4, the brainchild of a
physician named Adrian Gropper who has recognized the importance of
electronic records and made the leap into technology.

SMART challenge: Next steps for a quickly spreading open source API

I'm hoping the SMART Platform augurs the future of health IT: an open
source project that proprietary vendors are rushing to adopt. The
simple goal of SMART is to pull together health data from any
appropriate source--labs, radiology, diagnoses, and even
administrative information--and provide it in a common,
well-documented, simple format so any programmer can write an app to
process it. It's a sign of the mess electronic records have become
over the years that this functionality hasn't emerged till now. And
it's a sign of the tremendous strides health IT has made recently that
SMART (and the building blocks on which it is based) has become so

SMART has been released under the GPL, and is based on two other
important open source projects: the href="">INDIVO health record system and
the I2B2 informatics system. Like
INDIVO, the SMART project was largely developed by Children's Hospital
Boston, and was presented at a meeting I attended today by Dr. Kenneth
D. Mandl, a director of the Intelligent Health Laboratory at the
hospital and at Harvard Medical School. SMART started out with the
goal of providing a RESTful API into data. Not surprisingly, as Mandl
reported, the team quickly found itself plunged into the task of
developing standards for health-related data. Current standards either
didn't apply to the data they were exposing or were inappropriate for
the new uses to which they wanted to put it.

Health data is currently stored in a Babel of formats. Converting them
all to a single pure information stream is hopeless; to make them
available to research one must translate them on the fly to some
universally recognized format. That's one of the goals of the href="">report
on health care released in December 2010 by the President's
Council of Advisors on Science and Technology. SMART is developing
software to do the translation and serve up data from whatever desired
source in "containers." Applications can then query the containers
through SMART's API to retrieve data and feed to research and clinical

Justifying SMART, Mandl presented solid principles of modern data
processing that will be familiar to regular Radar readers:

Data as a platform

Storage should be as flexible and free of bias as possible, so that
innovators can easily write new applications that do surprising and
wonderful things with it. This principle contrasts starkly with most
current health records, which make the data conform to a single
original purpose and make it hard to extract the data for any other
use, much less keep it clean enough for unanticipated uses. (Talk to
doctors about how little the diagnoses they enter for billing purposes
have to do with the actual treatments patients need.)

An "Appstore for health"

New applications should be welcome from any quarter. Mandl is hoping
that apps will eventually cost just a few dollars, like a cell phone
app. (Note to Apple: Mandl and the audience tended to use the terms
"iPhone" and "Appstore" in a casual manner that slid from metaphors to
generic terms for mobile devices and program repositories.) Mandl said
that his teams' evaluation of apps would be on the loose side, more
like Android than iPhone, but that the environment would not be a
"Wild West." At each hospital or clinic, IT staff could set up their
own repositories of approved apps, and add custom-built ones.

A "learning health system"

Data should be the engine behind continuous improvement of our health
care system. As Mandl said, "every patient should be an opportunity to

Open source and open standards

As we've seen, standards are a prerequisite for data as a platform.
Open source has done well for SMART and the platforms on which is
based. But the current challenge, notably, allows proprietary as well
as open source submissions. This agnosticism about licensing is a
common factor across Apparently the sponsors believe
they will encourage more and better submissions by allowing the
developers to keep control over the resulting code. But at least most rules require some kind of right to use the app the
SMART challenge is totally silent on rights. The danger, of course, is
the developers will get tired of maintaining an app or will add
onerous features after it becomes popular.

An impressive list of electronic record vendors have promised support
for SMART or integrated it into products in some way: Cerner, Siemens,
Google, Microsoft, General Electric, and more. SMART seems to be on
its way to a clean sweep of the electronic health care record
industry. And one of its projects is aimed at the next frontier:
integrating devices such as blood glucose readers into the system.

P4: Bringing patients into the health record and their own treatment

SMART is a widely championed collaboration among stellar institutions;
P4 is the modest suggestion of a single doctor. But I'm including P4
in this blog because I think it's incredibly elegant. As you delve
into it, the concept evolves from seeming quite clever to completely

The project aims to create a lightweight communication system based on
standards and open source software. Any device or application that the
patient runs to record such things as blood pressure or mood could be
hooked into the system. Furthermore, the patient would be able to
share data with multiple care providers in a fine-grained way--just
the cholesterol and blood pressure readings, for example, or just
vaccination information. (This was another goal of the PCAST report
mentioned in the previous section.)

Communicating medical records is such a central plank of health care
reform that a division of Health and Human Services called the Office
of the National Coordinator created two major open source projects
with the help of electronic health record vendors: href="">CONNECT and href="">Direct. The latter is more
lightweight, recently having released libraries that support the
secure exchange of data over email.

Vendors will jump in now and produce systems they can sell to doctors
for the exchange of continuity of care records. But Gropper wants the
patients to have the same capabilities. To do that, he is linking up
Direct with another open source project developed by the Markle
Foundation for the Veterans Administration and Department of Defense:
Blue Button.

Blue Button is a patient portal with a particularly simple interface.
Log in to your account, press the button, and get a flat file in an
easy-to-read format. Linked Data proponents grumble that the format is
not structured enough, but like HTML it is simple to use and can be
extended in the future.

Blue Button is currently only a one-way system, however. A veteran can
look at his health data but can't upload new information. Nor can
multiple providers share the data. P4 will fix all that by using a
Direct interface to create two-way channels. If you are recovering
from a broken leg and want to upload your range-of-motion progress
every day, you will be able to do this (given that a format for the
data is designed and universally recognized) with your orthopedic
surgeon, your physical therapist, and your primary care provider. P4
will permit fine-grained access, so you can send out only the data you
think is relevant to each institution.

Gropper is aiming to put together a team of open source coders to
present this project to a VA challenge. Details can be found on the href="">P4 web page.

February 05 2011

Report from Massachusetts Health IT forum

To talk of a "revolution" in health care would be demeaning to the
thousands of people staking their lives on real revolutions right now
in various countries, but there is no doubt that the conflation of
out-of-control health care costs, fancy new technologies, and various
government mandates (not only from the US government, but from many
states including Massachusetts) have forced doctors, vendors, and
other people in the heath care field to scramble and order changes
throughout their organizations. A couple hundred of these people came
to the "Tools
for Meaningful and Accountable Care" conference
held yesterday by
the Massachusetts Health Data

I didn't interview many participants (the ones I talked to were very
happy with the presentations) but I wonder whether all of them got
what they came for. They may well be haggling over questions such as
"How many prescriptions do we need to order online in 2011 in order to
qualify for the first stage of Meaningful Use booty?" or "How do I get
an image from the radiologist down the street while satisfying HIPAA
privacy regulations?" What they got, however, was a broad look at the
needs of health care and a set of projections by various speakers that
congealed into what I find to be a coherent vision for health care in
the future.

And I think the communication of this vision is important. Costs will
continue to rise and reform will fail if doctors, vendors, and IT
staffs simply race to meet each stage of regulations and act in an ad
hoc manner without an overall coordination of effort. Just how broad
this coordination of effort must be--we're not talking here just about
gathering an entire hospital around a program, or even a whole
consortium such as Partners HealthCare, the biggest Massachusetts
provider--will come out during this article.

Capitation versus Clinical Effectiveness Research

One of the big changes in the Massachusetts health care scene went
oddly unmentioned during the whole day of talks. I'm referring to the
from Blue Cross/Blue Shield of Massachusetts announcing that they
will change from fee-for-service to a "global payment plan." This
mirrors recent plans from the state government to pressure the health
care insurers and providers to pay for outcome rather than for
individual procedures. But imposed on the current delivery system,
such a "global payment plan" is just a repackaging of old-fashioned

Nobody seems to want to admit this, just as people are reluctant to
announce the return of "managed care" and prefer to assign the new,
as-yet untainted term "accountable care organization." It was up to
the CEO of a leading ACO--Dr. Craig Samitt of Dean Healthcare in
Wisconsin--to display a slide in his keynote with an equal sign
connecting "managed care" and "accountable care organization." He said
this moment is our chance to do managed care right.

(It's also sobering that in Massachusetts, world center for health
care, the two organizations singled out at this conference for their
achievements in bringing to life the potential in health care IT both
lay outside the state: Wisconsin's Dean Healthcare and central Texas's
Scott & White Health Plan. Furthermore, the individuals who
traveled here to describe their work had both spent long careers in
Massachusetts health care organizations before traveling elsewhere to
lead these advances.)

Payments for outcome and ACOs can work: they can lower costs while
simultaneously improving health care. But by themselves they're like a
meringue fashioned out of only sugar and cornstarch. The egg that will
make them work is clinical effectiveness research, a topic excellently
covered in talks by two doctors, Harold C. Sox and Michael Fischer.

CER is a medical application of the quality control routinely done in
other industries; it perhaps has its origin in time-and-motion
studies. It asks tough questions such as why one surgeon has far
greater success on the same patient population as another--not in
order to reward or punish, but to convey the best practices from one
clinic and region to another. CER should overcome the enormous
disparities that we all know exist between doctors, between hospitals,
between patient populations (such as differences in outcome by race)
and between different parts of the country.

Dr. Sox pointed out that CER was being tried as early as the 1960s,
but took a great leap in the mid-1990s and continues to make advances
despite such cynical political pot-shots as raising the fear of death
panels. (I highly recommend href="">Atul
Gawande's New Yorker article for a sweeping overview of the real
purpose and effect of end-of-life decisions.) CER is now formalized by
the Federal Government in several initiatives that are not likely to
go away.

Dr. Fischer said that CER required big changes in education and in
how results are delivered. Crude impressions like "death panels" have
to be fought with better outreach to the public. Continuing medical
education (which has impolitely referred to as "broken") needs to be
more hands-on and to demonstrate that doctors understand the material
they've been given. And EMRs have to become much more sophisticated at
delivering information.

Currently, doctors using EMRs are pelted with notorious "alerts" that
resemble the warnings web browsers give all of us when we visit web
sites with outdated security certificates. Most doctors treat the
alerts like web users treat the security dialog boxes--they ignore
them and click through. And that's because they're just too darned
many alerts. Every medication has some potential impact on something
(a rare food allergy, for instance) and the computer systems can't
figure out what doctors really need to know. Furthermore, if a system
displays an alert and the patient experiences a problem later, the
doctor's liability is increased. If a doctor dismisses an alert, he or
she had better type in a reason for doing so.

Making CER work will require vendors to design more flexible systems,
and the IT staff at each institution to choose the alerts that can
actually affect medical decisions. Some of the enforcement can also be
spread around: nurses and other staff can be involved in CER.

All Together Now

The value that comes from aggregating results of procedures and
treatments raises several questions. One is the effects on patient
privacy, because it's well-known that anonymized data can often be
de-anonymized, and we're talking here of widely shared data being
crunched by dozens or hundreds of organizations. (I'm on the planning
committee for an href="">upcoming conference on
health data privacy.) But a deeper question concerns the ability
of many forces to work together to make change.

A small medical practice can't internally collect enough data to
determine statistically what works and what doesn't. Unless someone
coordinates these small practices, they will fall behind and lose both
money and patients. But even a large institution has limited access to
data. Michael Lee, a director at the fairly large Atrius Health
group, said they wished they could see data on their patients after
they move on to other institutions. Better care and lower costs will
require massive coordination across the country.

The Direct
at Health and Human Services, which reached a major
milestone last week with the announcement of some successful data
transfers, should become a platform for such exchange and coordination
(and they're taking privacy quite seriously). But it's just a
platform--echoing a point made by Joel Vengco of GE--whose value
emerges only through the proper encoding, exchange, and interpretation
of data, followed ultimately by the dissemination of results and their
use by providers. (Whew.)

This is perhaps why Micky Tripathi, president of the Massachusetts
eHealth Collective, stressed that doctors have to move from just
entering data into their EHRs to entering accurate data, and using
structures that allow it to be parsed and crunched. It was also
pointed out that many of the requirements for receiving meaningful use
payments depend on multiple institutions: specialists, labs,
pharmacies, and other institutions the doctor deals with have to be
set up to send and receive the communications for which the government
rewards the individual doctor.

It used to be that doctors would practice and health care researchers
would do research (with some overlap, of course, at teaching hospitals
and major research centers). Practice and research are now
intertwining and perhaps merging.

All these ways in which health reform becomes a group effort show why
a high-level vision is important. And someone at the top must firmly
hold on to this vision. That's why I had a second surprise yesterday
at a news item that went unmentioned: the upcoming href="">departure
of David Blumenthal, National Coordinator for Health Information
Technology. I trust that the ONC is suffused with enough smart
people holding firm to their goals for it to continue to make change.
If Blumenthal's departure slows down implementation, though, maybe it
will give us a welcome breathing space to re-evaluate our tools and
what we need them to accomplish.

Too expensive, too hard to use, and too disruptive to workflow

That was the three-sided accusation delivered to vendors of EHRs by
Dr. Marylou Buyse, the chief medical director of Scott & White
Health Plan, who spoke at yesterday's conference and won an
achievement award there. Nobody blinked when she delivered the
judgment, and indeed it's one I've heard repeatedly. Dr. Buyse should
have added that their proprietary formats and imprecise
implementations of standards throw up enormous barriers to the data
exchange required for meaningful use, as I discussed in a href="">report
from last year's HIMSS conference.

Few speakers picked up this theme, perhaps because many vendors were
present, and perhaps because the speakers figured we had to soldier on
with whatever we had. My third surprise of the day, regarding
unmentioned news, was the alarming href="">
report by the President’s Council of Advisors on Science and
Technology expressing concern about the ability of current EHRs to
carry out the basic data exchanges required for improvements in health

Maybe health care in the US is so far behind the digital age that any
upgrade would produce benefits. Paul Grabscheid of InterSystems
reminded the audience of a recent study showing that two-thirds of
doctors still use fax machines to send medical records out, and the
next biggest medium in use is snail mail. Adoption of EHRs is rising
in this country (it may be up to 20%, depending on how it's counted)
but is still extremely inadequate. Nevertheless, most observers don't
call for moving full-speed ahead with existing computer systems and
workflows. Before making investments, it's important to be smart.

Better standards, as the PCAST report called for, are important, and open source systems would address interoperability. (I feel it justified to insert a plug here for the health care track at O'Reilly's Open Source convention. But most of all, we've all got to work together. Spent forces with nothing new to offer must be pushed out of the way, while the vast majority of people have to set aside maneuvers for short-term advantage and focus on a common goal. To return to the stirring words of keynoter Dr. Samitt, insurers and providers (and he could have added patients and politicians) have to "work together to drive change."

Maybe that's the key to any revolution.

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