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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.

OSCON 2012 Healthcare Track — The conjunction of open source and open data with health technology promises to improve creaking infrastructure and give greater control and engagement to patients. Learn more at OSCON 2012, being held July 16-20 in Portland, Oregon.

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June 20 2012

How the federal government helps health care standards evolve

Health information exchange is on the front lines of cost control and health care improvements. To provide simple tools and channels for hospitals, doctors, and other institutions to exchange data with the government, patients, and each other, the Department of Health and Human Services coordinates an initiative called the Federal Health Architecture (FHA).

Dr. Lauren Thompson, director of the FHA, speaks in this interview about the FHA's accomplishments and the current state of health information exchange.

Topics in the interview include:

  • How the FHA arose as a solution to the problem of exchanging health data, both across government agencies and with partners in the private sector. [Discussed at the 0:45 mark]
  • Status of the Nationwide Health Information Network (NwHIN), which is participating in the NwHIN Exchange, and what the requirements are for participation. [Discussed at the 4:45 mark]
  • Initiatives at the Department of Defense and the Department of Veteran Affairs. [Discussed at the 7:45 mark]
  • Future of the NwHIN Exchange and the CONNECT project, including support for the Direct standard. [Discussed at the 9:45 mark]
  • Cost savings and other benefits offered by the work of the Federal Health Architecture to the health care field. [Discussed at the 13:15 mark]
  • Promoting services to Health Information Exchanges. [Discussed at the 14:45 mark]
  • You can view the entire conversation in the following video:

    OSCON 2012 Healthcare Track — The conjunction of open source and open data with health technology promises to improve creaking infrastructure and give greater control and engagement to patients. Learn more at OSCON 2012, being held July 16-20 in Portland, Oregon.

    Save 20% on registration with the code RADAR

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.

Related:

February 23 2012

Report from HIMSS 2012: toward interoperability and openness

I was wondering how it would feel to be in the midst of 35,000 people whose livelihoods are driven by the decisions of a large institution at the moment when that institution releases a major set of rules. I didn't really find out, though. The 35,000 people I speak of are the attendees of the HIMSS conference and the institution is the Department of Health and Human Services. But HHS just sort of half-released the rules (called Stage 2 of meaningful use), telling us that they would appear online tomorrow and meanwhile rushing over a few of the key points in a presentation that drew overflow crowds in two rooms.

The reaction, I sensed, was a mix of relief and frustration. Relief because Farzad Mostashari, National Coordinator for Health Information Technology, promised us the rules would be familiar and hewed closely to what advisors had requested. Frustration, however, at not seeing the details. The few snippets put up on the screen contained enough ambiguities and poorly worded phrases that I'm glad there's a 60-day comment period before the final rules are adopted.

There isn't much one can say about the Stage 2 rules until they are posted and the experts have a chance to parse them closely, and I'm a bit reluctant to throw onto the Internet one of potentially 35,000 reactions to the announcement, but a few points struck me enough to be worth writing about. Mostashari used his pulpit for several pronouncements about the rules:

  • HHS would push ahead on goals for interoperability and health information exchange. "We can't wait five years," said Mostashari. He emphasized the phrase "standard-based" in referring to HIE.

  • Patient engagement was another priority. To attest to Stage 2, institutions will have to allow at least half their patients to download and transfer their records.

  • They would strive for continuous quality improvement and clinical decision support, key goals enabled by the building blocks of meaningful use.

Two key pillars of the Stage 2 announcement are requirements to use the Direct project for data exchange and HL7's consolidated CDA for the format (the only data exchange I heard mentioned was a summary of care, which is all that most institutions exchange when a patient is referred).

The announcement demonstrates the confidence that HHS has in the Direct project, which it launched just a couple years ago and that exemplifies a successful joint government/private sector project. Direct will allow health care providers of any size and financial endowment to use email or the Web to share summaries of care. (I mentioned it in yesterday's article.) With Direct, we can hope to leave the cumbersome and costly days of health information exchange behind. The older and more complex CONNECT project will be an option as well.

The other half of that announcement, regarding adoption of the CDA (incarnated as a CCD for summaries of care), is a loss for the older CCR format, which was an option in Stage 1. The CCR was the Silicon Valley version of health data, a sleek and consistent XML format used by Google Health and Microsoft HealthVault. But health care experts criticized the CCR as not rich enough to convey the information institutions need, so it lost out to the more complex CCD.

The news on formats is good overall, though. The HL7 consortium, which has historically funded itself by requiring organizations to become members in order to use its standards, is opening some of them for free use. This is critical for the development of open source projects. And at an HL7 panel today, a spokesperson said they would like to head more in the direction of free licensing and have to determine whether they can survive financially while doing so.

So I'm feeling optimistic that U.S. health care is moving "toward interoperability and openness," the phrase I used in the title to his article and also used in a posting from HIMSS two years ago.

HHS allowed late-coming institutions (those who began the Stage 1 process in 2011) to continue at Stage 1 for another year. This is welcome because they have so much work to do, but means that providers who want to demonstrate Stage 2 information exchange may have trouble because they can't do it with other providers who are ready only for Stage 1.

HHS endorsed some other standards today as well, notably SNOMED for diseases and LRI for lab results. Another nice tidbit from the summit includes the requirement to use electronic medication administration (for instance, bar codes to check for errors in giving medicine) to foster patient safety.

February 21 2012

Building the health information infrastructure for the modern epatient

To learn more about what levers the government is pulling to catalyze innovation in the healthcare system, I turned to Dr. Farzad Mostashari (@Farzad_ONC). As the National Coordinator for Health IT, Mostashari is one of the most important public officials entrusted with improving the nation's healthcare system through smarter use of technology.

Dr. Farzad MostashariMostashari, a public-health informatics specialist, was named ONC chief in April 2011, replacing Dr. David Blumenthal. Mostashari's full biography, available at HHS.gov, notes that he "was one of the lead investigators in the outbreaks of West Nile Virus and anthrax in New York City, and was among the first developers of real-time electronic disease surveillance systems nationwide."

I talked to Mostashari on the same day that he published a look back over 2011, which he hailed as a year of momentous progress in health information technology. Our interview follows.

What excites you about your work? What trends matter here?

Farzad Mostashari‏: Well, it's a really fun job. It feels like this is the ideal time for this health IT revolution to tie into other massive megatrends that are happening around consumer and patient empowerment, payment and delivery reform, as I talked about in my TED Med Talk with Aneesh Chopra.

These three streams [how patients are cared for, how care is paid for, and how people take care of their own health] coming together feels great. And it really feels like we're making amazing progress.

How does what's happening today grow out of the passage of the Health Information Technology for Economic and Clinical Health Act (HITECH) Act in 2009?

Farzad Mostashari‏: HITECH was a key part of ARRA, the American Recovery and Reinvestment Act. This is the reinvestment part. People think of roadways and runways and railways. This is the information infrastructure for healthcare.

In the past two years, we made as much progress on adoption as we had made in the past 20 years before that. We doubled the adoption of electronic health records in physician offices between the time the stimulus passed and now. What that says is that a large number of barriers have been addressed, including the financial barriers that are addressed by the health IT incentive payments.

It also, I think, points to the innovation that's happening in the health IT marketplace, with more products that people want to buy and want to use, and an explosion in the number of options people have.

The programs we put in place, like the Regional Health IT Extension Centers modeled after the Agriculture Extension program, give a helping hand. There are local nonprofits throughout the country that are working with one-third of all primary care providers in this country to help them adopt electronic health records, particularly smaller practices and maybe health centers, critical access hospitals and so forth.

This is obviously a big lift and a big change for medicine. It moves at what Jay Walker called "med speed," not tech speed. The pace of transformation in medicine that's happening right now may be unparalleled. It's a good thing.

Healthcare providers have a number of options as they adopt electronic health records. How do you think about the choice between open source versus proprietary options?

Farzad Mostashari‏: We're pretty agnostic in terms of the technology and the business model. What matters are the outcomes. We've really left the decisions about what technology to use to the people who have to live with it, like the doctors and hospitals who make the purchases.

There are definitely some very successful models, not only on the EHR side, but also on the health information exchange side.

(Note: For more on this subject, read Brian Ahier's Radar post on the Health Internet.)

What role do open standards play in the future of healthcare?

Farzad Mostashari‏: We are passionate believers in open standards. We think that everybody should be using them. We've gotten really great participation by vendors of open source and proprietary software, in terms of participating in an open standards development process.

I think what we've enabled, through things like modular certification, is a lot more innovation. Different pieces of the entire ecosystem could be done through reducing the barrier to entry, enabling a variety of different innovative startups to come to the field. What we're seeing is, a lot of the time, this is migrating from installed software to web services.

If we're setting up a reference implementation of the standards, like the Connect software or popHealth, we do it through a process where the result is open source. I think the government as a platform approach at the Veterans Affairs department, DoD, and so forth is tremendously important.

How is the mobile revolution changing healthcare?

We had Jay Walker talking about big change [at a recent ONC Grantee Meeting]. I just have this indelible image of him waving in his left hand a clay cone with cuneiform on it that is from 2,000 B.C. — 4,000 years ago — and in his right hand he held his iPhone.

He was saying both of them represented the cutting edge of technology that evolved to meet consumer need. His strong assertion was that this is absolutely going to revolutionize what happens in medicine at tech speed. Again, not "med speed."

I had the experience of being at my clinic, where I get care, and the pharmacist sitting in the starched, white coat behind the counter telling me that I should take this medicine at night.

And I said, "Well, it's easier for me to take it in the morning." And he said, "Well, it works better at night."

And I asked, acting as an empowered patient, "Well, what's the half life?" And he answered, "Okay. Let me look it up."

He started clacking away at his pharmacy information system; clickity clack, clickity clack. I can't see what he's doing. And then he says, "Ah hell," and he pulls out his smartphone and Googles it.

There's now a democratization of information and information tools, where we're pushing the analytics to the cloud. Being able to put that in the hand of not just every doctor or every healthcare provider but every patient is absolutely going to be that third strand of the DNA, putting us on the right path for getting healthcare that results in health.

We're making sure that people know they have a right to get their own data, making sure that the policies are aligned with that. We're making sure that we make it easy for doctors to give patients their own information through things like the Direct Project, the Blue Button, meaningful use requirements, or the Consumer E-Health Pledge.

We have more than 250 organizations that collectively hold data for 100 million Americans that pledge to make it easy for people to get electronic copies of their own data.

Do you think people will take ownership of their personal health data and engage in what Susannah Fox has described as "peer-to-peer healthcare"?

Farzad Mostashari‏: I think that it will be not just possible, not even just okay, but actually encouraged for patients to be engaged in their care as partners. Let the epatient help. I think we're going to see that emerging as there's more access and more tools for people to do stuff with their data once they get it through things like the health data initiative. We're also beginning to work with stakeholder groups, like Consumer's Union, the American Nurses Association and some of the disease groups, to change attitudes around it being okay to ask for your own records.

This interview was edited and condensed. Photo from The Office of the National Coordinator for Health Information Technology.

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February 06 2012

Small Massachusetts HIT conference returns to big issues in health care

I've come to look forward to the Massachusetts Heath Data Consortium's annual HIT conference because--although speakers tout the very real and impressive progress made by Massachusetts health providers--you can also hear acerbic and ruthlessly candid critiques of policy and the status quo. Two notable take-aways from last year's conference (which I wrote up at the time) were the equivalence of old "managed care" to new "accountable care organizations" and the complaint that electronic health records were "too expensive, too hard to use, and too disruptive to workflow." I'll return to these claims later.

The sticking point: health information exchange

This year, the spears were lobbed by Ashish Jha of Harvard Medical School, who laid out a broad overview of progress since the release of meaningful use criteria and then accused health care providers of undermining one of its main goals, the exchange of data between different providers who care for the same patient. Through quantitative research (publication in progress), Jha's researchers showed a correlation between fear of competition and low adoption of HIEs. Hospitals with a larger, more secure position in their markets, or in more concentrated markets, were more likely to join an HIE.

The research bolsters Jha's claim that the commonly cited barriers to using HIEs (technical challenges, cost, and privacy concerns) are surmountable, and that the real problem is a refusal to join because a provider fears that patients would migrate to other providers. It seems to me that the government and public can demand better from providers, but simply cracking the whip may be ineffective. Nor should it be necessary. An urgent shortage of medical care exists everywhere in the country, except perhaps a few posh neighborhoods. There's plenty for all providers. Once insurance is provided to all the people in need, no institution should need to fear a lack of business, unless it's performance record is dismal.

Jha also put up some research showing a strong trend toward adopting electronic health records, although the small offices that give half the treatment in the United States are still left behind. He warned that to see big benefits, we need to bring in health care institutions that are currently given little attention by the government--nursing home, rehab facilities, and so forth--and give them incentives to digitize. He wrapped up by quoting David Blumenthal, former head of the ONC, on the subject of HIEs. Blumenthal predicted that we'd see EHRs in most providers over the next few years, and that the real battle would be getting them to adopt health information exchange.

Meanwhile, meaningful use could trigger a shake-out in the EHR industry, as vendors who have spent years building silo'd projects fail to meet the Stage 2 requirements that fulfill the highest aspirations of the HITECH act that defined meaningful use, including health information exchange. Meanwhile, a small but steadily increasing number of open source projects have achieved meaningful use certification. So we'll see more advances in the adoption of both EHRs and HIEs.

Low-hanging fruit signals a new path for cost savings

The big achievement in Massachusetts, going into the conference today, was a recent agreement between the state's major insurer, Blue Cross Blue Shield, and the 800-pound gorilla of the state's health care market, Partners HealthCare System. The pact significantly slows the skyrocketing costs that we've all become accustomed to in the United States, through the adoption of global payments (that is, fixed reimbursements for treating patients in certain categories). That two institutions of such weight can relinquish the old, imprisoning system of fee-for-service is news indeed.

Note that the Blue Cross/Partners agreement doesn't even involve the formation of an Accountable Care Organization. Presumably, Partners believes it can pick some low-hanging fruit through modest advances in efficiency. Cost savings you can really count will come from ACOs, where total care of the patient is streamlined through better transfers of care and intensive communication. Patient-centered medical homes can do even more. So an ACO is actually much smarter than old managed care. But it depends on collecting good data and using it right.

The current deal is an important affirmation of the path Massachusetts took long before the rest of the country in aiming for universal health coverage. We all knew at the time that the Massachusetts bill was not addressing costs and that these would have to be tackled eventually. And at first, of course, health premiums went up because a huge number of new people were added to the roles, and many of them were either sick or part of high-risk populations.

The cost problem is now being addressed through administrative pressure (at one point, Governor Deval Patrick flatly denied a large increase requested by insurers), proposed laws, and sincere efforts at the private level such as the Blue Cross/Partners deal. I asked a member of the Patrick administration whether they problem could be solved without a new law, and he expressed the opinion that there's a good chance it could be. Steven Fox of Blue Cross Blue Shield said that 70% of their HMO members go to physicians in their Alternative Quality Network, which features global payments. And he said these members have better outcomes at lower costs.

ACOs have a paradoxical effect on health information exchange Jha predicted that ACOs, while greatly streamlining the exchanges between their member organizations, because these save money, they will resist exchanging data with outside providers because keeping patients is even more important for ACOs than for traditional hospitals and clinics. Only by keeping a patient can the ACO reap the benefits of the investments they make in long-term patient health.

As Doris Mitchell received an award for her work with the MHDC, executive directory Ray Campbell mentioned the rapid growth and new responsibilities of her agency, the Group Insurance Commission, which negotiates all health insurance coverage for state employees, as cities and towns have been transferring their municipal employees to it. A highly contentious bill last year that allowed the municipalities to transfer their workers to the GIC was widely interpreted as a blow against unionized workers, when it was actually just a ploy to save money through the familiar gambit of combining the insured into a larger pool. I covered this controversy at the time.

A low-key conference

Attendance was down at this year's conference, with about half the attendees and vendors as last year's. Lowered interest seemed to be reflected as none of the three CEOs receiving awards turned up to represent their institutions (the two institutions mentioned earlier for their historic cost-cutting deal--Blue Cross Blue Shield and Partners HealthCare--along with Steward Health Care).

The morning started with a thoughtful look at the requirements for ACOs by Frank Ingari of Essence Healthcare, who predicted a big rise in investment by health care institutions in their IT departments. Later speakers echoed this theme, saying that hospitals should invest less in state-of-the-art equipment that leads to immediately billable activities, and more in the underlying IT that will allow them to collect research data and cut down waste. Some of the benefits available through this research were covered in a talk at the Open Source convention a couple years ago.

Another intriguing session covered technologies available today that could be more widely adopted to improve health care. Videos of robots always draw an enthusiastic response, but a more significant innovation ultimately may be a database McKesson is developing that lets doctors evaluate genetic tests and decide when such tests are worth the money and trouble.

The dozen vendors were joined by a non-profit, Sustainable Healthcare for Haiti. Their first project is one of the most basic health interventions one can make: providing wells for drinkable water. They have a local sponsor who can manage their relationship with the government, and an ambitious mission that includes job development, an outpatient clinic, and an acute care children's hospital.

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