Q&A: Karen DeSalvo on EHR, Audits, and Buggy Software

In Part Two of an in-depth interview, National Coordinator for Health Information Karen DeSalvo, MD, discusses EHR certification, modular functionality, meaningful use audits, and glitchy software.

At the annual Health Datapalooza in Washington D.C., recently, I spoke with Karen B. DeSalvo, MD, MPH, MSc, National Coordinator for Health Information Technology, one-on-one for the first time. This is the conclusion of that conversation. Read Part One.

HLM: You were quoted as saying that electronic health records are like giant battleships.

DeSalvo: [Laughs]

HLM: What's that about? Do we need a different navy? What's going on?

DeSalvo: No, I don't think we need a different navy. But especially for a giant healthcare system… think about the amount of granular data they've been capturing for years. And it all matters to them in many ways.

So whether it's for inventory control or for medical legal purposes, or for quality improvement, safety, workforce management – you know all the back-office and front-office purposes of data, but it's heavy and it's deep and it's granular and in some cases pertinent to that system.

What I'm hearing a lot from the providers is that as they expand perhaps and acquire new systems… or as they're looking to the future and thinking about how the user interface can be more friendly for both patients and providers, it's not that you want to necessarily rip and replace all that data and put it in a new repository.

It's that you want to be able to pull out what is relevant for the use case and/or share it as appropriate, and have the system talk to itself.

So that heavy data that battleship is, to turn that would be very hard. But you could actually layer on top, exposing APIs for example, and thinking about how the right pieces of data move in appropriate ways—privately, securely, for the right use cases.

There's a way to retain what we've invested in. Make it useful for that setting, but… be able to lift out what's relevant in a lighter way that can follow patients as they need it for their care, and [be able to use it] in all the other important ways that matter.

HLM: EHR certification is changing. There's a narrowed focus, but there's also tradeoffs between having an EHR that's flexible versus one that's simple. What's happening with certification in your office, after this talk about battleships?

DeSalvo: Our certification program is undergoing some improvements. We've been seeking feedback in formal ways and informal ways to understand how we can take a process that grew very quickly to meet the needs of the HITECH act, and we've had a couple of improvements and we are very serious about making it more user friendly for those involved.

We are also thinking about, just as we are with the meaningful use program, about what's the right technological floor that providers would know if they bought something off the shelf, that it met specific specifications and eventually be able to talk with other systems in a way that was more seamless, without the expectations of expensive interfaces, but still leaving room for innovation on top.

Because as we start to certify products that are not [in the meaningful use program]—in the behavioral health world or long-term post-acute care—we want to be really thoughtful about what are the shared expectations and the common things that would need to be available in those products.

Also, what we've heard a lot about the cert program is the testing procedures, and how we can do a better job of simplifying the process of testing procedures to make it a little more real-world. Does it make sense for the certification process to set some expectations around opening architecture and data?

HLM: A lot of providers are confused at this point about what it will mean to have more modular functionality, where you might not have to have everything, the whole battleship, but you can buy part of the battleship, and how that's all going to work.

It might make for a less simple world where you're trying to exchange data with someone else who has that same EHR, but they chose different modules than you did.

DeSalvo: Yes, and there's a mixture embedded in that of education. Before I was here, I was on the outside, and right before I came to ONC, I was involved in selecting a product for a hospital we were building in New Orleans East. I was the project lead. [We were a] small hospital, [with a] tiny budget, trying to figure out what would meet our needs.

And this modularity thing, even though it's not the same as the cert process, it comes up, because as a provider, trying to buy a system, it's not always clear what you're getting. Is it going to come with the bed management system or not? There's a whole laundry list of things you want to know about.

So I'm really tuned into that, and I want to make sure that the messaging is clear for the providers about what the modular means. The RECs, the regional extension centers, are a resource I want to find a way to continue if we can. That helps with some of the on-the-ground decision making.

The professional societies do have some of this already online, a kind of Consumer Reports option available for what products work and what don't. So there's places people can look. We want to make sure we're providing some boots on the ground support, and as we're thinking about the language we choose for the cert program, etc., I'm pretty tuned into this notion that they know what they're getting when they buy it.

HLM: To which professional societies are you referring?

DeSalvo: ACP, AAFP.

HLM: What do you say to people who are concerned about what they perceive as their level of exposure to meaningful use audits, and a sense of people being fearful of audits, of not quite knowing whether they've done everything correctly?

DeSalvo: The FAQs, the frequently-asked questions that we put out with CMS, are designed to help answer some of those questions. We've done our best to be responsive, to make sure that there's clarity.

There's an opportunity for people to put in a ticket, to ask questions, and then get some feedback to make sure that they have some clarity. Beyond that, it's important for them to do everything they can to make sure what they're attesting is right.

HLM: Certification is one thing. Quality of software is another. A lot of software is buggy. Not because of usability issues, but because it's buggy. How can this office raise the bar and make the industry put out software that is less buggy?

DeSalvo: We're looking at what tools we have that we could use in our existing array. One of the related issues—it's not exactly overlapping—is the issue of safety. And this proposal around a safety center where people could report in bugginess that may have led to some patient safety issues would be one safe place where that could happen.

[It] could help give some feedback and make improvements, so there wouldn't be bugginess, and both of us could probably come up with a pretty good list of things that you might call buggy, but some of them can have some pretty significant safety implications. That's a place where we would want to focus attention.

HLM: Some vendors don't even let customers report the bugs publicly.

DeSalvo: We are doing some work with The Joint Commission, for example, to collect data and start getting some understanding of what's the prevalence—how common are these kinds of issues. It's not part of our cert program feedback loop right now, but those are all things that we're open to talking with the community about.

At the end of the day, it's about the patient safety saving lives piece, more than anything. It's not just about the UI. It's about is it going to do something buggy that is going to interfere with care, and that's why I would go to the safety place as a starting point for how you'd want to know more about that.