The document, now open for public comment, presents the broad federal strategy which sets the context and framing of the Nationwide Interoperability Roadmap to be released in early 2015.
With the first national health IT interoperability roadmap imminent, the 2015–2020 Federal Health IT Strategic Plan is doubling down on making incompatible information systems collect, share and use health data with each other.
The 20-page plan, updated every three years, was released Monday, following collaboration with more than 35 federal agencies and the authors of the plan at the U.S. Department of Health and Human Services' Office of the National Coordinator for Health Information Technology (ONC).
It contains half as many mentions of interoperability as its predecessor.
The Strategic Plan, which is open for comments, serves as the broad federal strategy setting the context and framing the Nationwide Interoperability Roadmap that will be released in early 2015. The Nationwide Interoperability Roadmap will help to define the implementation of how the federal government and private sector will approach sharing health information.
"We are a purchaser, payer, provider and regulator of industry and of healthcare and of public health and other inputs to health, and that's what this document is meant to reflect," said Karen DeSalvo, M.D., national coordinator for health IT and acting assistant secretary for health, during a media phone briefing.
"We are continuing to advance collection of health information in the digital space, thinking about that collection beyond the set of eligible providers that have been the focus of the meaningful use program, connecting the care continuum," she said.
The plan's "strong emphasis on interoperability" and sharing of data is aimed at engaging and empowering individuals to become "real partners" in their healthcare, DeSalvo added.
"There's a strong sense, both within the federal government and the private sector, that it's time for the data to move, and then the uses can come to fruition, and that's going to encourage the further collection of additional health information."
Incorporating Behavioral Health Like the previous plan, the new one aspires to integrate behavioral health information into healthcare in general, but it lays out few concrete goals for achieving that objective, such as getting all behavioral health providers to use electronic health records. "We don't have a baseline yet, so it's hard to know," DeSalvo said.
"Where I'd [like] the country to be is where Vermont is, where they've got almost all of their behavioral health providers that are stood up on electronic health records and ready to join the information exchange."
ONC is exploring options such as using accountable care organizations to accelerate adoption of EHRs in behavioral health, DeSalvo added.
Of necessity, the new draft plan does look beyond the meaningful use incentive program—a key driver of the 2011 strategic plan—since the lion's share of dollars for that program have now been paid out.
Open for Comment Privacy, security, governance, and various business drivers for exchange and interoperability, including value-based payment, to be elaborated upon in the ten-year roadmap, will be foundational parts of the strategy, said Seth Pazinski, director of the office of planning, evaluation and analysis at ONC.
Goals of the new plan include expanding adoption of health IT; advancing secure and interoperable health information; strengthening healthcare delivery; advancing the health and well-being of individuals and communities; and advancing research, scientific knowledge, and innovation.
The comment periodon the Strategic Plan ends Feb. 6, 2015.
ONC hopes to see substantial feedback from states, the private sector and individuals on the draft plan, DeSalvo said. "We want to know if we're focusing on the things that matter," she said.
The 10-year ONC interoperability roadmap, due in January, looks to begin shaping an implementation of many of the goals of the strategic plan, DeSalvo said.
In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. They are making a difference in healthcare. This is the story of Andrea Ippolito.
This profile was published in the December, 2014 issue of HealthLeaders magazine.
"We have doctors who said they didn't think of themselves as entrepreneurs going back to their own organizations and deploying their own hackathons."
A few blocks from the main hall of the South by Southwest Interactive festival on a sunny March morning, a healthcare hackathon is in progress.
Having attended more than a dozen such gatherings, Andrea Katherine Ippolito, a biomedical engineer by training, can rattle off a long list of companies spawned at one of MIT's previous Hacking Medicine events—a list that includes Pillpack, Smart Scheduling, Podimetrics, RubiconMD, Twiage, Eagle Health Supplies, and HermesIQ.
Ippolito is a PhD student at Massachusetts Institute of Technology, Hacking Medicine's codirector for 2013–2014 (along with fellow MIT student Allison Yost), and now a Presidential Innovation Fellow working with the Department of Veterans Affairs.
Structured as a student organization out of MIT's Martin Trust Center for MIT Entrepreneurship, Hacking Medicine is the ultimate healthcare hackathon roadshow. So far, the tour has touched down in four different continents (with events in North America, Europe, Uganda, and India) with more than a dozen hackathons and more than 300 teams formed from them.
"The first year we existed, we had two hackathons," Ippolito says. "The second year, we had three. This last year we have 11, and next year we are slated to be working on at least 17, and those are the ones that we're going to be working on directly with people." That number doesn't count those who learn the ropes at Hacking Medicine's events and then peel off to do their own hackathons, she says. "I'm going over to the Institute for Healthcare Improvement today to explain what a hackathon is and how they can use it in their Innovation Relay, which starts today," Ippolito says.
The hackathons usually start on a Friday evening and run for 48 hours. The first evening, participants socialize and get inspired by a guest speaker on problems healthcare faces and how teams might be able to form to solve them. Saturday morning, participants pitch their ideas for 60 seconds, focusing on a healthcare problem or pain point they want to tackle in the remaining 36 hours. Based off those pitches, participants form teams and the hacking begins.
"They start to brainstorm and develop and iterate a solution," Ippolito says. "We then arm them with mentors, and by the end of the 48 hours, they demo what they came up with." The demo deliverables range from prototypes, or paper wireframes, to hardware hacks using small Raspberry Pi or Arduino computers—even objects created with 3-D printers.
"We have doctors who said they didn't think of themselves as entrepreneurs going back to their own organizations and deploying their own hackathons," Ippolito says. "It's this 'see one, do one, teach one' model."
In February 2012, one MIT hackathon even spawned a company with Ippolito on the team. "It's called Smart Scheduling," she says. "We predict no-shows in medical practices." A month after the hackathon, Hacking Medicine cofounder and faculty advisor Zen Chu (who is also entrepreneur-in-residence at the Martin Center) introduced the Smart Scheduling team to athenahealth executive vice president and COO Ed Park (brother of Todd Park, who until recently was the U.S. government's CTO). That was the start of Smart Scheduling's integration into More Disruption Please, athenahealth's incubator program for partner companies that plug into athenahealth's network of more than 50,000 providers, Ippolito says.
With all the high-tech thinking surrounding Hacking Medicine, it's worth noting that a single paper page plays an important role: the Business Model Canvas, developed by Alex Osterwalder, author of the bestseller Business Model Generation: A Handbook for Visionaries, Game Changers, and Challengers. (Osterwalder's Twitter self-description concludes: "Won't rest until senior executives and entrepreneurs operate like surgeons!") The Canvas helps health hackers get right to some key elements that will determine whether their startup could succeed—such as financing or identifying the right partnerships.
Ippolito's faculty advisors developed what she calls the junior varsity version of the Business Model Canvas, a simplified version that lets hackers use the single page to identify different stakeholders.
"While hackathons can't be applied in benchtop science all the time, it brings together diverse stakeholders and encourages them to seek feedback early and often, and validate their hypothesis developed at the hackathon to ensure that they're going in the right direction," Ippolito says. "That's really revolutionary."
In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. They are making a difference in healthcare. This is the story of Anne Wojcicki.
This profile was published in the December, 2014 issue of HealthLeaders magazine.
"The more we empower individuals to take ownership of their health and their wellness, the better outcomes they will have. People want this information because they want to learn about themselves."
Wojcicki, CEO of 23andMe, unexpectedly received word in November 2013 from the FDA that 23andMe would not be able to market its genetic sequencing technology to consumers as personalized health reports. Since then, the company has focused on satisfying the FDA's concerns—learning in March that its corrective actions met those concerns—and relaunching at a date yet to be determined. Meanwhile, the company is still selling ancestry and raw genetic data.
"When we got the FDA letter, it was definitely a surprise, but it was never sort of out of the blue," Wojcicki says. "We were obviously working with the FDA to figure out a path toward approval, so in some ways, this letter really just reprioritized the company. We've had some incredible hires, and we're really focused on relaunching and having a much, much better product out there that will have an FDA clearance. So in some ways, we've seized the opportunity with it." One of those hires is Kathy Hibbs, who now runs 23andMe's legal and regulatory operations. "It has definitely opened up doors for us because we're now speaking the right language," Wojcicki says.
23andMe's service delivers a customer's genetic code to them, but interpretation of that code is primarily limited to clues about the customer's ancestry. Still, that hasn't stopped customers from sharing their sequences and insights. "We have more than 750,000 customers, and I get a story probably every other day about someone where genetics has really transformed their life."
Wojcicki is intent on remaining consumer-facing. "Healthcare should be accessible to individuals, and it should be affordable," she says. "We are $99 now. We will be in that affordable range. The more we empower individuals to take ownership of their health and their wellness, the better outcomes they will have. People want this information because they want to learn about themselves."
Although 23andMe could have made great strides financially by focusing elsewhere instead of targeting consumers, its business is gradually broadening thanks to government grants. In July, the National Institutes of Health awarded a $1.37 million grant to 23andMe to discover rare variants associated with disease and to improve its survey tools for use by researchers. The ultimate goal, though, remains connecting those researchers with consumers, whose questions and conditions can drive genomic research; streamlining the delivery of results, also to the benefit of consumers; and accelerating the discovery process, Wojcicki says.
"There's a disconnect where people walk into their physician's office or they walk into a hospital, and they don't know yet how to use this information," she says. "Those are the two worlds that at some point have to be married."
23andMe's travails with the FDA, however, have highlighted the question of whether FDA regulation has put a damper not just on genetic research, but on all manner of healthcare innovation. "People are terrified right now of the regulation in healthcare," Wojcicki says. "There's clearly a role for the FDA. I think that the challenge is figuring out what that right structure is going to be. We want to be able to encourage innovation in a safe way that has the right risk/benefit ratios."
Towards that end, Wojcicki is going to Washington more often. She is urging the FDA to open an office in Silicon Valley, and agrees that the FDA needs a funding boost to jump-start a range of industry-friendly initiatives.
Like many others, she also wants fundamental change in the way clinical trials are conducted in the United States. "Once something's on the market, the public needs to be better educated about the fact that just because it's approved and it's on the market doesn't mean it's entirely safe," Wojcicki says. "There's an incredible potential for us to really understand how are therapies being used, and then detecting adverse events or side effects much, much faster, and hopefully then that will enable a process where you could have smaller clinical trials and you could get drugs out faster."
At the same time, there's a need for better vigilance of approved drugs. "We still need to have extensive phase 4 monitoring and vigilance about how is it that people are actually using therapies, and what is the right way that they should be used," Wojcicki says.
Still, in a year in which some massive healthcare information breaches have occurred, some might be surprised to learn that given a choice between revealing her genetic information and her credit card information, Wojcicki would choose the former.
"There's always a vulnerability with all these big data sets," she says. "Part of it again is understanding the balance between risk and reward. One of the things that 23andMe has always believed strongly is that people should always have the ability to opt out. So if you do not want to participate in our research, you don't have to."
Having said that, the majority of 23andMe customers opt to allow the company to continue to use their genetic data to further research. "More than 80% of our customers participate in the research, and that's part of what we're trying to do, is make sure people understand that there is a risk/reward," Wojcicki says. "If you have 10,000 people who all have sarcoma, and there's a high rate of mortality with it, but you can all use your data together to try to develop a cure, there's a risk of a data breach, but there's also a potential that you're going to have something transformative that comes out of all that data. Then I think it's a personal choice of do you want to weigh in, do you want to participate in making your data available, and is that risk/reward appropriate for you? For me, overwhelmingly. I'm more willing to have all my data come out there, because I feel like there's a real benefit of having my data combined with all the other data sets out there, because it's going to impact someone's health."
Wojcicki's philanthropy foundation, founded with her husband Sergey Brin, cofounder of Google, received $187 million in 2013. According to Philanthropy.com, it devotes most of its grant making to a handful of nonprofits, including Ashoka, an organization that brings together social entrepreneurs to work on education, the environment, and women's issues; the Human Rights Foundation; and Tipping Point Community, a charity that seeks to eliminate poverty in northern California.
Like most healthcare leaders, Wojcicki wonders how soon healthcare reimbursement will change to encourage awareness of one's genetics information, even as the cost of accessing that information drops to zero.
"That is a five- to 10-year project," Wojcicki says. "One of the things that we talk about all the time is, if you're high risk for Type 2 diabetes, and I prevent you from developing Type 2 diabetes, no one really makes money. But if you're diabetic, it's very easy for me to look at all the ways that you're monetized. It's a fundamental conflict that we have in the healthcare system, and I don't know how to resolve that either, but I do think that there's some interesting movement in that area, and one thing that I point to is the fact that Walmart is putting physicians in all their stores, because if you think about where you start to get your lifestyle, and if you think about how you want to prevent a disease, it has to do with your lifestyle, and if you're shopping at Walmart, that's sort of your lifestyle store, and you're high risk for heart disease, okay, you look for low-sodium foods, and you go to Walmart. You buy running shoes. You do other kinds of behavior modifications. So how does your retail world merge with your healthcare world? When I think about things like that, it becomes interesting."
"What keeps me up at night right now is the fact that I don't see any movement on the part of physicians or hospital systems in adopting genetic information, and so that vision, as much as it would be feasible for a child to have their full sequence at birth, if it's not adopted by institutions and by physician groups, that's never actually going to happen, and we're not going to reap the benefits of preventive care based on the genetic foundation until that adoption actually happens."
Analytics represents knowledge; population health represents action. Too many healthcare organizations make the mistake of simply expecting their health information exchange to provide sufficient analytics to drive a population health initiative, says a senior executive at Optum.
Payers, armed with analytics technology and data, are showing signs of breaking through some of the barriers to true population health progress.
While researching my November cover story on big data, I interviewed A.G. Breitenstein, chief product officer of Optum Analytics and a co-founder of Humedica, an Optum company. Optum is a division of UnitedHealth Group, which is also the parent company for mammoth payer UnitedHealthcare.
Breitenstein says some healthcare institutions are making the mistake of lumping together their analytics and population health initiatives, when instead they should be considered as two separate disciplines.
Analytics represents knowledge, and population health represents action, she says. Too many providers make the mistake of simply expecting their health information exchange to provide sufficient analytics to drive a population health initiative.
"The real problem is with the people who are not in your office and not getting care and [who] really need to be in your office," she says. The most basic pay-for-performance initiative must be able to understand analytically "who is in the population [and] who's attributed to which contract. Each of those contracts is likely to have different quality requirements."
Whatever those requirements, population health technology at its most fundamental identifies the actions associated with getting people at risk in for visits, Breitenstein says.
Providers then need to take "a more advanced proactive management stance relative to say predicting and then preventing hospitalizations and ED visits," she says.
With only so many healthcare dollars to go around, Optum can leverage millions of lives' worth of claims data to rate where a given provider stands in cutting costs through their population health efforts.
Payers, Providers Aligning "Most of what we do today is pay-for-reporting more than pay-for-performance, so giving people the beginning of a sense of 'where do I stand' relative to other folks who are competing for the same dollars or the same contracts or the same patients" will determine success, she says.
"The world of the payer and the provider and the Berlin Wall separating them, I think are largely gone," she adds.
"And the patient as well, those divergent interests are starting to align, so everything from utilization management and utilization review, clean claims submission, getting the whole process to work better in terms of accelerating time-to-value and time-to-money also comes into this picture, and benchmarks around those as well."
I mused on how CMS earlier this year had warned providers not to get too dependent on pop-up reminders in their electronic health records to do the heavy lifting of population health management.
"It may be my background in public health predisposes me to that anyway, but I absolutely believe that if you are sort of depending upon the physician at the point of care, as an incidental matter, to be managing all of the diversity of issues that come with bearing risk and managing quality and using a pop-up decision support too, you probably miss four fifths of the opportunities to really make a difference in a population," she says.
"And the most important one you're probably missing is the opportunity to more proactively identify and stratify patients based on more predictive analytic capabilities, to design more proactive interventions that can prevent events from occurring sort of before the patient even knows to call you and come in for that visit."
"We are definitely of the Sun Tzu school that [suggests] the battle is usually won or lost before the armies have even taken to the field, and I would say that clinical decision support is the point at which the armies are already on the field."
'Cheaper Than Nurses' One Optum client, which Breitenstein declined to name, identified several hundred patients out of tens of thousands who had "preventable opportunities" to avert congestive heart failure. "They built a clever little intervention that really focused around health coaches as the primary interventional clinician," Breitenstein says.
"Much cheaper even than nurses, and they were able to reduce the hospitalization, so they indexed hospitalizations [and] took 65% of those out of that pilot population, and they took 30% of all-cause readmissions, 84% of the CHF-specific readmissions out."
"This was really a sea change," she says, "in terms of actively managing the population before they were in the hospital, taking various cost-effective and clinically effective resources, applying it to a small number of patients in a large population and preventing highly preventable and predictable events and significantly taking cost out of the system and keeping patients happier and healthier to boot."
The news may not be good for small practices, however.
"The ability to take risk occurs when a physician is participating in a larger organization that has the shock absorbers to manage risk," Breitenstein says. "That's a very different model from, we take care of the sick people that walk in, and we write a script, and we tell them what they should do and either they do it or they don't do it, and if they show up tomorrow, they end up in the hospital. We just sort of collect more money."
Seeking Clinically Preventable Opportunities An aggressive organizational change in the mental model of a healthcare organization is required to attack population health opportunities, Breitenstein says.
The focus is on "finding statistically predictable, clinically preventable opportunities, and really teaching and working with organizations to maximize those they attack, the more scale they can add to, if they win in CHF, then they go after diabetes, and then they go after pediatric asthma and then they go after combinations of those different disease states, and if they do that, they can take anywhere from 30% to 40% of those hospitalizations and ED visits out of the system," she says.
There is still the garbage-in, garbage-out problem of structured data analysis missing the clinical narrative, but here too, Optum has a strategy for success.
Rethinking the Medical Model "I'm one of the cofounders of Humedica, and Humedica's business model was built on addressing the fact that particularly the most valuable data that you find in the EMR is also typically the least structured, the most highly variable, and the most prone to errors," she says.
"Humedica's core value proposition was building a very scaled, but incredibly anal-retentive data cleaning and normalization service, as part of preparing the data for analytics of the type we spoke of."
"Early on, I heard a bunch of people sort of say stuff like, we're just going to take the 1% of high spenders and just assign them a nurse. I think people are starting to realize that that's not actually the answer either. So it's not taking the good old fashioned medical model and applying it to expensive patients."
"It's really rethinking the clinical model in light of a more population-based approach, so I think we're going to see a second phase of what we mean by analytics and population health management which is much more sort of practice and protocol focused, and that I think is going to be really exciting, because then we're going to start to see the fruits of real outcomes and real data to prove analytically what we're doing and how well it works."
A firsthand look at how a population takes on improving its population health.
The prospect of a bunch of healthcare investors investing in California's unhealthiest county as a business opportunity may strike you as a bit wacky.
Rick Brush (L) and Esther Dyson (R)
But longtime readers of this column have seen this story unfolding as twice before I wrote about investor Esther Dyson's vision of lifting the health of an entire town through a combination of entrepreneurial spirit, a radical rethinking of healthcare, a dash of technology, and community organizing.
When I last visited Dyson's nonprofit startup, HICCup (for Health Initiative Coordinating Council), it had just put out its call for participants in a bold five-year experiment: Single out five communities of 100,000 population or less, then use those communities as hothouses of healthcare innovation, attracting investment capital and innovators to upend previous cultures of isolation and disease and replace them with cultures of cooperation and health.
Since then, HICCup selected the five communities out of an unexpectedly large pool of 42 applying communities applying from around the nation. Each had to complete an exhaustive 20-page application listing its resources, challenges, and sheer determination to improve the health of its entire population.
Four communities outside of California made the cut: Clatsop County, OR; Greater Muskegon, MI; Niagara Falls, NY; and Spartanburg, SC.
Last Friday, I traveled 120 miles north of San Francisco to the fifth community, Lakeport, the county seat of Lake County. The meeting, which took place in a large Seventh Day Adventist church, was not the first meeting between HICCup officials and the community, but it was the largest, and one attended by three HICCup officials, which prompted a healthy turnout.
The area is somewhat of a paradox. At the county's center is California's largest natural body of water, Clear Lake, long a favorite of the state's fishermen and women. But Lake County also has some statistics that are nothing to boast about. It is in the bottom 5 of California's 58 counties in the health of its residents' lungs, hearts, and livers. Drug-induced deaths and suicides are alarmingly high. The scourge of meth has taken a toll, according to one community organizer.
This, then, is one of the five places where HICCup's ideas will be put to the test over the next five years. But while I have described its Way to Wellville challenge as Dyson's population health dream, making big changes in Lake County will also require tackling social ills such as inactivity, unhealthy diet, school attendance issues, and overall economic issues.
In a vignette I would be hard-pressed to invent, when I arrived in town, I stopped first at the local Safeway, where a working mom and store employee in front of me was purchasing a single item: a ten-pound bag of sugar to bake holiday pies for her children. Type 2 diabetes is a big health issue in Lake County, as it is in many other unhealthy parts of the U.S.
Encouraged by the local yearning to turn all this around, HICCup is gearing up to practically swarm Lake County with resources, including piquing the interest of employers who might move jobs to a community should its healthcare fortunes be reversed. Dyson has made some important moves, such as hiring Rick Brush as CEO. Brush was at Cigna for nearly a decade, serving as chief strategy and marketing officer for Cigna's national employer segment. While there, he launched Cigna's Communities of Health venture.
For all that, Brush was humbled and impressed by the turnout in Lakeport. Paraphrasing Martin Luther King, Jr., he told the audience, "We may be crawling at times. We may be walking at times. We may be running. But we are making forward progress together."
But Brush was not the leadoff speaker. That honor belonged to Susan Jen, Way to Wellville's "ambassador" for Lake County and director of the Health Leadership Network of Lake County. Jen proudly displayed the first Way to Wellville coffee mugs produced by a local high school class.
"We have to ask ourselves, how long is it acceptable for us to live with these statistics, and how do we mobilize for action?" Jen asked the audience. "I don't know whether I want to call it a disaster, but it is very urgent."
Calls to action, tchotchkes, mission and vision statements…yes, Silicon Valley has arrived in Lake County. And with it came innovators, companies more commonly spotted at Health 2.0 or HIMSS, but now eager to associate themselves with Dyson's latest startup and a laboratory of health puzzles to solve.
Among those who made the trek to Lakeport last week were companies with technologies that build connections across patients, caretakers and providers; a healthy food website offering incentives and discounts; a commission that accelerates health measurement and promotes creation of markets for health; and a cloud-based behavioral health solution.
No one I heard there talked about the mobile phone being healthcare's salvation, as Eric Topol would; no doubt, my one-bar cellular reception would limit the ability of the smartphone to be the ubiquitous agent of change in Lake County. The day did not revolve around technology in any meaningful way. Instead, the town meeting was all about sounding the alarm and seizing the opportunity that HICCup's selection represents.
In truth, this town hall meeting was simply a rallying of stakeholders-—including the area's two major healthcare providers, Adventist Health and Sutter Health. The real work starts between now and January, when HICCup leaders introduce the five-year initiative to the Lake County population at large.
Between now and then, there are messages to craft, business proposals and websites to build, tips to share with the other Way to Wellville communities (including most of the 37 who were not chosen but wish to stay engaged) via a brand-new social network, and overtures to be made to investors and banks to share in the healthcare savings that these initiatives may contain.
Dyson's copious connections to tech and finance will open many doors, and her energy, and that of Brush, seem boundless at this point. Since the five communities are dispersed geographically, each represents a laboratory that might be worth your time to check out as each one launches. I found my day not only a reminder of the beauty that smaller communities contain—both naturally and in the spirit of their people—but also a reminder of the urgency of the task at hand, and the need to try just about anything to move the needle for better population health.
New technology is enabling easier access to information, creating collaborative care team interaction and improved clinical outcomes.
This article first appeared in the November 2014 issue of HealthLeaders magazine.
The next generation of decision-support technology leverages natural language processing (NLP)and continues to evolve by scouring unstructured text and presenting evidence-based medicine to providers in new, accessible, and interesting ways.
In two of the latest examples, clinicians themselves contribute via a growing set of predefined queries, as evidenced by Partner HealthCare's use of QPID, a queriable patient inference dossier technology recently spun out into its own Boston-based company; as well as threaded, Facebook-like conversations behind the firewall, as epitomized by the Mayo Clinic's recent six-month pilot test of Dabo, a technology developed by a San Francisco–based company in which Mayo has an ongoing investment. The result of both initiatives, executives say, is energized physicians who are helping themselves and each other achieve healthcare's Triple Aim: improving the patient experience of care, improving the health of populations, and reducing the per capita cost of healthcare.
The QPID technology originated when radiologists at Massachusetts General Hospital, a 999-bed teaching hospital in Boston, realized they were wasting too much time hunting through electronic medical records, looking for important information when making decisions, says Greg Pauly, chief operating officer of Massachusetts General Physicians Organization. "Once this bubbled up to management, there were a variety of other potential uses for this kind of technology," he says. "That's when we added to the resources to make it available to other departments, such as the ED, GI, and PATA [pre-admission testing area]."
Easy-to-digest reports and data dashboards may be an easier pill for physicians to swallow than trying to get clinical data into their EHR workflows. Especially if their pay depends upon population management performance.
My latest HealthLeaders magazine cover story on big data started on its journey to publication with the notion that big data is only a sideshow in the healthcare analytics space. During the course of my reporting however, it turned out to be the main event of 2014.
But don't let the industry's fascination with the data analysts' newest shiny object deceive you. Garden-variety data analytics is the immediate tool at hand to realign physician incentives away from fee-for-service and toward population health.
One organization that exemplifies this is Billings Clinic, a community-governed healthcare organization serving patients in Montana, Wyoming, and the western Dakotas. Its multi-specialty physician group practices are dispersed across this geographic area and employ 320 physicians. The anchor of the organization is a 285-bed hospital in Billings, MT, which has received national recognition.
Billings serves about 400,000 patients and participates in the Medicare Shared Savings Program with 13,000 covered lives in its Medicare ACO. In addition, Billings is the sole owner of a Medicare Advantage program with an additional 22,000 covered lives, for a total of nearly 50,000 covered lives for full or partial risk. So it has plenty of incentive to find ways to get its physicians to practice population health.
Data Dashboard
Karen Cabell, DO
Associate Chief of Quality
and Patient Safety,
Billings Clinic
What those physicians need, and what all physicians need to achieve success, is relevant data served up in a straightforward way. Starting this year, Billings provided a dashboard to its physicians powered by Caradigm technology, displaying data on readmissions and patient satisfaction data.
The readmissions data can follow a patient following hospitalization to make sure physicians are doing everything they need to do to keep patients from getting readmitted, says Karen Cabell, DO, associate chief of quality and patient safety at Billings Clinic.
Caradigm gets its information from Billings' system-wide Cerner EHR, and is in the process of further developing a drill-down capability on its ACO report card/dashboard.
Find the Gaps
For now, using the original 2011 list of 33 measures, Billings can slice and dice its populations based on payer status, primary care provider, location, age, and other measures. "You can really delve down into the tool to find out where your gaps in care are, and where you're missing on your clinical quality metrics," Cabell says.
The drill-down features under development will not only let physicians see how they are performing month-to-month, but will also drill down to patient-level data, and let nurse navigators see how they are doing taking care of a panel of patients, she says.
The monthly results for each physician yield a score for each physician, and at the end of the year, that score comprises part of their compensation as well, Cabell says.
"They've got skin in the game," Cabell says. "Most provider organizations that are doing risk-based contracts, whether it be Medicare Advantage or Medicare Shared Savings or private payer ACO, you are incentivizing your physicians to perform well in the clinical quality metrics."
At Billings, the incentives have an up and a down side. Half (50%) of physician compensation is based upon traditional fee-for-service production, and the rest is based upon either clinical quality performance, or performance on access or other operational metrics, Cabell says.
An intense six-month period coincided with the kickoff of the Caradigm-generated reports, a period in which physicians had to get comfortable capturing the proper quality measures on several thousand patients electronically in Billings' EHR.
"It's difficult for physicians to start getting this volume of information back on a regular basis and have them believe it," she says. "They definitely need to have the ability to drill down into their data if they don't believe something. There's a lot of validation that has to be done, so that you can get buy-in, and as part of the whole process… we attend the monthly department meetings for each of the departments that are in this process."
Managing Chronically Ill Patients
"If you have one group of physicians that's performing much better than another group, then we kind of share information about best practice and how they got there and how they have the conversations with the patients," Cabell says.
Chronic-condition patients are benefitting as well. For patient with high blood pressure, high cholesterol, heart disease, or diabetes, who were out of control at their last visit, "we produce a report… to help you kind of chart prep better for the patient on the encounter that's scheduled for the coming week," Cabell says.
Caradigm has a long history. Originally developed as Azyxxi at Washington Hospital Center, it was acquired by Microsoft, enhanced and rebranded as Amalga, then spun out and rebranded again as Caradigm (company name and technology). Before the Caradigm rebranding, Amalga garnered few customers and a Wikipedia page that reads like an obituary.
But for the blocking and tackling of population health, the 2014 iteration of Caradigm might just clear my bar of just-enough technology, and have an advantage that other, heavier-weight analytics technologies and data warehouses lack. For example, it can serve up the latest stats in near-real time. Some other analytics packages or warehouses require more time-consuming weekly or monthly report runs and a small squad of quants to modify reports.
A Simple Data Strategy
The Caradigm approach certainly seems to be working for Billings. True, the data it produces does not flow back into the EHR, and must be digested instead in report format, but for the day-to-day workflow of a clinic, that is probably good enough.
The pain of getting analytical data back into the EHR, coupled with the pain of then having the most important analytics bubble up to the surface of an EHR already bubbling with alerts, may mean that providers such as Billings are able to focus on the immediate business of managing a population and aligning physician incentives with less fuss.
Producing simple-to-digest reports may be an easier pill to swallow for clinicians than fiddling even more with their EHR workflows, provided physicians can be persuaded to read the reports. Tying their compensation to reading and dealing with those reports is a pretty straightforward way to do it.
For now, getting physicians in the mindset that their pay depends upon population management performance, and giving them simple tools to see it for themselves, seems to be plenty of work for healthcare as an industry to get under control.
The meaningful use program, though well-intentioned, is pretty much a morass of rules, exceptions, extensions and details so mind-numbing that it inflicts its own overhead on the program.
One EHR vendor has taken to calling this the "post-EHR" era. It's a silly bit of branding, for while it may be that CIOs have their eyes on how to use EHRs effectively, they are also living in a world where their EHRs, purchased with federal incentives, are also a source of constant irritation, and I am not just talking here about their primitive user interfaces.
Instead, I am speaking of the MU program, formerly known as the MU incentive program, but now more properly referred to as the MU compliance and penalty program. In response, CMS and perhaps soon Congress will recast MU as a compliance, penalty and flexibility program.
"It is really very, very confusing, and it just keeps getting more confusing," says Pam McNutt, founder of the policy committee of the College of Information Health Executives (CHIME), whose annual conference I attended two weeks ago in San Antonio.
Here is an abbreviated rundown on the various milestones, or millstones, currently in play in MU:
1. The Notice of Proposed Rulemaking (NPRM) for Stage 3 of MU is now expected to hit the Federal Register by the end of the first quarter of 2015, after having been delayed from its previous reported release date of the end of 2014.
This is the stage the program has to get to in order to bend the cost curve and provide better quality care by coordinating electronic medical records across all Americans and all health systems. At least, that was the original intention. But read on to discover why Stage 3 is the last thing on providers' minds right now.
2. As of October 1, 2014, almost 4,000 U.S. hospitals are scheduled to begin operating at Stage 2 of MU as the 2015 reporting year begins, according to McNutt, who is also senior vice president CIO of Methodist Health System in Dallas, Texas.
At least one major U.S. healthcare system, Intermountain, says it will miss the 2015 deadline and take "many millions" in penalties. Intermountain CIO Marc Probst told me in February that Intermountain would miss its 2014 reporting year attestations for Stage 1. At CHIME last month, Probst told me that Intermountain had actually managed to attest in the 2014 reporting year at the Stage 1 level for all but two of its 24 hospitals, and as a result, will receive a $35 million incentive payment.
However, 2015 is the year Intermountain switches from its own homegrown EHR software to Cerner's EHR software. For that reason, Intermountain will not be attesting for Stage 2 in 2015. Probst says the savings from switching to Cerner will improve Intermountain's provision of care in ways that will save substantially more money than any MU penalty for 2015.
3. For the other 3,928 hospitals, hopes are pinned on H.R. 5481, the Flexibility in Health IT Report Act, also known as "Flex-IT," legislation introduced in the House of Representatives in September with CHIME's active support.
As currently written, Flex-IT would permit those hospitals and other providers to attest for 2015 in a 90-day reporting period instead of the current 365 days. When Congress returns from the election break next week, CHIME intends to introduce a companion bill in the lame-duck Senate session.
Whether it can pass, or become part of a continuing resolution before the current Congress recesses for the holidays, is unknown. But read on to find out why something happening at the end of November will make a big difference in its prospects.
4. A spot survey of 350 CHIME members just before its annual conference found that a third of its members were confident they could meet the current 2015 attestation requirements, a third were unsure, and a third were doubtful, says CHIME director of public policy Jeff Smith. Smith also noted there is a smidge of wiggle room in starting the 2015 reporting year.
For instance, providers could actually launch their patient portals late in the 2015 fiscal year, and as long as more than 50% of those patients seen in that period have timely online access (within 4 days) and more than 5% of those view, download, or transmit such data to a third party, the provider will attest successfully, even though at the start of fiscal year 2015, the portal wasn't yet operational.
That's because November 30 is the deadline to file attestations with CMS for the 2014 MU reporting year. "When we get to the end of November, that's the killer data," McNutt says. "Once we have the solid numbers, I think we'll have a lot of ammunition… if they couldn't make [Stage 2] July through September, what makes you think that they're ready for a whole year?"
CHIME president and CEO Russ Branzell says there's a chance that less than 50% of the hospitals who should have attested for any stage of MU in 2014 did so, and that less than 20% of those who should have done Stage 2 were actually able to do Stage 2. "What it means to me is, hospitals are going to have another hard time in 2015, because if you're a hospital who was supposed to do Stage 2, but didn't do it, then the lift to get there in 2015 is going to be higher and harder, and you're going to be at 365 days," he says.
Branzell adds that Congress could make Flex-IT retroactive to the beginning of fiscal year 2015, which would keep those thousands of hospitals from having to pay penalties which, unlike Intermountain's, may otherwise represent the difference between the systems making or losing money during that year.
6. Now let's talk about the penalties that loom closest. You may remember CMS's announcements earlier this year about providers filing for hardship exemptions to avoid 2015 penalties. As of May, 72 hospitals and 600 eligible providers had applied for meaningful use hardship exemptions, according to CMS. As has been reported sometimes sketchily in the media, these 2015 penalties are for failing to attest for MU Stage 1 in the 2013 reporting year. (The process of filing for hardship exemptions for the 2014 reporting year, to avoid 2016 penalties, haven't even begun yet.)
CMS previously had required the 2013 reporting year hardship exemptions to be applied for by April 1 for hospitals and July 1 for other eligible providers. Instead, now applications are due by this November 30. So even though many providers did attest in 2013, CMS is still reaching out to those who struggled unsuccessfully to attest that far back.
All in all, the MU program and the kind of flexibility described above, though well-intentioned, is pretty much a morass of rules, exceptions, extensions and details so mind-numbing that it inflicts its own overhead on the program. It is no wonder that the AMA has called for a halt to all MU penalties.
"Another thing that some people may be riding on, is that if you don't make it in 2015, and their penalty doesn't start until 2017, just like AMA has come riding in on their white horse on various other things, pressure from AHA and AMA when the penalties are actually scheduled to begin [will] stop them from occurring." McNutt says. "That's another way you could roll the dice and say, okay, well I'm gambling on something that's going to happen in two years."
Despite a Congress-mandated fourth delay of the implementation deadline, ICD-10 preparations continue, though the effect on organizations varies.
This article first appeared in the October 2014 issue of HealthLeaders magazine.
Although Congressional action has postponed the ICD-10 coding mandate until at least October 1, 2015, preparations to adopt it continue at a slower pace, even though physician opposition to the mandate remains steadfast.
"We were prepared to be ready October 1 of 2014," says Randy McCleese, vice president of information systems and CIO at St. Claire Regional Medical Center in Morehead, Kentucky, which has 110 staffed beds and 2013 revenue of about $126 million.
Like many health systems, St. Claire had purchased the needed EHR software upgrades to run ICD-10: Meditech in its hospital, and Allscripts Professional in family medicine. In early 2013, the software was in place.
"The plan was we were going to start dual-coding in ICD-9 and ICD-10 in the spring of 2014," McCleese says. "We got our coders certified. They were ready to go. We hadn't started teaching physicians as far as what needed to go there for the ICD-10s, but we'd started meeting with them, letting them know that these changes are coming."
A massive government procurement will speak volumes about the market share, and clout, of one lucky electronic health records system technology. The rest of the healthcare IT industry will be living with the ramifications of the Department of Defense's decision for years to come.
In much of tech, market share plays an outsize role in determining which standards get adopted. The dawn of the Internet was never supposed to be based upon TCP/IP, but instead on OSI protocols, which blue-ribbon committees carefully crafted to be the best possible foundation for open networks. But then TCP/IP grabbed all the market share and there was nothing left for the OSI protocols to do but fade into history.
The same thing may be about to play out in electronic health records. While the Office of the National Coordinator reboots its various blue-ribbon committees, and struggles to adapt to losing its deputy, Jacob Reider MD, and the loan of its chief, Karen DeSalvo to the administration's response to Ebola, a massive government procurement will speak volumes about the market share, and clout, of one lucky EHR technology.
That procurement goes by the acronym DHMSM, commonly pronounced "dim sum" and short for the DoD Healthcare Management System Modernization. Final bids for DHMSM are due this Friday, on Halloween. Nearly 10 million active-duty military personnel and their beneficiaries will be affected by this procurement, which will replace and migrate data out of the incumbent Armed Forces Health Longitudinal Technology Application (AHLTA).
Even though leading EHR vendors such as Epic and Cerner are competing for DHMSM, I did not initially think the DoD procurement would have much impact on the civilian market. But this isn't the entire story. It turns out that about 60 % of the care provided to DoD beneficiaries is delivered in commercial hospitals, according to Jerry Hogge, deputy group president of Leidos Health Solutions Group, the prime bidder partnering with Cerner.
Enter Epic, Cerner That kind of statistic is all you need to know about why Epic and Cerner, among others, are grasping for this win. One can easily imagine regions of the country where civilian provider will want to be aligned with the EHR at military facilities nearby. And there can be only one DHMSM winner.
But didn't large, commercial EHR vendors get the U.S. into its current interoperability mess, requiring ONC to create a fix-it plan that will take 3 to 10 years, if successful?
Well, yes. It's a funny thing. Talk to each of these vendors and they will boast how many standards they support – HL7 and its Consolidated CDA document format, SNOMED, LOINC, IHE, the list goes on and on. And the DoD procurement calls for support of these standards as well. But as we've long since learned, mere support of a set of standards does not assure interoperability.
Perhaps no more ridiculous example of just how ill-equipped today's EHRs are as communication tools than the fact that Thomas Eric Duncan, the Ebola victim treated by Texas Health Presbyterian Hospital, accumulated a 1,400-page electronic medical recordover the course of his treatment. All the standards in the world could not correct deficiencies of EHR technology which often presents too much information. Although the EHR (in this case, Epic, but it could have been any number of others) did its best not to present all 1,400 pages at once. Presenting the right information at the right time is tricky at best.
Committees are not the crucible of the breakthrough technology for which technology is best known. Standards alone did not create the iPhone. Skeptics fear, with some justification, that the ONC 10-year roadmap, or DoD's procurement, expected to be awarded next year, will produce a camel – a horse designed by committee.
But is that fair? Camels are pretty useful animals, after all.
Memories of Healthcare.gov
Also hanging over the DoD procurement is the fresh memory of last fall's bungled healthcare.gov rollout. Inside-the-beltway operatives managed to snag the contract while a disjointed team of federal agencies failed to coordinate their efforts, and we all saw the result.
In fact, the DoD tried and failed to jointly procure a new EHR system with the Department of Veterans Affairs, and despite spending $1 billion and five years of effort, it was utterly unsuccessful.
Considering the other troubles the VA's scheduling system had, some critics can be excused for condemning the old-style DoD procurement and demand outright privatization of both DoD's healthcare system and the VA.
But technology is just a tool, and so far, private industry hasn't solved the interoperability problems healthcare faces. Not even close. (For the latest example, look at how Walgreen's and Rite-Aid snubbed ApplePay so they could float their own proprietary phone payment standard.)
Moreover, amalgams of public and private initiatives bring the kind of creativity that built the Internet. Or have we forgotten the role the National Science Foundation played in doing that?
For that matter, there is a team bidding on a commercialized version of the VA's VistA EHR as the potential DHMSM winner.
Among the features of the VistA-based entrant are "federal-grade security, military-grade cyber-threat detection and response," says Dan Garrett, principal, health industries & leader of the HIT practice at PricewaterhouseCoopers, which is leading the VistA-powered bid.
Unbeknownst to many, open-source-based VistA is deployed at numerous civilian hospitals, and has its own industry consortium, OSEHRA, promoting innovation on top of existing software. General Dynamics is supplying IT expertise, and DSS, which has worked with the VA for years on enhancing VistA, has implemented a modern user interface on top of VistA.
Some industry analysts believe PwC's bid has an edge, because a core requirement of DHMSM is to have seamless interoperability between the DoD EHR and VA's implementation of VistA, as active-duty personnel retire and enter the VA system.
Is It Truly Open Source? Then there is the issue of the open-source nature of VistA. Critics point out that open source is not the same as open standards. Open source is a licensing arrangement that permits customers to see and modify the source code of the software. Most software outside of Microsoft (and even some within) contains at its core some open source-derived code – even the iPhone. VistA has a lot more in common with Linux than it does with Apple, though, since companies such as Apple layer millions of lines of proprietary code on top of or aside open source.
I recently learned that every Epic customer has the ability to inspect Epic's source code. But that is not an open source license, since those customers cannot modify the code in any way that can be shared without Epic's express permission. They would be in big, big trouble if they tried.
Therefore, VistA proponents are banking on its open source licensing to permit a level of innovation simply not possible on top of Epic, Cerner or other proprietary EHRs.
There is also a problem when the work of agencies such as the VA only makes it partway into the standards world. The VA created an application called Blue Button, which makes it easy for VA patients to download their records. Unfortunately, ONC only championed the idea of patient access, not specific data formats so that the downloaded data could become a standardized platform upon which innovation could flower.
When ONC tried to champion a standardized Blue Button, known as Blue Button Plus, specifying the data formats, EHR vendors didn't adopt it, probably because it would have helped commoditize their EHRs. DoD, for whatever reason, does not appear to be requesting Blue Button Plus, only the earlier Blue Button.
Therefore, the DoD has minimized the amount of clout it could wield in the interoperability space, and yet it still faces a difficult choice. Try to go with a market-share leader such as Epic or Cerner, and enjoy whatever interoperability that brings, or go with the VistA solution which trails in market share (outside of the VA that is) and unleash the innovation so badly needed to avoid the next 1,400-page Ebola care record fiasco.
Go with the proprietary solution, and face what could be a difficult and costly mission of seamlessly integrating with the VA's VistA, or go with the open-source solution, and face the costly mission of integrating with the leading commercial EHRs in the private sector. Either way, the rest of the healthcare IT industry will be living with the ramifications of the DoD decision for years to come.