Deriving revenue from patient education, behavioral health treatment, and ambulatory care is a hot topic among more than 40 chief financial officers attending HealthLeaders Media's fourth annual CFO Exchange.
Healthcare providers are growing their top line revenue by investing in behavioral health, medical office buildings, even athletic rehabilitation facilities – although often as minority investors, according to a gathering of hospital and health system CFOs convened by HealthLeaders Media.
In roundtable discussions held Thursday morning, the senior finance executives not only discussed growth opportunities, they also tackled cost containment, health reform, insurance exchanges, risk-based payments, care continuum coordination, IT needs, revenue cycle pressure, and other complex financial challenges.
Forty-one chief financial officers gathered at the Grand Del Mar in San Diego, California for HealthLeaders Media's fourth annual CFO Exchange Aug. 13–15.
"Our health system has, in essence, doubled in size in 5 years, a little bit through acquisition, but primarily through primary care growth [and] some specialty group acquisitions," says Jim Dietsche, executive vice president and chief financial officer of Bellin Health System in Green Bay, WI.
Among the innovations that have kept Bellin growing are an oncology program which takes patients from diagnosis to treatment in three days, an expanding orthopedics program, and a partnership with D1 Sports Training, which brought the growing national training and rehabilitation chain onto the Bellin campus.
Another provider at the CFO Exchange, Jupiter Medical Center in Jupiter, Florida, is taking a 40 percent stake in a D1 Sports Training facility as part of its service offering.
"We're trying to be involved in many post-acute care and ambulatory ventures, but we don't want to run them because hospitals generally don't run these non-acute care businesses very well," said Jupiter CFO Dale Hocking.
Another growth strategy employed by Jupiter: It's converted part of a skilled nursing facility into a detox facility that can produce more profits. "We also lease out part of the facility to a hospice, which has [also] proven to be more profitable than skilled nursing," Hocking says.
Education as Revenue Source
In addition, Hocking says health systems may gain previously unavailable revenue from the Centers for Medicare & Medicaid Services to provide education to patients on a cardiac wellness program being offered to hospitals by Healthways, which is implementing the Dr. Dean Ornish Program for Reversing Heart Disease.
"We have all of that infrastructure to do it, and you get paid a pretty good amount of money to do education," says Hocking, who adds that the hospital is evaluating its own demographics to determine if the cardiac wellness initiative could boost revenue.
Partnerships as a path to top-line growth are also continuing.
"In the past 18 months we've partnered on eight ambulatory surgery centers in our market," says Karen Testman, chief financial officer of MemorialCare Health System in Fountain Valley California. "They are joint venture partnerships with physicians and a national surgery center operator, Surgical Care Affiliates."
Behavioral Health Revenue
MemorialCare also recently acquired six freestanding imaging centers. "Our goal is to capture a piece of the growing ambulatory revenue stream and at the same time create meaningful partnerships with our physicians and others who are experts in operating in the freestanding ambulatory environment."
"In addition to our focus on ambulatory growth, we have also recently entered into affiliations with UCI Health to expand primary care access and with Torrance Memorial to expand pediatric access in our local communities."
At Firelands Regional Medical Center in Sandusky, OH, its standing as one of the largest providers of outpatient behavioral health counseling services in the state is now allowing the organization to be the recipient of federal grants aimed at reducing drug and alcohol addiction, says Daniel J. Moncher, executive vice president and chief financial officer.
The behavioral health move is benefiting other revenue streams, Moncher says.
"We've been the beneficiary just recently of grants to do a patient-centered medical home for behavioral health patients, because they tend to have acute care issues and primary care physician issues, but they don't have a doctor," Moncher says.
"Just because of the nature of that patient, they don't take care of themselves clinically. So we've gotten grants and actually put inside of our counseling centers nurse extenders and PAs, and they actually take care of those patients, and that's grown our outpatient revenue."
Outpatient Revenue Growth
After evaluating acquiring other hospitals to grow revenue, Mission Health System in Asheville, NC, decided instead to build medical office buildings in those rival hospitals' service areas, says Mission senior vice president of finance and chief financial officer Charles Ayscue. "We just opened a 30,000 square foot MOB and three more are in the works, one in an area with a new market tax credit."
Since 2010, Mission has grown its outpatient revenue from 32 percent to "the mid-40s," Ayscue says. "We won't settle until we can get that percentage up to around 60 percent."
One barrier to revenue growth at some hospitals: capacity constraints.
"Last week the occupancy at one of our hospitals was at 101 percent for several days," says Beth Ward, chief financial officer of University Hospitals and Clinics, UT Southwestern Medical Center in Dallas, Texas. "The other hospital was at 96 to 98 percent. So a big issue with us is throughput [and] length of stay. We're quaternary/tertiary care. We don't have a lot of the lower-acuity activity that you would find in other hospitals."
Even though revenue growth opportunities seem promising, numerous executives remain nervous about shifting healthcare market conditions that could shrink their existing revenues.
In the past several weeks, MemorialCare has heard of several large local employers who are considering getting out of managing healthcare insurance, so that healthcare would be arranged between physicians and patients directly.
The talk "woke us up a bit, because we had been talking about going direct to employers," Testman says. "If they actually do that, it would definitely change our strategy on the commercial front."
Innovation is tough. "Failure is definitely part of the process. It becomes an opportunity if you can transform each failure point into a navigation beacon to solve the next problem," says Unity Stoakes, co-founder and president of StartUp Health.
Unity Stoakes
This week, the conclusion of my conversation with Unity Stoakes, co-founder and president of StartUp Health, which runs a three-year "startup academy" for healthcare technology companies. Read Part I.
HLM: Do you believe the role that an organization like StartUp Health plays will be complemented by the innovation centers I see springing up at healthcare institutions themselves, whether that be Partners or Mayo or whoever? Some of the inventors are coming right out of healthcare – doctors who are tech savvy.
Stoakes: We have to work together. There's been a lot of wonderful innovation centers internally at some of the largest stakeholders in healthcare. Those can be good for intrapreneurship, where there's great talent within these companies that can keep building things. But a lot of the great invention throughout history comes from new startups that think about solutions in completely different ways.
There's a serendipity approach. There's a naiveté approach, where some of the best solutions get created almost by accident, from outsiders. But you'll see a bridging of the gap where those leaders in healthcare will start to acquire some of these companies, will start to invest in some of these companies. We're already seeing this.
HLM: Samsung's putting in money, as is Apple. How important will their movements in this market be?
Stoakes: Health consumerism is going to drive a lot of the innovation. The concept of price transparency, couple that with the fact that there's new services, new technologies, new tools being made available to empower consumers, and new platforms to build whole companies on, and then you get some of the greatest brands of our time.
Whether it's Google or Apple [that] focused on this… it creates a whole new environment for where things are going that will impact our health and wellness. But what about automotive companies as an example? What about airlines? What about manufacturing companies that build refrigerators?
You start to see how, for a variety of reasons, these companies will become healthcare companies. When you look at Apple, Samsung, Google and IBM's announcements altogether in context, there's definitely an 'aha' moment.
It's almost the next wave of infrastructure and innovation that's happening in the sector. One of the outcomes will be more of a focus on software and the applications, and less of a focus on the hardware itself.
HLM: Healthcare is regulated not just by Washington, but by 50 states. What could they do better?
Stoakes: The HITECH act created a lot of innovation funding for startups. The ACA created an opportunity for competition and for new business models to emerge. It's broken the stagnation that's happened for so many years. At a regional level, there are certain markets that are really seizing the opportunity.
New York, for example, has been very effective in terms of supporting innovation. They've opened up a lot of data. New York City has a whole big apps program for health. They've opened up a lot of city data, health data. It's called Big Apps. This started in the Bloomberg administration and it's continued on.
HLM: Do you ever hear people say, all this technology is great, but who's going to pay for it?
Stoakes: I hear that all the time. A lot of the business models are in flux right now. There's a lot of mystery around who the payers will be. What I do know is when there's a changing environment, or this moment of creative destruction, that creates a lot of opportunity for new entrants.
It was once assumed that people wouldn't pay for their own healthcare. I think that's a fallacy. We're starting to see that change. Whether it's pay for a device, or pay for a service, or pay for some new type of care, you will see consumers pay for healthcare.
And we're already starting to see new risk-based models emerge, where there's different types of incentive structures around healthcare services, so instead of the fee for service, it's more based on quality care or results. If you have a business that can prove you can save money or create efficiencies or improve care in some tangible way, there will be plenty of opportunities.
HLM: What's your attitude on failure? You've got so much invested in all these companies. Some of them are going to fail. That's part of innovation, part of the discovery process. How do you manage failure?
Stoakes: Failure is definitely part of the process. It becomes an opportunity if you can transform each failure point into a navigation beacon to solve the next problem. If it becomes a data point to help you improve and recalibrate for the future, then it becomes an opportunity.
So we see the best entrepreneurs pivot, learn from experiment, really navigate around the challenges over time. If you balance failure with persistence, it can become a great asset.
HLM: What has been an interesting pivot in your group of companies?
Stoakes: We have a really great company, now called Maxwell Health. It started as a company called Daily Feats. They started as a rewards and incentives platform to help [consumers] with behavior change. [Now] they're more of a service layer on top of health insurance. Really interesting behavior change solutions on top of health insurance.
So a completely different customer, a completely different experience, but still focusing on behavior change. The end result, the benefit for the person, is still the same. So they reworked their whole business and now have a really successful business.
HLM: You're not an accelerator or an incubator.
Stoakes: What we realized very early on is that a long-term approach to building a business and specifically focusing on customer development was needed in healthcare, because the business models are shifting, the sales cycles are very long, and often times the regulatory and compliance issues take a long time to navigate in healthcare.
So we created a three-year program, what we call an academy. It's also a network and a community, so we've organized 25,000 stakeholders who are members of the StartUp Health ecosystem. These are investors. These are customers like hospitals and insurance companies. And [these are] innovators themselves.
By one measure, the amount of money invested in healthcare startups in the first half of 2014 exceeds the total amount invested in all of 2013. The co-founder of StartUp Health talks about where innovation is headed.
While the healthcare industry struggles to meet its mandates and stay in business, players outside the traditional industry have not been idle.
Unity Stoakes
Google recently announced its Google X Baseline study to map the human body. In June, Apple launched its new Health app and HealthKit developer tool, to build an application platform for innovative mobile solutions. IBM promptly signed a deal with Apple to integrate its Watson analytics platform with Apple's technology. And Samsung announced it was investing $50 million to accelerate innovation in personal health.
By one measure, the amount of money invested in healthcare startups in the first half of 2014 exceeds the total amount invested in all of 2013.
To make sense of what some of these investments mean, and why they are happening now, I turned to StartUp Health, a global three-year "academy" for health and wellness startups. The 71 companies participating in StartUp Health have collectively raised $150 million in capital across seven countries. Nearly half (47%) of these companies were founded by physicians or practitioners.
HLM: So what startup areas are hot now versus six months ago?
Stoakes: Big data and analytics is definitely still hot, but in different ways. We had a company, Aver Informatics, announce an $8.5 million round. They take bundled payments data and use that to find price efficiencies in the marketplace, on behalf of payers and employers. Everything related to sensors is gaining a lot of traction.
There's been the story of how those have impacted the consumer landscape. But now you're seeing them integrated into hospitals as an example.
So you take our company IntelligentM, where they're tracking how providers or clinicians or healthcare workers are washing their hands. Not just 'did they move by the sink?' but did the correct motion happen for 15 seconds? …Did they wash their hands when they entered the room, when they left the room, when they went by the syringe, when they left the syringe?
So using sensors in very interesting ways. The price of sensors has come down so much. They're getting smaller, so they're being integrated into everything, and the data's now being connected to things in very interesting ways, and now you mix that with the big data and analytics platforms, they're able to analyze this data in more interesting ways.
HLM: What's your opinion of the head-mounted display area and how real that is? There's been some high coverage in the press of places like Beth Israel Deaconness and places like that. There seems to be a lot of grassroots interest in Google Glass, but do you think it's the right time to be building entire companies around that platform, given that it's so new?
Stoakes: We're really in the first inning of the innovation cycle in terms of those types of technologies. You have to start there. They're very rudimentary. A lot of the details around privacy, for example, haven't been figured out.
There are applications of those types of technologies that will proliferate much more quickly than other areas, so for example, surgeons adopting something like Google Glass and using it as an instrument during surgery might be a lot more relevant than some futuristic concept where every nurse is wearing one and it's got the patient record on it and things like that.
There's going to be very tangible, practical use cases where we'll start to see traction, and then over the years, as the technology gets better, as it gets more affordable, as it gets more useful, we'll see those types of tools used in many exciting ways.
HLM: I write about health information exchange, and issues such as patient ID and master-patient index technology. Do you see startups bringing interesting things to the table right now to help providers with those knotty problems?
Stoakes: Yeah. One of the core concepts around what we're doing at StartUp Health is that there's going to be this army of entrepreneurs and innovators that are going to be the ones rebuilding the solutions for all of those types of issues in the marketplace.
The big challenge we have now is really bridging the gap where the entrepreneurial ecosystem understands the marketplace needs, understands the true problems that the industry has, so they can start to build these new solutions, rather than just build something that looks cool or seems like a good idea.
HLM: There was a revolt in Georgia recently. All the doctors gave the CEO of a regional medical center a vote of no confidence, because their EHR implementation was bungled. It was a Cerner implementation. They voted him off the island. He is out. What is the opportunity for a whole reimagining of the EHR itself, due to so many botched implementations of them, and they're so heavyweight, so ancient in their pedigree?
Stoakes: There really is an opportunity for a leapfrog effect in that. We as consumers have come to expect a certain ease of use. We're used to our iPhones or our Androids. We're used to our Nest devices now. We're used to things just working in simple ways [and delivering a] beautiful design and user experience.
The truth is, providers and doctors and nurses expect the same thing, too.
So when they're in their day-to-day lives doing their job, and the tools during their work day don't work as elegantly as what they're using as a consumer, that's a problem. But it's also an opportunity, so I believe these challenges are going to be resolved pretty quickly over the next few years, by a leapfrog effect.
HLM: It seems the incumbent EHR vendors have thrown up all these opportunity roadblocks, of the meaningful use program, certification – this thing that does a thousand different things, probably none of them well. It's a roadblock to new entrants. We're either going to have a revolt, like those doctors in Georgia, or something's going to change so that new entrants can get to the playing field and the opportunity.
Stoakes: We saw this in the software industry years ago, where there would be bloated software, where there would be very complicated computers, and then over time, consumer-friendly PCs came to be, or consumer-friendly software, or Web-based tools came to be.
It takes time, but one of the good things we're seeing happen is, design and user experience is becoming as important as the actual engineering of these new solutions. Healthcare is a unique opportunity in many ways.
The safety issues, the diligence that's required to create solutions, but also the regulatory environment, as well as the established industry is so key to the solution here. The music industry or the travel industry can sort of go around entire aspects of the industry. In healthcare, much more of a collaborative approach is required, so that the innovation works with regulation, and works with the established industry.
They really need to work together in unison in order to be effective. Whereas in other industries, you can bypass completely. That being said, I still believe there's an opportunity, and I believe the entrepreneurs are going to be the ones that end up solving these big challenges that industry has today.
Next week: The conclusion of our conversation, including what a global "academy" for healthcare startups does, the role Apple and other new entrants will play, as well as more about centers of innovation within healthcare providers themselves.
When it comes time for healthcare providers to get paid, forget complex algorithms and cutting edge reporting systems. It's the lowly JPEG—yes, the common PC image file format—that's bringing home the bacon.
So much of the sizzle of healthcare information technology seems like a tour of the bridge of the starship Enterprise, or perhaps a quick sprint through Starfleet engineering.
Sophisticated analytical algorithms tease out hidden provider or patient behaviors. Google Glass offers up in-clinic encounter hints and notes. Increasingly miniaturized mobile technology tracks "quantified selfers" who expect up-to-the-minute telemetry on what's ailing them.
But when it comes time for providers to get paid, the lowly JPEG, a common PC image file format, is bringing home the bacon.
According to the 2010 National Ambulatory Medical Care Survey, more than a billion ambulatory care visits per year produce claims or encounters with 13 percent requiring attachments, each of which averages 3.2 pages in length, before the payer could adjudicate the claim and pay the provider.
The annual claim denial rate in 2013 was 2.17 percent. That translates to managing more than 70 million attachment pages annually, as providers try to get paid by submitting (or resubmitting) appropriate documentation.
Boca Raton Regional Hospital, with 400 beds, is probably pretty typical when it comes to striving to get its claims paid. Rudy Braccili, Jr. is executive director of revenue cycle management and a previous leader of Tenet Healthcare's National Medicare and Medicaid Center in Florida.
If Medicare had a ground zero for patients, Florida would be it. Boca Raton's payer mix ranges from 65 to 75 percent Medicare.
"The hospital industry has been steadily moving toward replacing paper submissions of all administrative type paperwork from paper to electronic," Braccili tells me. "The industry's been moving in that direction for 15 years, slowly, and arguably slower than most other industries." A few years back, submission of claims to payers went electronic; payments, a.k.a. remittance advice, also went electronic.
But where payers take issue with what's been submitted by a provider, and request additional documentation, technology lags behind in too many places.
"There has not been an electronic solution," Braccili says. Too often, providers' claims submitters have had to locate appropriate electronic patient medical records, print them out, then mail or fax them to payers.
The medical records themselves may now be electronic, but when you print it all out, including documentation by physicians, nurses, pharmacists, nutritionists and physical therapists, it's blizzard conditions. There are boxes and boxes of dead trees clogging mail rooms even in hospitals with bright, shiny new EHRs running on clinicians' desktops.
What's more, once a communication leaves a provider's IT system and enters the mailroom of provider and payer alike, too often the opportunity exists for the documentation to go astray.
Even if that doesn't give you the HIPAA willies, think about how it slows down the provider revenue cycle. When providers can send this documentation electronically, payers can no longer plausibly deny they ever received such documentation.
Enter the JPEG
In 2011, after giving a presentation, Braccili was approach by a representative of MEA, short for Medical Electronic Attachments, a clearinghouse for scanning the needed attachments, such as before-and-after pictures of a hip replacement—documentation that can get a claim paid. MEA takes care of getting the attachments to payers, and confirms back to payers such as Boca Raton that they were received.
MEA had just submitted a request to CMS to become a certified Health Information Handler (HIH), a group with which CMS was preparing to pilot Electronic Submission of Medical Documentation (ESMD). MEA became one of an initial dozen HIHs, and remains the second largest of the two dozen currently registered, according to Lindy Benton, CEO of MEA.
"We had been waiting and wanting electronic medical record submissions to Medicare for years," Braccili says, shuddering at the thoughts of RAC audits he's known. "It's awful without it. We couldn't say yes fast enough."
Two years ago this August, Boca Raton submitted its first medical record to its Medicare Administrative Contractor, First Coast Solutions of Jacksonville, Florida. Because MEA's service is not yet entirely cloud-based because of security precautions, Boca Raton had to download a small program to its medical record professionals' PCs in order to run the service.
"The install was done 95 percent without the involvement of our IT department, which is extraordinary for any kind of implementation that I've ever witnessed in my career," Braccili says.
Medical records professionals access Boca Raton's previously installed in-house electronic repository, find the specific documents they need to send, and create JPEG files, which MEA then grabs and allows to be transmitted to Medicare with a single click. Confirmation of receipt arrives back from Medicare the next day.
The new business process moved the hospital from a claim denial rate of 40 percent to zero, and has saved the hospital a cool half million.
By the way, the next time payers want to impress you with their advanced analytics, ask them why payers have no nationally adopted standards for submission and receipt of these claims-related attachments, necessitating the creation of companies such as MEA to solve the problem.
Are mailrooms at the trailing edge everywhere? "Payers are in the business to make money off the float," Braccili suggests.
But with just enough technology, they will be making a little less, and putting money back in the pockets of providers more quickly.
For hospital and health system boards, CIOs, and CISOs, better data breach analysis tools, or more consistent legislation cannot come soon enough.
Earlier this month, the HHS Office for Civil Rights issued its Annual Report to Congress on Breaches of Unsecured Protected Health Information, the second such annual report. The findings are sobering.
From September 2009 to December 2012, OCR received 710 breach reports affecting approximately 22.5 million individuals. The frequency of those breach reports, according to one tally, is spiraling upward, up nearly 46% in the period between January 2014 and May 2014 over the same period in the previous year.
Another recent report notes that more and more organizations are learning of breaches by phone calls from, among others, the FBI.
Criminal prosecutions, always permitted under HIPAA, may be on the rise. In March, U.S Department of Justice indicted a former employee of an unnamed East Texas hospital, charged with wrongful disclosure of individual identifiable health information in violation of HIPAA.
The former employee faces up to 10 years in prison and a fine of $250,000 if convicted, according to the indictment, unsealed in July. While such indictments are rare, the recent toughening of enforcement actions may anticipate the growth in such criminal indictments.
The OCR itself continues to step up its game. At a recent American Bar Association Health Law Section conference, a chief regional civil rights attorney from OCR warned that covered entities can expect enforcement to increase dramatically, along with fines.
About the only reprieve covered entities can expect will be brief, as incoming OCR chief Jocelyn Samuels transitions over from the civil rights division of the Department of Justice. But she will be on duty soon enough, succeeding Leon Rodriguez, who moved on to a post in the Department of Homeland Security.
Breaches Shift to Online
A preponderance of previous breaches were triggered by lost laptops or misplaced boxes of paper records. But those days are rapidly fading. Today's breaches are increasingly taking place via the same Internet that enables easier patient access and legitimate health information exchanges.
Criminal hackers are also targeting bigger repositories of data, such as state departments of health. The state of Vermont recently confirmed that a development server of the Vermont Health Connect, the state's health insurance exchange under the Affordable Care Act, was the target of cyber-attack last December.
Investigators traced the attack to an IP address in Romania. Another cyber-attack hit the computer server of Montana Department of Public Health and Human Services.
The fines are adding up as well. Parkview Health System in Fort Wayne, Indiana recent paid an $800,000 fine to OCR for unloading 71 boxes of records in a doctor's driveway. But again, that's just paper. The amount of information in those 71 boxes could be dwarfed by a single digital compromise from a cyber-attack.
A Patchwork of Laws
And federal penalties aren't the only ones waiting to trip up covered entities. Data privacy regulations vary from state to state. Recently, Florida toughened its breach notification law, which is also prompting greater calls for more uniform state breach notification laws nationwide.
Right now, those laws vary. A lot. For instance, the California Confidentiality and Medical Information Act carries a $1000 penalty per patient if a provider discloses certain medical information without the consent of the patient, says Ted Kobus, partner and co-leader of the privacy and data protection team at BakerHostetler, one of the largest law firms in the U.S., which represents covered entities in data breach cases at both the state and national level.
"Documenting and compliance are the two most important things," Kobus says. "If you're forced to do something that may not be exactly the way that you think the security rule requires you to do it, or you make a decision and accept a risk, the key is going to be documentation. If OCR comes in [and] they see that you've documented that risk, you've understood that risk, and you've responded to it in a certain way, whether it's physical controls or administrative safeguards or some other technological safeguard, you're going to be in a much better position."
Large providers, as usual, are in better shape. "The problem is there are so many healthcare providers that have small physicians' offices or small surgical centers, that may not be as prepared as a sophisticated health system," Kobus says.
What is a Data Breach? "They don't really understand the extent of compliance that's going to be required. Many of them just aren't prepared to deal with an OCR investigation, and they're not prepared to show their compliance with the HIPAA security and privacy rules."
When I first talked to Kobus a year ago, as I reported on the HIPAA Omnibus legislation then going into effect, he was looking forward to tools the OCR said it would provide to help covered entities go through breach analyses.
A year later, he is still waiting for the release of those tools.
"We really haven't seen any firm guidance on what is considered to be a breach and what's not considered a breach," Kobus says. Some covered entities might also be over-reporting breaches due to lack of such tools, he adds.
"Over-notification doesn't serve anyone well," Kobus says. Those notified of a potential HIPAA breach may become blasé about such notifications; when they receive one that they should pay serious attention to, then they may discard the notification due to a string of prior notifications that led to no serious consequences.
The other event that probably colors the uptick in HIPAA and state breach law notifications is the Target data breach in the 2013 holiday season. "The reason everyone is talking about Target is not because of the numbers, because we've had breaches larger than Target," Kobus says.
"The reason is because every single American was affected by Target, because you either shop at Target, or you know someone who shops at Target. So everyone you know has been affected by this in some way."
The result is "a discussion that's occurring at the board level. People don't want to be the one where it happens on their watch."
For those boards, CIOs and CISOs, better breach analysis tools, or more consistent legislation cannot come soon enough. As more and more healthcare data flows across the Internet, expect more breaches, more headlines, more fines, and more questions than answers.
At Mt. Sinai Health System in New York, a combination of personalized medicine, natural language processing, and clever integration with electronic health record software is allowing clinicians to adjust medication selection and dosages based on patients' genomic differences.
Omri Gottesman, MD
Personalized medicine is one of those technology topics that perpetually comes up in conversations about The Next Big Thing.
Think combining genomics data with population health, throw in some predictive analytics, and you've got the basic idea.
As a direct-to-consumer play, personalized medicine has run into some roadblocks, and at least one big setback. See the FDA's takedown of 23andMe's service that tested consumers' genomes and suggested correlations to particular predicted conditions or diagnoses.
But within the controlled environment of a health system, personalized medicine is making inroads.
At Mt. Sinai Health System in New York, a combination of personalized medicine, natural language processing, and clever integration with electronic health record software is allowing clinicians to adjust medication selection and dosages based on patients' genomic differences.
The clever integration, invented at Mt. Sinai, is the Clinical Implementation of Personalized Medicine through Electronic Health Records and Genomics platform, or CLIPMERGE for short.
Heading up development of CLIPMERGE was Omri Gottesman, MD, a UK-trained physician-scientist focused on the translation and implementation of genomic and data-driven medicine into clinical practice.
Gottesman's work focuses on developing and evaluating tools and best-practices that will facilitate the translation and implementation of genomic and data-driven medicine into clinical practice today.
Much of this involves the Institute for Personalized Medicine BioBank, a clinical cohort of more than 30,000 Mount Sinai Hospital patients who have donated their DNA to an electronic health record-linked DNA biorepository. These patients have consented to research on a de-identified image of their medical record and to being re-contacted for clinical trials.
Gottesman's work at the IPM has included clinical data representation and electronic phenotyping—creating case definition algorithms that leverage information from the electronic medical record to automatically assign case and control status for use in Genome Wide Association Studies (GWAS), replication studies and implementation trials.
"We wanted a way to be able to implement this kind of genomic medicine at the point of care, and so we built the CLIPMERGE system," Gottesman told me.
"It sits on top of the electronic health record and communicates with it in real time, and so when a consented patient is filling [a prescription] with a Mt. Sinai physician, if there is something relevant for us to say, then we respond and interject in the clinical workflow by firing clinical decision support which kind of pops up on the physician's screen and gives them advice that's tailored by the patient's data, be it genetic or otherwise."
CLIPMERGE alerts are already able to fire based on three paired relationships between genes and drugs. So far, the drugs are clopidogrel, simvastatin, and warfarin, and, soon, codeine will be added.
"If there is a pharmacogenomic reason why that patient should not receive that medication, then the alert fires on the provider's screen," Gottesman said.
"In the case of simvastatin, there is a genetic variant that predisposes a patient to a higher risk of a side effect of simvastatin called statin-induced myopathy, and if a patient has that genetic variant, and is prescribed certain doses of simvastatin, then an alert flashes on the provider's screen that says, the patient carries this genetic variant, which places them at higher risk of statin-induced myopathy. Consider prescribing a lower dose of simvastatin or a different statin."
Mt. Sinai's early outcomes aren't public yet. In fact, the studies are still accepting patients. The results will be the subject of peer-reviewed publications to start appearing at the end of 2014 or later, Gottesman told me.
There's also a role for another potential breakout technology, natural language processing (NLP), in the Mt. Sinai studies. The reason why this is has to do with the way doctors enter medication information into EHRs.
"What we were finding was that even though 40 mg of simvastatin were prescribed, actually the patient was only being prescribed 20 mg," Gottesman said. "The reason that was, that there was an option in the electronic medical record, if a medication is being re-prescribed, you could re-prescribe the existing dosage and modify it.
"What I mean by that is if a patient is taking say 40 mg of simvastatin, and the provider wanted to halve that dose, they could re-prescribe the simvastatin and put in the comment section, they could put take half a pill at bedtime."
The inverse of this is also true. If a patient was on a 40 mg dosage of simvastatin, and the care provider wanted to double that dose, they could re-prescribe 40 mg and put in the comment section, take two at bedtime.
"So what the CLIPMERGE platform was receiving for a patient that being prescribed 20 mg was 40 mg, so that was incorrect, and if a patient was being prescribed 80 mg, in those situations we were receiving 40 mg, which meant that the genome-informed clinical decision support that we were returning to the EMR was incorrect, because it was based on the wrong information."
The solution was an NLP technology, in this case from Clinithink, that turned the narrative text into something discrete that CLIPMERGE could recognize, to adjust recorded dosages accordingly, Gottesman said.
Where today there are four drug/gene pairs being processed by CLIPMERGE, in the future we will see dozens, hundreds, and eventually thousands. Some patients will balk at signing the consent forms that allow these alerts to fire. Others will welcome the information.
Physicians themselves will also have to adjust to a growing number of such alerts. Over time, it may become the standard of care.
It may be that each large medical institution will eventually have its own tech take on personalized medicine. Over time, expect the best of these ideas to either be licensed widely through the healthcare industry, or else be absorbed into existing EHR and analytics software, so patients everywhere can benefit from these ideas.
For the time being, savvy patients will need to shop around to see which providers are offering what flavors of personalized medicine.
If the top dog in the EHR food chain is feeling like he is dragging regulatory chains around, then we have a technology modernization program that is, at best, troubled, and at worst, in crisis.
The federal government's EHR certification program is in disarray and may not be able to achieve its most important outstanding aim—to provide interoperability between different vendors' EHRs—anytime soon.
This despite CMS's meaningful use audit program striking terror in the hearts of even the staunchest healthcare CIOs, who fear an overlooked detail will lead to hefty givebacks of EHR incentive payments.
ONC's distracting effort to push forward with a 2015 set of EHR standards itself has generated a massive amount of negative feedback, and accusations that the organization hasn't incorporated three years of extensive public feedback into a troubled program. Now the program is facing considerable budgetary limitations as its original Congressional funding runs out.
Carl Dvorak, chief operating officer of Epic, the largest, and probably most profitable EHR vendor, recently testified that his job makes him "one of the people who wears the chains and drags the cinderblocks of [EHR] certification through life."
Meanwhile, Dvorak says he watches ONC "stand on the stage with West Venture Capital Funds people and… shuttle money to the smart medical record people in Boston, and I do get a sense of disparity."
Regulatory Chains Folks, if the COO of the top dog in the EHR food chain, at a company swollen with much of the $23 billion handed out in meaningful use incentive payments, is feeling like he is dragging regulatory chains around, then we have a technology modernization program that is, at best, troubled, and at worst, in crisis.
Meanwhile, in response to a banshee-howl from the AMA, CHIME, AHA and just about every other professional organization in healthcare IT, ONC and CMS are methodically in the process of extending Stage 2 of the meaningful use incentive program such that the obligations of providers to attest to achieving Stage 2 are extended at least into 2015.
This spring's finger pointing in Washington at vendors failing to get certified products to market has long since faded, replaced by a chorus of criticism that regulators at CMS and ONC created a hydra-headed set of implementation guidelines which made Stage 2 attestation reachable by only a handful of providers so far.
"Whether you call it evolution or revolution, there is groundswell among the peasantry calling for sweeping changes to the CMS EHR incentive programs," wrote meaningful use audit expert Jim Tate in late May.
Triggering Tate's rant was a CMS proposed rule, called for by most of the industry, offering relaxation in the requirements to achieve meaningful use in 2014.
A Backlog The proposal is a byzantine menu of options for providers, with the common running theme of providing relief from deadlines which would have come crashing down upon their heads this October. "Although 2014 Edition CEHRT may be available for adoption, there is a backlog of many months for the updated version to be installed and implemented so that providers can successfully attest for 2014," the NPRM states.
The NPRM proposes that providers be able to continue using 2011 edition certified software, or a combination of 2011 and 2014 certified software, during calendar year 2014, but withhold incentive payments for any provider still running 2011 edition software.
"CHIME supports the new pathways as defined in the proposed rule," CHIME's letter to CMS reads:
"We believe these options will provide needed flexibility for EHR optimization, encourage continued participation in the program and help maintain the upward trajectory of EHR adoption in the US. This is a necessary extension to give policymakers time to evaluate past experience and incorporate lessons learned into the third stage of Meaningful Use."
But a theme of public comment so far is that even a one-year relaxation of stage 2 deadlines is not enough.
One of CHIME's primary requests is that the Centers for Medicare & Medicaid Services allow providers to choose any three-month quarter for an EHR reporting period in the next federal fiscal year or calendar year to qualify for Meaningful Use in 2015. As currently structured, the program requires providers to report a full year of data to qualify for incentives.
'EHRs are Seen as Cumbersome' The AMA, which traditionally takes more issue with the requirements of EHR implementation or meaningful use than CHIME or other groups, wants more relief than that. "EHRs are seen as cumbersome" by AMA members, testified Mari Savickis, AMA assistant director for medical affairs, at an ONC hearing in May.
Meaningful use adds "extra steps in their workflow. Many of these steps are smattered across the EHR with little identification to how they provide value back to the care of the patients," Savickis added.
Instead, AMA continues to urge that meaningful use be pared back to a program "focused on promoting meaningful data exchange, improving the ability to report clinical quality measures, areas which are mandated under HITECH and with the industry as a whole experiencing serious challenges."
The capper to AMA's proposal: providers should only have to achieve 75 percent of stage 2's requirements to obtain an incentive payment, and only 50 percent in order to avoid a penalty.
While ONC and CMS are unlikely to agree to AMA's demands—indeed have shown a history of fairly ignoring many such demands in the past—it seems like meaningful use at this rate may end with a whimper and a bang. Whittled down by some combination of government mismanagement, vendor burnout and/or malfeasance, and provider exhaustion, meaningful use may be about to enter a kind of life support status, at least for a year.
The bang will come when Congress comes asking where the $24 billion went.
After public comment ends, the other missing continuency, the patients, will probably also weigh in. It's a sad state of affairs that the continuing dialogue about how to fix this increasingly troubled program hardly ever seems to get around to what's best for them. Clearly, what the industry is trying to do for them right now isn't working very well at all.
After emergency surgery, a few observations on the clinical narrative, the value of the medical record in any form, and the small miracles that make our healthcare system hum.
On Monday, June 16, I was preoccupied, preparing to head to the annual Computer-Physician Symposium run by AMDIS in southern California. But I had a scheduled doctor's appointment to tick off my to-do list first.
Fortunate thing.
A block from my doctor's office, as I was crossing a street in Alameda, California, I felt like my guts had been sliced open. I doubled over in pain and, with effort, continued to my doctor's doorstep.
In the exam room, my doctor found my abdomen distended and me generally feeling like I wasn't going anywhere but the emergency room.
The staff called me a taxi, and 15 minutes later, I was at Alameda Hospital, gladly accepting a wheelchair ride. The pre-op history report told the story: "CT scan shows acute appendicitis."
So, that night, into surgery I went. Initially, the surgeon detected "no sign of perforation" and I remained "alert and oriented" going under anesthetic. But, once inside, he found a "gangrenous appendix with perforation" and what should have been a 30-minute procedure took two and a half hours. It sounds just about as awful as it felt.
I awoke Tuesday with a drain in my side and no appendix. By Friday, I was also down one leather jacket. I had changed rooms twice since my surgery and forgotten I had even had the jacket when I arrived at the hospital. A check the following Monday yielded sympathy from staff, but no leather jacket.
But who am I to complain when I had just survived what can be a life-threatening condition? A month previously, I had embarked on a marathon cross-country business trip. To have this happen when I had safely returned home, a block from my doctor's office, has to qualify as a blessing.
My care at the hospital was attentive and responsive. I am so impressed by what nurses accomplish day after day, night after night. I was one of the younger patients on the floor, and some there naturally had much graver conditions than mine.
Although I've often advocated for patients, something about being near them and their suffering makes me open anew to their experiences and needs.
Thoughts on Tech At Alameda Hospital, technology is present but not omnipresent. The 281-bed hospital, which sports 100 acute care beds, 35 sub acute beds, and 146 skilled nursing facility beds, recently became part of the Alameda Health System, a major public healthcare provider in the East Bay region of the San Francisco Bay Area.
Mostly I was smitten by the hospital's location, nestled between two lagoons on the island of Alameda, set back from the main street, with windows that opened, barely the sound of a siren, or even a car alarm. Twice a day, someone on a PA system asked for those with cars blocking the portable MRI van to move them. But that was made up for by the occasional sound of a passing ice cream truck.
As technology editor, of course I wanted to know everything about my condition as soon as possible. But the healing process isn't helped by checking one's online medical record every five minutes.
Those things that truly helped me heal often boiled down to things like the kind advice of a nurse to take ten deep breaths an hour, or my willingness to get up out of bed and walk, as determined to use my feet to improve my condition as if I were trying to induce labor.
Someone, I don't remember who, also cracked wise that under Obamacare, if I liked my appendix, I could keep my appendix. I smiled wanly and suggested that I was not as fond of my appendix as I used to be.
Just the Fax That following Monday, as I tried to retrieve my lost jacket, I also was able to obtain a paper copy of my medical record, and to send a copy of it along to my primary care physician, via that old reliable, the fax machine.
The narrative of the laparoscopic operation itself reads like something of a cliffhanger. I will spare you its entirety, but this passage will give you an idea:
"…There was evidence of perforation. The appendix was tenaciously adherent to the surrounding tissues. These adhesions were taken down carefully…"
After discharge, a week's rest was just what the doctor ordered. During that time, I saw some things pass my radar that made my eyebrows rise—still ten years to achieve healthcare interoperability? Really? Do we have that long?
But for now, I am glad to be on the mend, with a fresh perspective on the practice of medicine, the value of the medical record in whatever form, the value of the clinical narrative, the many small miracles that make our healthcare system continue, and the tireless work of so many to fulfill the promise of our system.
I have a new appreciation for just how important it is that we find a way to continue to modernize this system without losing those small but substantial things that give patients hope, dignity, and the best possible care.
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.
Karen B. DeSalvo, MD
National Coordinator for
Health Information Technology
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.
In an in-depth interview, National Coordinator for Health Information Karen DeSalvo, MD, discusses meaningful use, EHR usability, innovation, and the recently announced restructuring at the Office of National Coordinator. Part one of two.
Karen B. DeSalvo, MD
National Coordinator for
Health Information Technology
At the annual Health Datapalooza in Washington D.C., last week, I spoke with Karen B. DeSalvo, MD, MPH, MSc, National Coordinator for Health Information Technology, one-on-one for the first time.
DeSalvo, who was appointed to the ONC position in December, has a record of public service. She served as Health Commissioner for the City of New Orleans and as a senior health policy advisor to the mayor. After Hurricane Katrina in 2005, she led the creation of a neighborhood-based primary care and mental health services model for underserved individuals.
In the first part of our conversation, we covered everything from ONC's restructuring to what to do about buggy software that could threaten patient safety.
HLM: The proposed rule on meaningful use Stage 2 – what was the thinking behind that, how do you help large healthcare providers make sense of where Stage 2 is going from here?
DeSalvo: Meaningful use as a program has a large policy goal of advancing adoption of electronic health records in the clinical environment, and seeing that they were not just set up but used in ways that could improve patient care and outcomes.
The reason I start with all that is because we should keep in mind that the goal is to push as many folks forward as possible, and help offset the cost of the installation and use of electronic health records in the clinical environment. That's the incentive payments.
Those who are in the meaningful use program think meaningful use Stage 1 is very successful, [with] huge adoption across the country, incredibly rapidly.
For Stage 2, as you know, we have recently done a couple of things. One is [we've] clarified a hardship exemption that existed in the law, so that if providers, for whatever reason, wanted to claim hardship, it would be clear what those options might be.
But then we just put out a notice of proposed rulemaking that we seek comment on, which gives some flexibility that we think might help providers. [Providers] who, through no fault of their own, have been unable to install a 2014-edition product, and see that it is part of their workflow, so all of the patches— everything's installed.
That's what we're asking for some feedback on.
There are some small and rural critical access providers who sometimes are at the end of the queue for an install, or perhaps it takes them longer to change the workflows, etc., so we want to make sure that the original policy goal of bringing as many providers along, that any issues with 2014-certified product availability etc. don't get in the way of that.
We want to understand if the flexibility in that makes sense, and we do want people to know that we do want to progress, and that there is an opportunity for this country to continue pressing forward.
Some of the things in Stage 2, for example, around transitions of care and the opportunity for patients to be a part of the access to the data, are an important policy goal, and this is something we want to see advance.
HLM: At Datapalooza, Atul Gawande was talking about the number of faxes he still processes a week. That's the issue. Some physicians don't want to work that hard on modernization. On the other hand, the current status quo is unacceptable.
DeSalvo: And most providers, once converted to an EHR, want to stay on it. It's a much better way to get your data, especially if they have systems that are Web-based. They can access [data] after hours when they are on call or they are offsite.
It's really enabling, but you're touching on what is the important next chapter of work for everyone, whether it's ONC's thinking, CMS, vendors, [or] the innovation community. How do we make the systems such that they're enabling and supporting workflow and better workflow, instead of just having the fax system become electronic.
There are better ways that it can be done—ways to present data that actually can really support care. That is the exciting next chapter, because the technology is allowing for it more now that the data is in the EHR.
We want it to come out in such a way that it is more user-friendly, that it enhances safety, enhances quality, and makes the workflow really something's that better, more efficient.
HLM: Your predecessor kicked off a big conversation about usability, but I imagine that really continues under your watch. How will usability of EHRs get better, soon?
DeSalvo: There are a couple of things working in our favor. One is there's a lot of pull about the data, meaning that whether it's consumers who want to understand their own health, or whether it is innovators who want data to come out in such a way that they can produce applications that are interesting and useful to consumers or providers or others.
There are also technological advances—the potential of technology like FHIR to really make it lighter, faster, smarter, cheaper, to take the heavy data and turn it into something that is useful. So the technology and the pull—the desire for it—is changing.
The reality also is that because we have been capturing all this standard data for some time, people know it's there, and so we have this responsibility to have it surface in such a way that it really makes care better and safer.
It is a priority for me, because it's a reality that to keep this momentum, we have to show that the technology isn't just replicating paper charts in an electronic fashion.
It's like your phone, that we used to think was a thing that you dialed to call someone else, and now we realize is a way that measures sleep. It's a new way of thinking.
The innovators and technology are really ready for that. Our goal with our certification programs and our regulations is to make sure we're setting the right floor for standards, but not getting in the way of innovation.
HLM: You held a series of listening sessions last month. What did you learn about meaningful use?
DeSalvo: What we're hearing is that people want to see that we're advancing with meaningful use, meaning that it's not going to be a static program, but that we are going to continue to progress.
This is particularly important for consumers and public health, that the opportunity to enhance individual care and population-level care continues. A lot of comment and interest is in the space of interoperability and seeing that we're standardizing standards to allow for the systems to talk to each other and for the data to follow patients across the continuum.
There's concern about the complexity and making sure that the rule meets the technology ability, so that when a rule is published, technology can do the things that were asked of it.
There's desire to simplify some of the sets of expectations, maybe quality for example… so that instead of there being a defined line between success and failure, there's incremental improvement recognized for providers, so we heard some interesting ideas, which we're taking in and listening to.
HLM: How does your newly announced ONC restructuring work? I heard the phrase that you were moving from healthcare to health. What is this restructuring about, and how does that relate to that concept?
DeSalvo: A couple things. First of all, the timing is important for us to think about a more efficient organization. We're reshaping based upon resources available and thinking about how we can be more efficient and effective with the resources we have, so that pivot into the next decade is part of this new chapter.
The second thing is, we're really focused and tuned into the notion that health IT is more than electronic health records, and more than meaningful use. It is about building a robust health IT infrastructure that can support again not just healthcare, but health.
What does that mean? That means for our country, we have a national priority of better health, lower cost, better care, that three-part aim. To get there, it's much more than just the healthcare system. It's a part of it, but we want to build the right kind of robust health IT infrastructure that is inclusive beyond meaningful use, so beyond providers that are part of the meaningful use program – that's one piece.
So behavioral health, long-term post-acute care—it's expanding that. And then expanding the platform of interoperability, such that there is a chance for data, whether it's big data like genomics… all the way to patient-generated outcomes, to be a part of that overall thinking, but then a whole host of other sources.
For example, [data may include] information about those aging populations, and social services programs that might serve them, or for populations for feeding programs, like WIC and SNAP, to be included, so this is a broader view on the kinds of data that might come in, and the opportunity to put it to good use.
HLM: And part of the restructuring is a move towards care transformations? I guess you now have an office of chief scientist. Why did you do those things?
DeSalvo: We've had a few name changes, putting some structure on work we were doing, so care transformation is a great example. We have been partnering with CMS through both the innovation portfolio, the Medicare work, and Medicaid work, to help drive the movement towards value-based purchasing, price transparency, quality measurement.
[These are] things that can enable and support payment and other reform, but at the same time, this is also an opportunity for technology to in and of itself transform care, so an obvious example is telehealth, which is a different way to deliver care, or e-consults.
And technology can do that, but it has to work in tandem with the payment system. It has to be wanted and understood by the private sector, whether that's payers or employers or providers. So there is enough work and focus that we wanted to make sure that there was a small team of people who were thinking about that every day, even though we already had been, but just to define it.
We also have innovation responsibilities, not to necessarily lead always, but to be thinking and innovating with others in the private sector.
But we have in our standards portfolio a lot of work to implement that we want to make sure leads to a defined roadmap to implement around interoperability, so the data's not just in one system, but following patients where they need it, available for providers when they need it, and then able to roll up into other uses.
HLM: I read a report that the ONC office of consumer health is going away. Is that true?
DeSalvo: It's absolutely not going away. It still exists where it has been. It's been in policy and programs. Policy and programs split apart, so it's still with programs. It's an incredibly important part of our portfolio. No change to the resources. No change to the interest. No change to the focus.
As I wrote in my note to the team, we get up every day, well I'll speak for myself, I get up every day to work for the people of this country. That is the reason that I am in this job. It is who I serve. It is how we want to build health IT, to serve their needs as individuals for health, to help them take care of their families, and to see that we're doing a better job at public health and population health. So it is absolutely not lost, and it's a critically central part of what we do every day.