In the first of this guest series of posts, the chicken and the egg question was updated as a way to frame one of the critical questions in health IT, “which came first, the individual or the institution?” Thus far, we have looked at this topic from the perspective of the individual, unpacking the EHR, PHR, privacy, and transparency, amongst other topics.
In this final and third of three guest posts, we flip our perspective to the institution and ask if there can be a virtual geography of healthcare, rather than a physical one. This is a vital question, because the evolving HIEs (Health Information Exchange) and ACOs (Accountable Care Organizations) run the risk of being the healthcare system’s version of a hardening of the arteries. By dynamically linking people and data, we can reframe our approach and infuse flexibility into this incredibly complex system, achieving the same goals but allowing for dynamic and evolving innovation. Although Don Berwick, Administrator for the Centers for Medicare & Medicaid Services (CMS) has spoken of a patient-centered ACO, he assumes that the institutions will create the definitions, rather than the patients.
Patient-centered is not patient-driven. It would be intriguing to have crowd-sourced the 65 quality measures in the new rule released on March 31, 2011 by HHS. Millions of medicare patients may have a very different view of these rules and meaningful use. Regretfully, institutional thinking is implicit in all we do and traps us and our health system in the physical geography of healthcare. As a consequence, the current trajectory and decision-making by HHS as they dutifully implement the rule-making required by both the Patient Protection and Affordable Care Act and the Health IT provisions of the American Recovery and Reinvestment Act create the high likelihood that our current healthcare system will be further hardened against real change.
For example, the quality metrics by which an ACO will be measured will require a patient stay within the system for tracking of outcomes. If they go outside of the predefined organization, both continuity of care and outcome tracking become difficult, which doesn’t seem very patient-centric to me! If we moved from a physical to a virtual mindset, however, real change could be possible. A virtual geography of healthcare would make ACOs truly dynamic, with patients’ choices determining the contours of who is accountable for their care. In some cases, it may be an ACO of one. In others, it may be an ACO of millions, but it is the patterns of patient choice, not arbitrary decisions and agreements between institutions ahead of time that define the geography. Regretfully, this impending sclerosis of our healthcare system is reinforced by CMS because for health care providers to get paid they must follow the institutional approach required by the rules. It is a no win situation, and it all flows from the mindset of a physical geography of healthcare.
This physical geography mindset is on even more vivid display with the health information exchange. I’m not arguing that an exchange of health information isn’t valuable, but stop and think about what we are attempting to build with the HIEs. We have one global Internet moving around trillions of bits of information daily across industries, languages and cultures, but we’re creating who knows how many RHIOs (regional health information organization) to manage HIEs. There is no other way to say it. This is nuts! The Internet already provides the foundation for an exchange of health information, but we will not succeed if we see the problem as one of moving electronic documents between the new digital filing cabinets of healthcare institutions.
As was made clear in @CLOUDHealth’s first post, the EHR and PHR are nothing more than presentation layers for our health data in the appropriate context. That is not only true through the lens of an individual but also institutionally. If you are pulling information, rather than pushing it, then you don’t need HIEs, and you sure don’t need to reinvent what the Internet already enables. Just like the EHR can be virtually and dynamically assembled one by one, aggregating the needed data, with the new model for privacy, security and data that a CLOUD-enabled Internet will allow, an organization can do the same at the macro level, whether for disease tracking, clinical trials or to assess outcomes across populations.
Even more importantly, the availability of anonymous clinical data (remember how CLOUD separates WHO I Am from WHAT I Am) is available across institutional boundaries, rather than prearranged groupings of ACOs and HIEs. This is critical because what CLOUD is proposing with the contextual markup language and its underlying rights servers will not only be architecturally sound but will also be sustainable. Those HIEs that have been stood up thus far continue to depend almost completely on federal, state and independent grants. Such a CLOUD-based way of thinking about the Internet, cloud computing and healthcare is best understood through the lens of my talk at TEDxAustin this past February on “Reweaving the Fabric of the Internet.”
There is much more to say, but I conclude this guest series of posts first with a thanks to Erica Olenski at Corepoint Health for the invitation to write for Health Standards and the latitude to cover such a wide set of topics. I’d also like to thank the many folks that have been part of the #HITsm tweet chats on Monday nights the past several months. For those that participate, you will see many themes in these guest posts that emanate from earlier 140 character tweets from @CLOUDHealth. At the core of the CLOUD vision is a deep belief in the power of the individual, and that power properly harnessed and linked to our various data, creates a foundation for not only reweaving the fabric of the Internet but allowing for a truly virtual geography of healthcare.
Gary Thompson is Co-Founder and CEO of CLOUD, Inc. (www.cloudinc.org), a non-profit technology standard consortia founded in March 2009 and based in Austin, Texas.
Prior to CLOUD, Gary has been involved with numerous startups, all of which push the leading-edge of their industries, including his most recent role as founding VP of Sales and Marketing of Kimbia, Inc., a Web 2.0 online fundraising company for Giving Power™. Gary also served in several sales management capacities at Apple, Inc. over two decades during the John Sculley and Steve Jobs’ eras. His responsibilities covered corporate accounts, education and Apple’s reseller channels from the first color Macintosh to the iPhone.
Former Governor Bush appointed Gary to the eGovernment Task Force for the State of Texas in 1999 and was reappointed by Governor Perry to the Texas Online Authority until 2004. Gary’s education includes a BA from Northwestern University, an MBA from the Kellogg School of Management and a JD, University of Texas School of Law. Gary is deeply involved in the Austin community, having participated in the Leadership Austin Essential Class of 2004-2005 and currently serving as Board President for the local chapter of the Leukemia and Lymphoma Society.
Gary has been blessed by 21 years of marriage to Maureen, his wife, and is father to Taylor (12), Kyla (9.5) and Katelyn (7). They live west of Austin, TX.
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