At HIMSS15, I had to the pleasure of teaming with Mandi Bishop and four health IT leaders to organize our annual #HITsm live event. The previous three events mostly consisted of a meet and greet and passing the microphone around for introductions and discussions. This year’s event was the best HIMSS event yet, in my opinion, with approximately 150 in attendance, which was due in large part to our expert panel who graciously agreed to attend our unique session — with no assurance of it being a success — to answer questions from our passionate #HITsm community.
After I had the pleasure of briefly welcoming everyone in attendance and describing what we had planned for the session, Mandi then led the panelists through a set of four questions we solicited from an #HITsm tweetchat.
After introductions I realized it would be a good idea to record the session and share the transcript with those unable to attend in person. It appears that I didn’t start my recording until halfway through question one, but I did capture a majority of the discussion. Since the transcript is so long, I’m breaking this up into two parts. This post will cover the first two topics presented to the panel:
- Let’s say in 5-7 years FHIR has eliminated a lot of the complaining about health data interoperability, what will become the new “top problem” for health IT?
- Should interoperability compliance be regulated by the government, or will market drivers force change? And, is interoperability – syntactic and semantic – truly a realistic goal?
First, a special thanks to our four panelists:
- Keith Boone, Standards Geek for GE Healthcare
- Dr. Doug Fridsma, President and CEO of AMIA
- David Muntz, Senior VP and Chief Information Officer at GetWellNetwork
- Dr. Rasu Shrestha, Chief Innovation Officer at University of Pittsburgh Medical Center and Executive Vice President of UPMC Enterprises
Part 1 of the transcript:
Question 1: Let’s say in 5-7 years FHIR has eliminated a lot of the complaining about health data interoperability, what will become the new “top problem” for health IT?
Rasu Shrestha: Hopefully we won’t be blinded by buzz words when it comes to FHIR. Hopefully, we will have something that will be of substance.
Let’s assume that FHIR actually does solve for the data, health data, and interoperability challenges that we’ve had in the last decade in the industry. I think we’ll still have issues that we’ll have to contemplate to go on the theme of the patient.
We’ve talked a lot about patient engagement, but what does that really mean? How do you create the right business models to sustain, not just patient engagement, but engagement to empower and to enable it? I think that’s going to be huge from a payer perspective because I think the reality, in the last five to seven years, the reality of health care in the United States is that this is not just a provider-driven world.
We’re seeing already the shift of risk moving from the payer to the provider and soon to the consumer. In that dynamic, the conversation really has to shift from intelligent management of disease, which is what we’ve been doing for decades now, of management may be more intelligent than others, to better management of wellness. Disease management is cost-acceleration and wellness, conversations around wellness, really pushing for wellness, that’s cost-deceleration. So, I think that’s going to be pretty interesting.
Mandi Bishop: So, what we’re talking about here is addressing the other 90 percent of health care that takes place outside the clinical setting. Is that, going to be the next thing?
Doug Fridsma: Would that FHIR could solve all of those problems. I do think that there is going to be a shift from an emphasis on the EHR and the practice and I think it’s going to be a shift to focusing on the individual, the person, in terms of all of the different devices that are going to be coming and then population health as well. I think that’s going to be another aspect that’s going to be important with all of this.
I think FHIR will solve some of the technical issues that we have. We still have a long ways to go. We’re right on the very top of the Gartner Hype Curve. I think, actually… it’s going to solve the Iraqi problem. There’s an obsession about that.
But I do think that we’re going to have some struggles over the course of next couple of days, couple of years as we have to start developing profiles and figuring out and agreeing on a way in which we’re going to exchange the information.
I actually think that, even if we have the technical problem solved, there are three other things you need to get to interoperability that we don’t often talk about it because we tend to be pretty technical.
The first is context, you have to know where the data came from so that you know how to use it if you’re going to be able to use it effectively. The second thing is workflow, you need to know where you are in the process and where you’re going to go next. And then the third of the things that you really need is policy and business practice. It has to make sense and there have to be rules that say that you can do it.
So, even if you have all the technical, semantic and syntactic interoperability worked out, you have to have context, workflow and policy business drivers to really get to true interoperability.
Question 2: Should interoperability compliance be regulated by the government? Should that contact, should that be supplied by the government or will market drivers force change? And is interoperability, syntactic and semantic, truly a realistic goal?
Doug Fridsma: I think the most significant thing that has come out of HHS in terms of driving interoperability are the CMS goals for the payment reform in value-based purchasing. I think that is probably the single most important thing in terms of driving towards interoperability because to do population-based health and to understand the risk that you have within your population, you’re going to have to be able to integrate lots and lots of data and you’re going to have to be able to do analytics to determine the risks. To me, that is one of the most significant things that has happened to help drive us in that direction.
Mandi Bishop: So, it’s all a business driver problem then?
Doug Fridsma: Well, it does, but it isn’t about a regulatory approach, it’s really about setting the goals and then creating a way that, not necessarily saying what we need to do, but not necessarily telling us the path to get there, because there are probably shortcuts and other ways that we, as a market, can drive things a little bit better.
David Muntz: The fact is that I would hope that the market would be the preferred choice. I think that the interesting thing about legislation is the threat that it will done. That forces the market to behave the way that it would not otherwise behave. Of course, I’m thrilled that Meaningful Use came along because it forced people to adopt technology they would not have otherwise adopted. The question is, was it done in the most effective and efficient way and were the goals actually met or will they be met is still an ongoing process?
I would hope that the private interests would prevail here and the efficiencies, the innovations and—I think what Doug said is critically important—it’s more important to set the objective and then let innovation figure out how to go down these difficult paths. I think he used the phrase “the path of least regret.”
Doug Fridsma: The path of least regret.
David Muntz: The question is can we get to the path of least regret to get us where we need to be?
The other thing I’d like to do is comment on the workflow issue. Again, when we talk about workflow, we really are focused very much on providers and the people in the business environment and what I’d like to add to workflow is the word lifeflow.
The fact is that patients don’t work at health, they live for health. If we don’t think about the patient’s role in the process of care then we won’t be doing the right thing. So, I’d like to see us add that to our vocabulary.
Doug Fridsma: Certainly, as you move from being EHR and practice-centric, into ones in which you are in the home and at a population level, the workflow that happens is actually in the home.
Keith Boone: So, now that we’ve gotten some prior regulators experience, I’d actually like to give some kudos to the ONC for a national program that has exceeding the expectations in terms of EHR adoption based on what any other national program is doing.
In five years we’ve gone from a lower adoption rate of EHRs to one of the highest in the world in the hospitals. We still have some work to go on the ambulatory side, but we’ve made tremendous progress. So, we’ve had some really good successes. I think we’ve also had some really big failures.
You’ve probably heard about the recent change in the patient engagement metrics and the most recently released ONC rule dropped just in time for HIMSS. Go find Regina Holliday in the hallway, she’ll tell you all about it. Just make sure you’ve got your ear plugs because it’s going to be wild.
So, essentially, they dropped the patient engagement metric from five percent to one patient. Well, how does that actually meet the goals? So, I think there’s some really good progress being made. I think there’s some missteps.
Quite honestly, this is a learning process for everybody. I wish some of it hadn’t been necessary. But, we certainly needed the incentives, we needed the kick in the pants, and now we no longer have an incentives program, but a penalties program. We need to continue with a kick in the pants and keep going.
Rasu Shrestha: I do believe that the government can actually help. The real question is, is this market driven or do you really want to drive the market?
For me, personally, I’d rather be behind the steering wheel than in the passenger seat—in front or in back—and when you look at an organization like where I come from, we’re a large provider organization, we’re sort of really trying to drive change forward and innovation forward. We’ve been doing interoperability for almost a decade. So, syntactic interoperability, semantic data harmonization, these are things we’ve actually been doing and have been talking about at HIMSS.
So, this is real. For us, since we’ve been looking at the eight petabytes of data that we have across our enterprise where we have multiple EHR solutions, we are actively bringing the meaning out of the data in terms of semantic data harmonization and then trying to bring that patient’s story to life because at the end of the day, it is about that patient’s story.
It is about enabling intelligent data workflows. But yes, I think that it’s interesting that we have the ONC really pushing the charge and the carrot-and-stick approach of Meaningful Use is pushing us along, which is really good, but at the same time, I think it’s really important for us to drive the market and really be behind the steering wheel and really show how it can be done.
Mandi Bishop: Now, you’re talking about we and I’m very curious, who is the we entity that you’re referring to?
Rasu Shrestha: So, it’s a good question. When I say we, it’s really leading health care organizations, it’s the industry at large, it’s IT leaders, it’s vendors who care to stand up and make a difference and not be part of the rat pack. It’s individuals and organizations at large.
These are individuals, these are groups, individuals, payers, providers who want to be on the driver’s seat. When HIPAA regulations came out, not to uncover another big issue, when HIPAA regulations came out way back then, there was a lot of “HIPAAnnoia” but individuals, organizations…
Mandi Bishop: That’s the best phrase yet.
Rasu Shrestha: Absolutely. It’s an excuse. For goodness sake, it’s not that we’ve been ignoring privacy and security before the HIPAA regulations came out. All right, so we, collectively, need to be in the driver’s seat, pushing for change, really pushing for innovation and doing things the right way, not just because we’re told that it needs to be done that way but because we know that that’s how it needs to be done.
David Muntz: Yes, as long as somebody said the phrase patient engagement as it relates to regulations, I just had to jump in.
One of the things that I am glad to see is the phrase patient and family engagement in the regulations. What I’m sorry to see is that the methodology that was selected is important, but it doesn’t go far enough.
Essentially what you do, if you look at regulations, is delivering data after the event has occurred. If you really want to interact with patients in a way that’s going to be meaningful and you want to have some significant impact, you really need to get data depictions in real time. That’s where interoperability has to be absolutely automatic. You have to be able to avoid going over the cliff.
It would be terrible if we didn’t have alarms that occur inside an aircraft to warn before something bad happened. It’s great that they pick up the black box afterwards but, essentially, that black box approach is ‘I’ll tell you what happened to you, but I won’t let you know while things are happening.’
So, I would like to see us take a much more aggressive approach about getting information in the hands of the patients and the families in order to be able to make wise decisions about what the course of treatment should be in the next minute, not after a visit occurred or before the next visit.
Doug Fridsma: So, I’m going to take you and raise it. I think patients need to be first-order participants in their care. They have to have equal standing. In fact, probably they need to be listened to more, and more time spent with them. So, it’s one thing to give them the data in real time and to be able to give them that information, but unless they are first-order participants, it’s doesn’t matter.
Mandi Bishop: I think they need to be empowered to feel that they can be first order participants in their care, right?
David Muntz: Yes, well, one of the things that happens, and we’ll talk about whether patients are consumers or civilians or whatever the appropriate term is… But, you’ve got to remember that when you start life, you start it as a patient and as a family. People have criticized me for using the word patient but, the truth is, when you’re born, it’s a mother and child event. So, at that point in your life, you’re incapable of participating. So, I’m raising you again, on this – not just patients but caregivers as well.
At the end of life, generally, and I hope this doesn’t happen to me, it could happen sooner than I like, but it’s you become incapable or incapacitated. So, we use that model.
We go back to patient and family and now, the patient and family is defined in a different way than it was at the beginning of life. The truth is not just the mother, it’s the spouse, the friends, or whatever the patient has chosen.
So, the question is why, during the entirety of life, do we not talk about patients and families. So, if we don’t have tools that allow participation—and I love your expression in the first-order participants—the question is why aren’t the patients and families first-order participants in the care process?
Read Part 2 of the #HITsm at HIMSS15 transcript.
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