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Friday
Sep302016

Health IT Infrastructure Enables Clinical Decision Support within Workflow

“Infrastructure enables innovation” –Mignon Clyburn, FCC Commissioner 

I like this quote by Mignon Clyburn that Rob Havasy used in his presentation at the New England HIMSS National Health IT Week event last evening in Boston. People often balk at the effort and expense required for large infrastructure projects (remember, I’m from Boston and lived through the Big Dig!). Nonetheless, a strong reliable infrastructure is essential to establishing the basis for a vibrant and innovative ecosystem. 

Since attending my first national HIMSS meeting in 2010, this has been my consistent refrain: we need to establish foundational health IT infrastructure so that we can move on to disseminating information more efficiently and enabling advanced analytics. Large scale outcomes analysis and population health management simply aren’t feasible without a basic layer of data organization and management provided by open standards and interoperable systems. 

Much has been achieved in establishing the core record-keeping infrastructure. Currently, we’re making good progress in establishing interoperability standards for basic data exchange. Still, we need to go further than simple data exchange; the data that are exchanged have to be executable if we want to build real-time clinical decision support applications. In other words, we need a higher level of data interoperability that includes sufficient metadata to enable real-time integration into analytics systems for population health management analysis, diagnostic support systems, and the like.

CDS hooks

One of the initiatives in the health IT standards domain that I find promising is the CDS (clinical decision support) Hooks effort spearheaded by Josh Mandel, MD, a health informatics researcher at Harvard Medical School & Boston Children’s Hospital[1]. CDS Hooks works within the SMART on FHIR ecosystem to send notifications of information sources that may be of value to the user in real time. Users don’t have to know in advance that resources are available; instead relevant resources are presented within the user’s workflow for them to consult at their option.

For the most part, CDS resources have been important reference sources for academic and medical researchers, but their usage by practicing clinicians has remained limited. To move from being “nice to have” reference sources to truly achieving the goal of “making the right decisions as easy as possible to come by, and as easy as possible to execute”[2], clinical decision support tools need to be embedded in the workflow of the clinician, patient, or other decision maker.  There are still a lot of interoperability issues to work out, but I plan to watch the development in CDS Hooks and encourage publishers of evidence-based databases and other resources to explore intently how they can connect their resources to the SMART on FHIR ecosystem.

Delivering the right information to the person at the right time in the right format via the right channel (the 5 rights of clinical decision support) enables better decisions and supports improved information flows to all stakeholders, including patients. Advancements in core health IT infrastructure and improved interoperability standards will help make these 5 rights an everyday practice. That’s why #IHeartHIT.

 


[1] This interview with Josh in Healthcare Informatics provides a useful introduction to CDS Hooks: http://www.healthcare-informatics.com/blogs/david-raths/interoperability/what-cds-hooks-interview-josh-mandel-about-fhir-and-clinical

[2] Jonathan Teich, MD quoted in http://www.healthcareitnews.com/news/amia-maps-road-decision-support, June 14, 2006.

Friday
Feb262016

Parsing the Progress of Health IT at HIMSS16

Since my first HIMSS conference in 2010, my consistent theme has centered on how health IT will get more interesting as it matures. My rationale: the types of problems we can solve become more complex and impactful as more core data become accessible for analysis.

That’s the focus on one of my articles in the HIMSS16 newsfeed, Identifying Signs of Maturity in Health IT at HIMSS16. One sign of maturity includes an increasing volume of partnerships and merger & acquisition (M&A) activity, especially among established firms. I’d like to thank IBM for announcing its acquisition of Truven Health Analytics prior to HIMSS16; that relieves me of relaying that information during the conference! At $2.6 billion, I expect this acquisition to be one of the biggest announced for the health IT and analytics community for the whole quarter and I look forward to learning more about the combined entity next week.

Another sign of maturity can be found in terminology changes. I’ve already seen indications that some specific categories in health IT will be rolled up into larger categories. For instance, the distinction between the EMR and the EHR categories is blurring.[1] Over time, more amorphous categories such as clinical decision support will likely get subsumed into larger categories like clinical intelligence. And, before long, we won’t need a dedicated area to showcase interoperability at HIMSS; instead, we will be able to talk about all the things we can do because of the underlying interoperability between previously distinct systems.

Moving From Meaningful to Valuable Uses of Health Data

With the foundation for ‘meaningful use’ of basic EHR data nearly complete, we can move forward to developing analytic solutions that depend on a solid foundation of process and outcomes measures. We’re making progress understanding the relationships between outcomes and interventions, but in this segment, we’re at very early stages of maturity. However, the shift to a value-based payment system will accelerate developments in outcomes measurement and analysis.

Where to Find Me at HIMSS16

My schedule for HIMSS16 is a mish-mash of 1:1 meetings, press briefings, receptions, keynotes and education session with a few minutes here & there left open to wander the exhibit hall.

A few notable sessions & events where I hope to run into friends and colleagues follow:

 

  • Opening keynotes on Monday, March 1 at 5 pm.
  • HIStalkapalooza Monday evening
  • #HealthITChicks meetup, Tuesday, March 1 at 10 am, HIMSS Spot
  • #TheWalkingGallery meetup, Tuesday, March 1 at 1:30 pm, Xerox booth #8005
  • New England HIMSS reception, Tuesday, March 1 at 4:30 pm, Elsevier booth #3039
  • Social Media Ambassador meetup, Wednesday, March 2, HIMSS Spot

 

I look forward to a super-charged week at HIMSS16. I’ll try to live up to the new “Health IT Maturity Champion” moniker that HIMSS Media has coined for me (or maybe not!).

 


[1] The HIMSS Analytics team tipped me off to some terminology changes that are likely to occur soon. See my article on HIMSS Analytics LOGIC here: http://www.himssconference.org/updates/himss-analytics-logic-health-it-market-intelligence-value-based-world

Thursday
May302013

Health Data Meaningful Updates

I’ve been so busy with guest posts and speaking engagements in the past couple of months that I’ve neglected updating my own site. I’ll try to rectify that now with condensed versions of some recent activity below.

       I.            Navinet Expert Interview Series, March 2013

Laura McCaughey and I discuss big data, population health, health IT, shared decisionmaking, the Accountable Care Act and medical cost trends, all in under 2 pages! A few outtakes:

 

Laura: What do you see as the biggest developments in HIT in the next year?

Janice: “I think the biggest developments will occur as provider organizations build upon the population health analysis that got its start with the foundation laid by the Meaningful Use framework. In particular, we’ll see more analyses of treatment plans, costs, and outcomes by segments of patients. The segmentation possibilities are almost endless. When combined with genomic data and other nontraditional types of data, they will bring us a long way toward the goal of personalized medicine.”

Laura: There’s been so much talk around big data for a variety of industries, but what does it mean for the healthcare industry?

Janice: “…to benefit from many of the existing Big Data technologies and modeling that are being used in retail, financial services, and other industries, the health care industry needs to improve the amount of collaboration at the level of sharing data sets and sharing results from previous analyses. Obviously, there are some limitations on how patient registries can be shared, but there is good progress in creating large research datasets that include de-identified patient data. In fact, the Agency for Healthcare and Quality recently released a registry of patient registries (RoPR).”

Laura: Last year you identified the accountable care organization (ACO) model as one of the major factors to shape care collaboration. How much of that has happened, and how much further do we need to go? 

Janice: “I think most ACOs have just scratched the surface in establishing a new model of providing care and involving patients in decisions about their care. It will take some time for the culture of physician-patient communication to change. Furthermore, the tools that have been available to educate and support clinicians and patients haven’t kept up with the organizational changes. In particular, patient education/patient information tools and materials are sorely lacking for patients who want to take a more active role in their health and medical care. I cringe every time I hear that patient education materials have to be prepared to meet the reading level of the “lowest common denominator” in the spectrum of patients. While I understand that some public health messages must be understandable to a very broad spectrum of the population, the same rationale doesn’t apply to all information made available to patients.”

Laura: What are some of the key components that a HIT platform needs in order to be successful in today’s changing healthcare landscape? 

Janice: “ACOs and the so-called patient-centered medical home (PCMH) concept should put a high priority on configuring their systems so that patients can both contribute information and download information from their records. This way patients can act as their own up-to-date “mobile record.” Not all patients are ready to take on this role, but that’s not a good reason to prevent those patients who are ready from improving access to information that can improve the quality of care they receive and possibly reduce the cost. The early innovators among the patient populations who actively track, update, and analyze their personal health records can serve as models for the “laggards” who will wait until the benefits become more obvious and the tools become easier to use.

Laura: The Accountable Care Act (ACA)will soon be implemented, and millions of newly insured Americans will be receiving care that did not previously. How are payers planning to handle this? 

Janice: “Apart from having designed new plans that are ready to be promoted and sold on health insurance exchanges (now called health insurance marketplaces), I can only make an educated guess on how payers are planning to handle the new populations of patients who will be insured as a result of the ACA. Note, I have a different view on how much the newly insured will increase the demand for medical services, compared with the conventional wisdom, which estimates that the previously uninsured will flood primary care physicians with pent-up need for medical care. I agree that physician practices will enroll many new patients in areas where there had been a large number of uninsured. However, I think that a large number of the newly insured patients will have so much experience managing their own care that they won’t overburden the provider organizations as much as some analysts predict. Plus, many of the insurance plans available to these populations will include significant co-pays (significant is in the eye of the beholder in this case!). With high co-pays, I predict that populations that were unable to afford insurance coverage in the past will not be able to afford most co-pays and will find ways to reduce their costs of care whenever possible by using retail clinics and other lower-cost options, such as telehealth.”

Laura: The medical cost trend has slowed considerably in the past few years. What can providers and payers do to help keep costs from rising?

Janice: “The best advice I have to keep costs from rising is to provide more information about costs to patients before they choose a course of treatment. Providing more information about the likely benefits and risks of treatment plan options under consideration to patients will also increase the patient’s level of commitment to the chosen treatment plan. Moving to this “shared decision-making” model will likely reduce costs in the short term, although that’s not a sure bet, since cost is not the only criterion that patients will consider.

As I consider the topics we’ve just discussed, it occurs to me that the most significant move that payers could make to slow the rise in costs would be to simplify health insurance plans so that costs are far more transparent. Some payers are ahead of others in offering data on costs. For instance, Aetna offers an average estimated cost by region in its Aetna Navigator tool. Although not complete, Aetna’s move in the direction of providing cost information is a step in the right direction.”

 See full interview at: http://www.navinet.net/blog/2013-navinet-expert-interview-series-janice-mccallum-health-content-advisors


     II. Making Health Data Healthier: How to Determine What’s Valuable and How to Use It

A dialogue between Geeta Nayyar, MD, MBA, Chief Medical Information Officer at AT&T, and me about managing and leveraging health data for the benefit of providers and patients.

On the topic of Meaningful Use:

Geeta: In your opinion, how does Meaningful Use help advance the value of data in medical research and clinical applications?

Janice:  “The Meaningful Use incentive program has jump-started the adoption of electronic health records and set the framework for coordinating a fragmented group of providers, health IT vendors, and analytics companies. The common sets of data to be collected, tracked, and analyzed set the stage for greater collaboration between providers/clinicians, payer organizations, medical researchers and patients.

...

Frankly, I wish the value of data standards and collaboration were so obvious that providers and payers would develop industry standards without external pressure. Since that wasn’t the case prior to the Meaningful Use program, I would say that we’ve seen great strides in enhancing the value of data available for medical and clinical applications in a short period of time.”

 

See full interview at:

http://networkingexchangeblog.att.com/enterprise-business/making-health-data-healthier/.

 

   III.            Webinar on Meaningful Use for Medical Librarians

I recently gave an hour-long webinar, Meaningful Use: A Means to an End, to the National Network of Libraries of Medicine (NN/LM), New England Region.  Along with providing some context to the Meaningful Use program, the webinar focused on roles for medical librarians in implementing meaningful use programs, especially elements that relate to patient engagement, quality measures, and clinical decision support.

Please contact me (janice@healthcontentadvisors.com) if you are interested in a customized version of the webinar/presentation for another audience.

Tuesday
May312011

Look to Payers for Innovation in Health Information

So much attention has been focused on the adoption of EHRs by provider organizations—largely because of ARRA HITECH funding—that one could be led to believe that most health IT advances are occurring on the clinical side of healthcare.  In reality, the business side has been quicker to adopt IT systems that add efficiency to the workflow of the participants. Practice management software and revenue cycle management solutions are two examples.

However, the exchange of data between stakeholder groups remains the stumbling block in improving the efficiency of our healthcare system.  On the provider side, it has been evident from the start that one of the most “meaningful” uses of a patient’s electronic record is the ability to make the information available where, when and to whom it is needed.  But, the pathway to meaningful health information exchange (HIE) is a bumpy one—not just because of technical issues, rather because of the regional nature of healthcare laws and regulations that has led to a very fragmented healthcare market.  I overheard someone from a hospital system in Florida at HIMSS say that a Florida-wide exchange may be a good thing, but it doesn’t solve his real problem of the snowbirds who come to Florida in winter but whose primary healthcare providers are in the Northeast. 

But once again, payers are leading the way in “meaningful” exchange of patient data between providers and payers.  The infrastructure created for revenue cycle management applications—eligibility checks, claims submissions, etc.—already exists, so why not build upon it?

In March, I attended the grand opening of NaviNet’s new headquarters in Boston.  I knew that NaviNet provided a communications platform for payers to exchange information with providers and that they were actively expanding their portfolio of services, so I wanted to know more about them.  I left that evening thinking that NaviNet’s existing platform that already connects 470,000 physicians in 128,000 offices to a growing number of large health care plans could be leveraged for exchanging clinical data. 

This week I had a follow-on conversation with Kimberly Labow, Chief Marketing Officer at NaviNet.  Kim confirmed that NaviNet recognizes the opportunity to leverage their existing network to become a single point of contact for business and clinical communications. 

At this point, NaviNet has already expanded to offer practice management and EMR applications to provider clients and has recently launched a mobile eprescribing application in Florida in conjunction with Aetna.  It’s interesting to note that Availity is also part of this strategic partnership because they were working with Aetna and Prematics prior to NaviNet’s involvement.  NaviNet subsequently acquired Prematics, which led to this multi-factorial “coopetition”.  [Note: Aetna has recently acquired Medicity, a health information exchange vendor, which makes the level of coopetition even more multi-dimensional.] However, this level of cooperation is not an anomaly; I see it is a sign of things to come as our healthcare system undergoes periods of consolidation within and across stakeholder groups. 

Given the existing structure of our healthcare system, the payer segment— unlike the providers—has clear incentives to use information to increase efficiency in business and clinical areas.  Payers recognize the benefits of working with patients to encourage more healthful behavior and are taking an active role in creating care plans and follow-on communication with patients.   At the recent Patient-Centered Computing and eHealth: Transforming Healthcare Quality course, Blackford Middleton suggested that in an alternate future, if providers don’t respond to the challenges of adopting health IT and learning how to use and analyze data, they will be disrupted and the insurers will become our healthcare coaches. 

I doubt that many patients, physicians or hospital groups want health insurance plans to become the primary source of health advice and care management.  However, we are moving toward a more integrated payer-provider model with ACOs and we have witnessed the success of integrated delivery networks like Kaiser Permanente. Convergence is occurring from all directions: providers are merging with physician groups, providers are consolidating, payers are consolidating, and payers are also diversifying into healthcare delivery.  A recent Wall St. Journal article described the payer diversification efforts as including: “acquisitions and partnerships that will allow the [health insurers] to employ doctors directly, delivery health information technologies, and participate in new hospital-doctor groups known and accountable-care organizations”. 

With alliances and acquisitions occurring within and across stakeholder lines, it is becoming a challenge to coordinate standards efforts and for analysts like me to try to diagram an industry that’s in flux.

NaviNet is trying to make a contribution toward coordinating efforts with the Unified Patient Information Management (UPIM) platform they are supporting. For my part, I rely on variations of the convergence diagram below that I created some time ago, which attempts to illustrate the clinical information market in an EHR-centric world. The initial version had payers outside of the inner circle. After writing this post, I think it’s time for another updated illustration that more closely aligns providers and payers!

 

Clinical Information Flows in an EHR-Centric World

Tuesday
May312011

Patient-Centered Computing and eHealth 

In early May, I had the opportunity to attend the Harvard Medical School CME course, Patient Centered Computing and eHealth: Transforming Healthcare Quality. The 2 1/2 day course is directed by  Blackford Middleton,MD, MPH, MSc Corporate Director Clinical Informatics Research and Development Partners HealthCare and co-directed by Patricia C.Dykes, DNSc, MA, RN Senior Nurse Scientist Nursing Research Program Director Center for Nursing Excellence Brigham and Women’s Hospital.  The outstanding faculty of experts included Brent James, Paul Tang, Patti Brennan, John Halamka, Fabienne Bourgeois, Josh Seidman, Victor Strecher, Judy Murphy, and many others.  The full list of the faculty and their affiliations is included on the site linked to above.   I served as the “official tweeter” for the course and want to share with my readers some of the highlights of this practical course designed for the physicians who are responsible for adopting EHRs and applying health IT in “meaningful” ways to improve healthcare quality.

The full transcript can be found at: http://hashtags.foxepractice.com/healthcare-hashtag-transcript.php?hashtag=PCeHealth11.  For smaller doses, you can read the daily summaries here:

Day 1 Summary

Day 2 Summary

Day 3 Summary

The course included workshops, panel discussions and plenary presentations. To give a taste of the topics covered and insights shared, I’m posting a few outtakes from the Twitter stream for #PCeHealth11 below:

 

dahern1 

 Brent James opening keynote sobering view of healthcare crisis but making case of HIT as one key factor for positive change

Clinicians are poor at “rate estimation” and need technology tools to support decision making - James 

bfm 

Brent James — more important to standardize care than anything else to control costs and improve quality. Great opening talk!

 

Sobko: 25% of Medicare recipients had a complication during care transition within 30 days post-discharge

janicemccallum 

Sobko on care transition: setting goals helps engage patients with care plans; also teach them when there is a red-flag.

bfm

 

Vic #Strecher #UMich to achieve behavior change don’t always need Health Coach, often eHeatlh tools sufficient, or combo 

janicemccallum 

Common theme for engaging #patients : establish a mission or goal to drive behavior change. Tools alone aren’t sufficient.

 

#MU incentives have to be aligned so that efficiency gains aren’t viewed as income reduction by some: @jhalamka.

 

#NHIN isn’t a “thing”; it’s a set of data usage agreements and standards: @jhalamka #HIE

 

Micky Tripathi: think of #HIE as a verb, the act of exchanging information. 

 

Common theme here: secure provider-patient communication saves time b/c it replaces phone calls that typically take more time.

 

Recap from @bfm for day 1: healthcare system is in crisis (Brent James) & has severely negative effect on US financial health.

 

Need to train physicians to be effective knowledge managers; simply too much to know everything. @bfm #KM #CDS #pcehealth11

bgaustin 

Paul Tang keynote: cannot change issues like obesity one person at a time. Change must be community-driven.

janicemccallum 

Jon Wald—biggest driver of usage of patient journals in study: marketing of the patient portal by the practice. #PHR

bgaustin 

“Any doctor who can be replaced by a computer deserves to be replaced.” -Dr Warner Slack

janicemccallum 

Who sponsors #PHRs? 50% health insurers; 25% providers. J. Wald, RTI.org

 

Not much focus on #patient-reported data yet in #EHRs; Wald calls it “patient-entered data” or P-E-D. #PHR

 

BI-like dashboards w/ trend data in #EHRs help provide early warning signs to physicians. #analytics

 

Too many facts to remember & the right information is often not available at point of need. #CDS #EBM #POC @bfm

 

Referral is weak link in continuum of care: Zuccotti’s team developed clinical referral management system. Patient role was key.

 

Jonathan Teich def of #CDS: makes the right thing to do the easy thing to do. #EBM

 

Teich refers to #AHRQ’s eRecommendations project: http://bit.ly/jMMS3G #CDS

 

Cool: @jjseidman describing new program #pophealth: http://projectpophealth.org/ Open-sourced qual measures prog. #CDS #MU

 

AF4Q works with #ONC #REC (regional ext. centers) to help them w/ #quality measures; also trying to harmonize the many meaures.

 

janicemccallum

Alt. future: If providers don’t respond to challenges they will be disrupted & insurers & payers will become coaches @bfm

 

#ARRA #HITECH: the $27B tail wagging the $2.5T dog (Paul Tang). #HCR

 

#EHR and #CDS adoption isn’t so much a function of fear of techology; rather physicians need to be convinced of added value. @bfm

 

#ACOs will shine light on importance of handoffs btwn providers & reduce missed communication. Luke Sato

bgaustin

Powerful keynote by Brent James: “Today’s problems are nearly always yesterday’s solutions.” #EBM