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.

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[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.

Mom-memorials from #IHeartHIT Session at HIMSS15

Lindy Stotsky, known to many of you by her Twitter name @EMRAnswers, gave a compelling and compassionate account at HIMSS15 of how the lack of access to patient records — by clinicians, patients, and especially family members/caregivers— failed her mother during her stay in a long-term care facility. Her story, appended below, resonated with the audience and led several other people to describe how experiences trying to navigate the healthcare system without full access to information from health records spurred them to become involved in health IT.

I followed Linda with a story of how my mother became interested in examining the data in her health record only after I prodded her primary care practice to provide access, once I realized that they had implemented a patient portal.

It was notable that most of the personal stories from the audience that followed Linda & my brief talks at the #IHeartHIT session related to caring for our Moms. I want to thank Linda for sharing her story here on the Health Content Advisors site.

I Was My Mother’s “Scrap of Paper”

I’ve worked in healthcare over 25 years:  In administration through hospital credentialing and procurement, as a practice administrator shuffling through paper charts, missing codes, and reimbursement in an era of managed care.  It was during this time that my Mother became ill with CLL (Chronic Lymphocytic Leukemia), and COPD (Chronic Obstructive Pulmonary Disorder). My Mother was a staunch believer in Health CARE. She grew up believing that physicians were healers- and that nursing facilities took care of the elderly. Her decision to reside in such a facility began our descent into a world I could not have imagined.

I looked, as most caregivers do, at the inside of the building, the floors, the paint and the aesthetics. We are preoccupied, vulnerable and first impressions are everything. I judged the worthiness of the facility by its locale, the staff and our welcome.  I took for granted that “Nurses” were RN’s, having an MD as Chief of Staff meant he was there every day, and daily living meant more than struggling to survive. I didn’t know about physician track records, medical malpractice and negligence. All blue skies and daisies, until my Mom became a resident. That started our fragile dance between long-term care (LTC), emergency departments (ED), hospital, provider, back to LTC.

Thus began my advocacy. Not just for MY Mom. I was vigilant about everyone’s Mom— policing halls, looking into rooms, and answering cries for help.  I watched my Mother change from a vibrant, confident superhero to a terrified, confused and helpless patient. I took her to providers who placed her on medication, only to bring her back to a facility where medications were routinely discontinued because of cost.

I was “on call” 24/7. My Mom became my mission. My 3 year old knew where all the toys were kept in the ED, as we were frequent fliers.  “AMA” meant no ambulance was ever called. I loaded her, her wheelchair, her O2 tank, and my son into the car, and as I was running out, I grabbed a piece of notebook paper with her medications scribbled on it. This was her medical record. And I was the keeper of the key information.

My Mother passed away after three years of suffering, much of which was preventable. Not only was there a lack of communication, a culture of caring had been replaced by one of cost. Human lives took a back seat to ROI. Instead of treating aging elders with the respect and dignity they deserved after years of giving, nursing homes were nothing more than “death beds” waiting to empty. I was so engrossed in the day to day challenges, that I didn’t have time to stop and think about the larger picture of what was wrong. 

15 years later I am sorry to say that things have not changed much. My daughter recently had Thyroid Cancer. She was eager to use the patient portal to coordinate her labs, multiple tests, from all providers.  It was not that easy.  Information gaps were everywhere; care coordination was still back in the year 2000.  We need patient access. But it’s more than that. We need actionable information. It’s been nearly five years since the enactment of the ACA and little has been done to promote shared decision making. The recent proposed rule change in the Meaningful Use Stage 2 measure related to patient access and downloading of their information[1] will reduce the  threshold for Measure 2 from 5% to “at least 1 patient”  for eligible providers (EP). This change HALTS progress. WE CAN DO BETTER. My daughter is working hard to be a partner in her care, yet she has a toddler, and she’s tired, and sometimes it’s easier to give up rather than continue asking.

 Linda, Regina Holliday and me at HIMSS15

 Please help us win this. Stand up and ask —-demand electronic access to your patient record.  We should not have to carry around a tattered scrap of paper with medical information on it. Join members of The Walking Gallery[2] of Healthcare as we tell HHS, CMS, Politicians and Advocates that PATIENT LIVES MATTER.

My name is Linda Stotsky, and I share my story as a patient, a caregiver, a Mom, a daughter and a Health IT Product Manager. I am currently the Director of Business Development at LogicNets.

 I can be reached at Linda.Stotsky@gmail.com or on Twitter via @EMRAnswers

[1] http://e-patients.net/archives/2015/05/add-your-voice-meaningful-use-regulations-musnt-leave-patient-engagement-in-the-dust.html

[2] For information on TheWalking Gallery, see http://reginaholliday.blogspot.com/2011/04/walking-gallery.html.

Data Was Big at HIMSS15

Data Was Big at HIMSS15

Since I attended my first HIMSS in 2010, my consistent theme has centered on the fact that implementing EHRs with some standard functionality was a necessary precursor to achieving the core goals associated with improving quality and increasing the value of the healthcare we provide to individuals and groups. Having the ability to track and analyze outcomes in a systematic fashion benefits medical researchers, payers, patients, and policy makers (Pharma and device companies, too), not just providers.

HIMSS15 confirmed that the spotlight is now on data—and what can be done with digital data. In other words, we’ve moved on from the era of adopting EHRs to the era of leveraging the data collection and reporting capabilities of EHRs. To someone who has been a champion of “meaningful use” of EHR data through the rough times of less-than-perfect EHR platforms, I feel as though the HIMSS universe is finally reaching the stage where the benefits of putting outcomes data to work via software solutions are apparent.  

Marc Andreessen said that “software is eating the world”, but from my perspective software isn’t of any use without the data to fuel the software engine.[1]

Granted, we haven’t entirely said goodbye to issues related to basic EHR architecture, usability, and interoperability, but the spotlight has shifted to what can be done when the data generated by EHRs and other sources. Note, it goes without saying that careful data management is required throughout the entire process of generating, analyzing, integrating, sharing and reporting data.

In a follow-on post, I’ll dive more deeply into some of the clinical decision support solutions I saw at HIMSS15. For this post, I’ll stay at 35,000 feet and review the HIMSS15 experience relative to my expectations.

A couple of months prior to HIMSS15, I was asked by the HIMSS Social Media organizers what top trends I expected to see at HIMSS15. I narrowed it down to three topics:

1. More advanced uses of population health data.
2. Consolidation in the health IT segment led by enterprise software vendors.
3. Evidence of 2015’s becoming the “The Year of Patient Decision Tools”.

I’d say I scored a 2.5 out of 3, but let me explain in case you don’t see things through my lens.

On the first trend, I don’t think anyone would argue against the point that population health applications and analytics were at the top of the list of buzzwords at HIMSS15.

Regarding the continued relevance of the Meaningful Use program, I’ve argued in the past that we’ll know that we’ve made progress when we no longer need external regulations to drive optimal design and use of health IT systems. At the current time, healthcare providers are still largely driven by external regulations, except we’re moving from ONC-driven EHR adoption incentives to CMS reimbursement/payment-driven policies. Long-term changes in payment/reimbursement and delivery models will have a stronger impact on IT priorities of providers than a short-term incentive program like the Meaningful Use program.

On number 2, the consolidation theme, this is what I wrote prior to HIMSS15:

Just about everyone expects consolidation among the fragmented EHR vendor segment; but I predict that we’ll start to see some EHR vendors acquired by large multi-industry enterprise resource planning (ERP) vendors, such as SAP or Oracle. The large vendors have experience integrating multiple systems and already have some experience in healthcare with financial and talent management software systems. It doesn’t take a big stretch of the imagination to envision further integration with clinical systems, especially in light of new payment models where financial performance is a function of clinical performance.

It’s a shame I didn’t include IBM in my list of large multi-industry enterprise vendors, since one of the biggest announcements was the acquisition of Explorys and Phytel by IBM for its Watson Health unit. [2]

Although Watson Health isn’t an ERP solution, it is part of a large corporation that provides multiple solutions to provider organizations. Furthermore, IBM is more entrenched in the business side of the spectrum and building up Watson Health represents an investment on the clinical side of the spectrum. My overarching point is that new reimbursement models are driving the need to close the divide between admin systems and clinical systems. New reimbursement models tie financial outcomes to clinical outcomes, so admin and business intelligence systems need to integrate clinical outcomes data.

On point 3, with my optimist hat on, I predicted that HIMSS15 would highlight patient decision tools, not only decision tools designed for clinicians. I did see some impressive communications and decision tools for patients, including GetWell:) Network and Tonic, which has partnered with Elsevier to market its patient engagement solution. There were other patient engagement & decision tool vendors at HIMSS15, and this topic merits more attention. For now, I’ll stick with my prediction that in 2015 we’ll see a lot of activity in the patient decision tool space and I will provide more indepth coverage later.

Finally, I’d like to thank HIMSS for including me in the Social Media Ambassador program this year. It was terrific to be grouped with the elite digerati in health IT and healthcare. This is a forward-thinking group that generously shares their insights via social media.

I’ll wrap up with a few photo highlights from my HIMSS15 experience. 

The awesome Social Media Ambassador group for HIMSS15. Nearly all long-time health IT social media friends, along with a couple of new connections for me.

Meetup of #TheWalkingGallery members at the #IHeartHIT session on Monday, April 13, 2015. 

 

Last, but not least, the HIMSS experience always extends into the evening. Here’s one of my favorite pictures, a group selfie taken by @DrNic1 at John Lynn’s #HITMC meetup at Gino’s East on Tuesday, April 14, 2015, with @DrNic1, me, @OchoTex and @askJoyRios, photo-bombed by @DocWeighsIn and @SarahBennight:

Stay tuned for additional posts on HIMSS15 that will cover developments in Clinical Decision Support. 

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[1] Marc Andreessen, Wall St. Journal, August 20, 2011:http://www.wsj.com/articles/SB10001424053111903480904576512250915629460, accessed April 23, 2015.

[2] http://www.healthcareitnews.com/news/ibms-big-buy, accessed April 23, 2015.

Update on Thursday, April 23, 2015 at 3:55PM by Janice McCallum

I realize I should have included a link to the HIMSS site. I shouldn’t assume everyone knows what the acronym stands for — even though the reach & reputation of the HIMSS brand extends far enough to attract over 43,000 people to the annual conference! Here you go: HIMSS.org and HIMSSConference.org.

Post-HIMSS Interview with NaviNet

2014 NAVINET EXPERT INTERVIEW SERIES

Laura McCaughey’s Interview with Janice McCallum on 2014 Outlook for Health Insurance Exchanges, Health Start-ups, and Need for Price Transparency Tools

Janice McCallum, Managing Director of Health Content Advisors, is a leading blogger and contributor to healthcare IT conversations on social media. Last night, Janice graciously spent time with us after Hillary Clinton’s HIMSS14 keynote address to discuss what surprised her in 2013, her thoughts about the progress of health insurances exchanges (HIX) to date, the most interesting start-ups she’s seen in the past few months, and what applications she expects to have the biggest influence on healthcare in 2014.

(1) What event/nonevent or trend surprised you the most last year?
I’ve lived through several periods of rapid change where digital technology radically improved access to information and transformed how we purchase goods and services. So, it’s not easy to surprise me; I’ve seen a lot!

But, to answer your question, I’d have to single out the problems with the Massachusetts Health Connector as it transitioned to an ACA-compliant health exchange last fall as the biggest surprise. The HealthCare.gov problems didn’t surprise me as much, since I had an inkling of how complex the set of data extraction and matching algorithms had to be. However, within Massachusetts (my home state), where we had ample experience with an existing insurance marketplace that we call the “Connector,” it took me by surprise that the transition to the ACA HIX was—and still is—such a disaster. Perhaps it was due to overconfidence, or more likely, it was due to the fact that Mass chose the same IT contractor as the federal government used for the launch of Healthcare.gov: CGI Federal. I don’t place the entire blame for early problems with the Healthcare.gov site on CGI’s shoulders, but it does appear that they had insufficient resources to complete either job on time. Overall, I’d say there’s plenty of blame to go around, but for now the focus has to be on moving forward and fixing the problems.

(2) Uncertainty and painful reality around health insurance exchanges (HIX) are keeping payers, providers, and patients up at night—and demanding a lot of problem-solving during the day. What advice would you give to health plan CIOs as they strategize to leverage technology to insulate their companies from the reality of HIX versus the model?
I can only offer high-level strategic advice, since I’m not an expert in the technology underpinnings of the exchanges. My advice is to learn from the successes and failures on HealthCare.gov and the state exchanges, adopt best practices from the successes, and avoid duplicating the mistakes made by others.

(3) You are quite active in the world of innovation. What are some of the most interesting start-ups you’ve seen in your travels over the past few months?
I see a lot of well-intentioned start-ups that aim to help patients/consumers manage their health—whether their audience consists of consumers managing chronic diseases, trying to maintain wellness, or fitness enthusiasts who want to analyze data to gain a competitive edge – or just a better understanding of the effects of exercise. However, I think it will be a couple of years before these consumer apps really take off, because it will require more connectivity between consumers, researchers, providers, and payers. More important, business models that offer benefits to consumers are needed. I’m concerned that the business model that is gaining momentum involves sending data to providers and payers who will use the data to dictate to patients/consumers what they must do to stay compliant with their health plan. Personally, I want to see a more inclusive model where motivated patients have full access to the data and their observations and analyses are taken seriously by payers and providers. At present, we don’t have an evidence base that is solid enough to jump to a model where health plans make decisions based on device data without involving the consumers, whose observations about the data could reveal insights about interactions or other factors that affect the interpretation of data.

Apart from devices and sensor data start-ups, I’d point to investments by Google Ventures for early-stage companies that merit watching. Their investments include One Medical Group, Foundation Medicine (which recently went public), InformedDNA, and About.me. On February 20, 2014, Google Ventures announced investments in two enterprise/mobile security companies—Ionic Security and ThreatStream. These applications certainly play a big role in healthcare enterprises. Also, I think Rock Health does a very good job of tracking and categorizing healthcare start-ups.

(4) What application do you expect to have the biggest influence on healthcare in 2014?
Apps that help consumers track healthcare expenses and aid in price transparency will be in demand in 2014 as high-deductible and health savings account (HSA) plans expand. Castlight Health is a player in the price transparency space and is a darling of the investment community, but it is targeted to the employer, not consumer, segment. I am more interested in tools that help consumers understand what an encounter with a provider or an episode of healthcare will cost. To really make an impact, apps will have to provide information to consumers before they make a decision to visit their general practitioner, urgent care center, a specialist, or choose some other path.

Apple’s planned Healthbook platform may be a game-changer in this space if they can go beyond consolidating data from apps and patient health records (PHRs) and connect that data with information from a consumer’s health plan. I think Intuit had planned to focus on the financial tracking aspect when they acquired Medfusion in 2010 to grow the Quicken Health Expense Tracker. But, that goal was short-lived when Intuit’s corporate strategy shifted away from the consumer market, and they sold Medfusion back to its founder.

To succeed in achieving the price transparency and out-of-pocket expense tracking objectives, these consumer application developers—Apple, HealthVault, and others—will have to collaborate with health plans in order to have access to the cost-sharing structures of each health plan. Policymakers and health plan executives keep emphasizing how important it is for consumers to make wise healthcare decisions. In 2014, I’d really like to see significant movement toward giving consumers access to information that helps them make better decisions about their health and their utilization of healthcare services.

This interview was originally published at http://www.navinet.net/blog/2014-navinet-expert-interview-series-janice-mccallum on February 27, 2014.