The Path to Clinical Groupware. by Vince Kuraitis

The Path to Clinical Groupware

April 24, 2010

Vince Kuraitis JD, MBA

Better Health Technologies, LLCwww.e-CareManagement.com blog (208) 395-1197

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Is HITECH working?7 Observations Mom Could

Understand.

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Is HITECH Working? 7 Observations

1) Hospitals are grumbling but are playing in the game; success is not guaranteed.

2) Key physicians will sit on the sidelines (at least for now).

3) ONC got it right on the 3 major policy issues: Meaningful Use, Certification, Standards

4) The supply (vendor) side of health IT is already transforming.

5) “Gimme my damn data!” The stage is being set to enable patient-driven disruptive innovation (PDDI).

6) Health care payment reform legislation and HITECH are synergistic.

7) Where’s Plan B? Congress and ONC need to address major flaws in HITECH.

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Intro

• Top of the 3rd inning• POV

– Cross industry– Bias: Pro-innovation (dog)

• A cacophony of voices and perspectives on HITECH• Blog series: http://e-caremanagement.com/is-hitech-working-7-

observations-mom-could-understand/

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HITECH Recap

• The Problem: hospital and physician EMR adoption is low• ARRA HITECH Act

– Incentives: $30-45 B

– New Programs: $2 B• Regional Extension Centers (RECs)• Health Information Exchange• Workforce training• Beacon communities• Strategic Health Information Technology Advanced Research (SHARP)

projects• Nationwide Health Information Network (NHIN)

• Key HITECH objective: set bar high enough but not too high• Complexity

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1) Hospitals are grumbling but are playing in the game; success is not

guaranteed.

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76% of Hospitals Plan to Pursue HITECH Funding

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2) Key physicians will sit on the sidelines (at least for now).

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Fear, Uncertainty, Doubt (FUD)Physician Perspectives

• My early adopter colleagues have horror stories about their EMR• The costs outweigh the benefits. HITECH financial incentives aren’t significant

enough to bother with• My workflow will be disrupted and productivity will decline• The current generation of EMRs are not user friendly; they’re downright difficult• Adoption time lines are too aggressive• The benefits of EHRs accrue primarily to insurance companies and government, not

me• I don’t trust the government. Look what a mess PQRI turned out to be.• The reporting burdens are a hassle• I understand there are potential penalties in 2015, but the government would never

clamp down on physician reimbursement – we’re too important• I’m really confused about what “certified EHR technology ” really means. Who is

certifying, and what’s this I hear about EHR modules?• Prices of EHRs will come down...let’s wait• I’ve been hit by the recession and don’t have the money to invest• Will the EHR I buy be interoperable with the hospital next door?• Will the EHR be interoperable with all the hospitals in the community?• What? I don’t get any money up front?• Will I buy the wrong EHR and then be locked-in?• What will ONC’s final rules for MU look like?• What extra burdens will be added by Phase II & III MU objectives? These are

unknown.

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Physicians Have Differing Views of HITECH

• Large Physician Groups• Small/Medium Primary Care Practices• Specialists• Hospital-Based Ambulatory Care Physicians

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3) ONC got it right on the 3 major policy decisions:

a) Meaningful Use (MU) Emphasizes “Meaningful”, Not “Use”

b) Vendors Get a Level Playing Field With Certification

c) Lightweight, Open Standards Promote EHR Interoperability and Modularity

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Modularity: Dis-Integration of the Computer Industry

Source: Venkatraman, N. Winning in a Network Centric Era, 2006

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From EMR 1.0 ...

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.... EHR 2.0/ Clinical

Groupware

v1.1, June 2009

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Expanded View: EHR 2.0/Clinical Groupware (v. 1.1, June 2009)

Office of the National Coordinator (ONC): 3 “Rights”

a) Definition of “meaningful use” (MU) focuses on quality and outcomes improvement– Meaningful use objectives– Quality metrics– Health information exchange requirements

Point/CounterpointIs the MU bar set too high or too low?

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b) New certification rules put HHS and ONC in charge and create a new independent process and requirements– Certification linked to ability to achieve MU.– Certification will focus on minimum requirements for

security, privacy, interoperability, and data exchange.– Certification process will be defined by HHS (not

CCHIT)– Multiple certification organizations

© www.bhtinfo.com

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c) Open standards promote interoperability and plug-and-play modularity– Promotes creation and certification of EHR modules– Separates patient data from applications – Emphasizes creation of “NHIN Direct” + Nationwide

Health Information Network– Focus on data liquidity vs. HITSP-like technical

standardization– Allows both HL7 CCD and ASTM CCR for summary

records

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4) The supply (vendor) side of HIT is already being transformed.

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TODAY: “Walled Garden” Proprietary EHR Platforms

• AMA to team with Dell for EHR info platform 3/10• AT&T Expands Healthcare Community Online to Improve Patient Care 2/10• Axolotl Corp Showcases New SOA Technology at HIMSS 2010 3/10• Covisint Jumps onto PaaS Bandwagon 11/09• Eclipsys

Introduces Open Platform to Transform Health IT and Drive Electronic Health Record Adoption 3/10

• GE IT CEO touts debut of next-gen clinical knowledge platform, eHealth Platform 3/10• Henry Schein

Announces the Launch of Innovative Henry Schein ConnectHealth (TM) Collaborative 3/10

• MEDecision Webinar Will Introduce New InFrame Collaborative Health Information Service Technology 3/10

• Medicity Opens Its Health Information Exchange Platform to Third-party Application Development 11/09

• Microsoft and Eclipsys Announce Health Care IT Alliance 2/10• NaviNet Offers End-to-End Healthcare Communications Platform 2/10• Quest Diagnostics Unveils Care360 EHR 3/10• Verizon Launches IT Platform to Help Accelerate Adoption of Electronic Health Care

Records 3/10

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TOMORROW?: Open EHR Technology Platforms with Plug-and-Play Modular Apps

• Analogy: Google Android and Open Handset Alliance

• Open at many levels (not necessarily all)– API– Open source – Open standards– Data portability– Cross-platform apps– Low barriers to entry/restrictions for

developers– etc.

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Drivers Toward an Open EHR Technology Platform

• Application developers• The Office of the National Coordinator for Health IT (ONC).

– …we believe that it will be common in the near future for Certified EHR Technology to be assembled from several replaceable and swappable EHR Modules. Health & Human Services, Interim Final Rule on Standards , December 2009 p.41

• Google Health and Microsoft HealthVault . • The Clinical Groupware Collaborative • Free or freemium EHR offerings such as Practice Fusion • Free and open source software (FOSS) e.g., Mirth , VISTA • openEHR • NHIN-Direct • ONC SHARP Grant for Childrens Hospital Boston and

Harvard Medical School

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5) “Gimme my damn data!” The pump

is being primed for disruptive

innovation by patients.

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HITECH -- Direct Provisions to Share Data With Patients

• Stage 1 -- 2011 (from MU NPRM, 12/09)– Physician (EP) Objectives

• Send reminders to patients for preventive/ follow up care • Provide patients with an electronic copy of their health information (within 48 hours) • Provide patients with timely electronic access to their health information within 96 hours of the

information being available to the EP • Provide clinical summaries for patients for each office visit

– Hospital Objectives• Provide patients with an electronic copy of their health information (within 48 hours) • Provide patients with an electronic copy of their discharge instructions and procedures at time of

discharge, upon request

• Stage 2 – 2013 (from 8/09 MU Matrix, HITPC)– Physician (EP) Objectives

• Access for all patients to PHR populated in real time with health data • Offer secure patient-provider messaging capability • Provide access to patient-specific educational resources in common primary languages • Record patient preferences (e.g., preferred communication media, health care proxies, treatment options)• Incorporate data from home monitoring device

– Hospital Objectives• Access for all patients to PHR populated in real time with patient health data • Provide access to patient-specific educational resources in common primary languages • Record patient preferences (e.g., preferred communication media, health care proxies, treatment options)

• Stage 3 – 2015 (from 8/09 MU Matrix, HITPC)– Physician (EP) and Hospital Objectives

• Patients have access to self-management tools • Electronic reporting on experience of care• Provide patients, on request, with an accounting of treatment, payment, and health care operations

disclosures

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6) Health care payment reform legislation and HITECH are

synergistic.

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7) Where’s Plan B? Congress and ONC need to address major flaws.

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HITECH “Issues”• Does HITECH address core issues explaining hospital and physician non-

adoption of HIT? – Lack of usability– Loss of productivity– Changes in workflow– Culture– Failure rates, perception of risk

• All or nothing, pass/fail should be replaced with incremental payments for incremental demonstration of MU

• 10% Medicaid match for States is challenging in light of State fiscal challenges• HITRECs and other grant programs will create jobs, but no guarantee of

physician adoption• Privacy/security: comprehensive federal legislation needed, e.g., to clarify

patient right to control over data, eliminate conflicts across states• Should there be incentives/regs for other providers, e.g., nursing homes, home

health agencies, behavioral health, etc.?• Should there be incentives for other “EHR technologies”?• Consider differential incentives for high-leverage physicians?• What about specialists? are there sufficient incentives to create adoption?• If NHIN Direct takes root, do we need HIEs? • Should incentives be provided up-front rather than back-end?

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Summing Up

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THE END

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Better Health Technologies, LLC

• Technology and health care delivery are shifting:  – From: Acute and episodic care delivered in hospitals

and doctors’ offices– To: Chronic disease and condition management

delivered in homes, workplaces, and communities

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