In his opening keynote for the Physicians' IT Symposium at the HIMSS16 conference in Las Vegas, John Halamka, M.D., CIO of Beth Israel Deaconess Medical Center in Boston, reflected on how health IT has progressed in the last decade, and what the industry can do better moving forward.
As part of the pre-conference education, Halamka's opening keynote, "Are we there yet? Health Information Technology's Report Card," at the Sands Expo Convention Center, started off by looking at how the health IT industry has evolved from the days of when David Brailer, M.D., was the National Coordinator for Health IT. Halamka narrowed in on several areas of focus, from electronic health records (EHRs) to interoperability to patient engagement to big data and analytics, and finally, to the cloud and mobile health (mHealth).
He then gave report card grades to each of these areas before outlining his call to action on how to improve. For EHRs, he gave a grade of C+, noting that there has been an 80 percent adoption rate, but with 453 clicks to admit a patient and 140 structured data elements per encounter to support clinical quality measures, 40 percent of clinicians feel burned out. Halamka also gave interoperability a C+, saying that the industry has made reasonable progress pushing payloads from place to place, but have not built the enabling infrastructure to support pull.
Halamka gave patient and family engagement a B, noting reasonable progress has been made with portals but an app that enables true patient stewardship of data is needed. He graded big data and analytics, and cloud/mobile as Bs as well, attesting that the greatest challenge with cloud is lawyers. "We need to accept that the risk can never be zero," he said.
Perhaps the most noteworthy part of Halamka's keynote was when he laid out his call of action on how to do better. "Meaningful use has run its course," he said. "We tried to move too far and too fast before we had cultural change or enablers," which he said are a master patient index, provider directory, and a trust fabric. "We must move to outcomes-based payment models for clinicians and hospitals. Let's embrace MIPS and MACRA. If the goal is to reduce readmissions and you want to give your patients Apple Watches, go for it. But saying that you need to enter tons of data elements for every CHF patient isn't the answer. We need to move away from this," Halamka boldly said.
What's more, Halamka said that certification, in its current form, has paralyzed innovation and doesn't improve interoperability. He added and reinforced, "We need a national provider directory, a voluntary national patient identifier, a trust fabric, a governance framework, and consistent privacy policies."
He continued, "We must reduce clinician burden. We need all care members to contribute to the record and reduce burden overall. Clinicians as data entry clerks are not operating at the top of their license, and we need everyone to contribute at the top of their licenses."
Finally, Halamka said that it's time to return the agenda to the private sector. "We need CommonWell, Surescripts, and The Sequoia Project to all come together. The private sector can take the leadership role to move us forward in this call to action," he said.
Halamka also reflected on where the industry has evolved from years ago. On healthcare's interoperability journey, Halamka noted that standards have been "skinnied down some," but they are still too challenging to navigate. "With Argonaut and FHIR [Fast Healthcare Interoperability Resources], they are simpler standards that take days, rather than months to implement, so our trajectory in that sense has been good," Halamka said. "But they are still too complicated. You need a Ph.D. To [fully] understand HL7 [Health Level Seven]. However, there is FHIR work coming in the next year that will empower that," Halamka predicted.
Regarding patient engagement, Halamka said progress has been made in making it a shared medical record between the doctor, patient and family, specifically referring to the OpenNotes movement. "It's not a personal health record as much anymore. Shared data at one time was considered rogue. Now, malpractice insurance rates have gone down with patient, family and doctor engagement. Engaging the patients, as equals....we have made good progress there," he noted.
Halamka then touched on big data and analytics. "You can go down the HIMSS show floor asking people about population health. What is population health? The answer you will get is, 'I don't know but my EHR isn't delivering it.' It's still very early, and I've yet to see a leader in the space of analytics and care management," he said, while pushing the need to go from managed care to care management. "In our ACO [accountable care organization], 50 percent of the cost is generated by 5 percent of our patients," he said. "What if you could predict who will be the super utilizers next year and prevent them from getting to that level this year? You can intervene by getting them a Fitbit, gym membership, or [something to that end]," Halamka said.
He drew an analogy from the personal experience of his wife being diagnosed with Stage 3 breast cancer in 2011. "I wanted to know about the last 3,000 patients like her who have been diagnosed with breast cancer," he said. "What were their side effects, morbidity and mortality?" As such, via an open-sourced, data platform, Halamka was able to put together a treatment plan for his wife based on data across hospitals. "She ended up getting treated and it was a result of looking at 10,000 previous patients like her," he said, speaking to the power of big data.
Regarding EHRs, Halamka said that if he were to ask clinicians if they would be able to better coordinate team-based care between all members through their EHRs or through Facebook, most would say Facebook. "You have a wall, you can change your status, you can add people," he noted. Meanwhile, EHRs were well designed for the regulatory drivers, such as meaningful use, but not for care coordination, he added. "You have 140 data elements to enter, but you have 12 minutes to see the patient, and make eye contact with them, and not commit malpractice! And you can't blame vendors, they did exactly what we told them to do," Halamka said.
He added that he brought up the idea that secure Facebook could be better in delivering care than existing EHR technology to the feds, and they said you would be violating 3,000 pages of regulations. "Look at what we have done to ourselves regarding physician satisfaction and workflow. Are we achieving better coordination of care? Halamka asked.
As such, Halamka defined interoperability as having access to data when and where you need it for care coordination. "We are better than we have been before, but about half of clinicians feel that data isn't available when and where they needed it. Maybe the data was there there but they were not able to integrate it. So we have work to do," he said.
