Donald Rucker, M.D., National Coordinator for Health Information Technology, told the medical informaticists gathered at the AMDIS/HIMSS Physician Executive Symposium on Monday morning that CMIOs and other medical informaticists that they can be instrumental players in helping move healthcare computing to improved usability and interoperability going forward. Dr. Rucker presented the opening keynote address at that preconference symposium, one of numerous preconference symposia being held Monday during the annual HIMSS Conference, currently taking place at the Sands Convention Center in Las Vegas this week. The symposium is being cosponsored by AMDIS (the Association of Medical Directors of Information Systems) and HIMSS (the Chicago-based Healthcare Information and Management Systems Society). The Symposium is being held at the Wynn Hotel and Resort, across the street from the Sands.
Rucker cited increasing consumer empowerment—which he made clear that he supports—and advances in information technology, as elements that will stimulate enhanced interoperability in healthcare going forward, with interoperability being one of the key goals of federal healthcare officials.
“If you look at the computers we have today, they’ve really grown up in an environment where they weren’t really about computing for automation,” but rather primarily for billing. “Our computers today are deeply grounded in documentation and billing. We’ve just had a little bit of elimination of unnecessary workflow. But computers in healthcare look very different from computers in other industries—manufacturing, even service industries,” partly because of the complexity of healthcare delivery processes. Fundamentally, Rucker said, the shift in the health insurance market towards high-deductible health plans will compel consumers forward to search for greater value from the healthcare services they consume, which will in turn force innovation among providers.
Rucker urged the CMIOs and other medical informaticists in his audience to take things into their own hands and participate in pushing their own patient care organizations towards greater usability on behalf of their fellow physicians. “It doesn’t have to be just someone in IT who ‘does it to you,’” he said, referring to internal efforts to improve physicians’ workflow. “You have as much power as anybody in the hospital administration, when it comes down to it. Doctors are noisy, but we don’t use our powers. So take that user-group meeting, figure out how to build a better order system, how you can label things with labels that make common sense to folks. There’s a lot of stuff you can do to advance your work. And with just a little bit more work, you can really dive into these systems.”
Moving on to the federal healthcare IT policy level, Rucker said, “Now, as we look at things that make more sense for the government to be more involved in today in the healthcare IT space, two things stand out. We have the electronic medical record, in large part because of the HITECH [Health Information Technology for Economic and Clinical Health] Act. And everybody intuitively thought they would automatically hook up with each other. But that didn’t happen. And that’s just the case everywhere. Windows didn’t have an Internet IP stack in it until the early 90s. So one issue is the raw usability. When clinicians are spending four or five hours a day on the computer—an hour of which has been described in our listening sessions as ‘pajama time’… usability and interoperability are massive issues. And there’s really a national consensus to work on those things.”
Further, he said, “Congress in December 2016 passed the 21st Century Cures Act, with an entire section on usability and interoperability. That was passed with 390-plus votes in the House, and over 90 votes in the Senate, and that’s pretty rare in U.S. politics these days. And it was signed into law by President Obama, after the election. And President Trump has made consumer empowerment a major campaign issue and issue for his organization, and has charged Secretary Azar at HHS[Health and Human Services Secretary Alex Azar] to really be working on consumer empowerment.”
Speaking further about consumer empowerment, Rucker said, “Drilling down into these two issues, that’s a complicated stack. The usability issue has a number of components to it. Often, people will say, they didn’t design the user interface well. You can argue back and forth on that. Some of it is the nature of tools, the nature of incentives. Sometimes, we as docs give bad advice to developers. But there are a number of things on the policy side—I would stay tuned for Administrator Verma’s talk on meaningful use tomorrow. A number of things that make sense in a paper world but don’t make sense in an electronic world. The E & M codes were actually requested by our colleagues in the 1990s in lieu of having time stamp codes. But we have to think about that entire burden. We’re working very closely with CMS [the Centers for Medicare and Medicaid Services] on putting together an entire program on that. John Fleming [M.D.] of ONC is working with Kate Goodrich at CMS to put that together.”
Meanwhile, he said, “So now we get to interoperability. Interoperability is hard; I can get my money out of an ATM in whatever faraway country you might want to go to. But our biological complexity is way, way more complicated than anything in banking. What we do in healthcare is more complex, and therefore harder to do. So the way we look at interoperability is to look at three specific use cases, and gear our interoperability work to do that. Provisions on information-blocking, trusted exchange networks, and open application programming interfaces, are in 21st century Cures.”
Speaking of the Cures Act, Rucker said, “As we look at the use cases to guide us in these provisions, the first is, how do patients get the data themselves? Patients want on their smartphones what they have in the rest of the economy. They want that set of tools on their smartphones. How do we broaden that conversation from just one provider sharing it with another? Patients want control. And that means we’ll have to be on our game, because if patients have it under their control, they’re going to shop. So we’re going to have to up our game; and that’s good for all of us.”
Meanwhile, Rucker said, “The next big case is looking at patients as part of a population. It turns out it’s actually hard to look at patients as part of a population, esp. across multiple health systems. And most of our healthcare is still paid for by third-party payers. And those payers who are ultimately buying on our behalf—they don’t have good visibility into our institutions and what’s going on. A lot of these are one-off [exchanges of data], but there are no standard ways to do this: a broad overview of some swath of data is essential. I don’t believe you can have a learning healthcare system without aggressive computerization. I think a big-data learning healthcare system requires interfaces to get at the data. Why is it that Amazing can look at what we do when we shop and suggest other things to buy, using brilliant machine learning? Why couldn’t we get that data to know that the treatment we’re embarking on, works? That’s modernity, and that’s part of open APIs.”
And, Rucker added, “The third use case is what we’ve always anchored on: how do we get data from one provider to another? And there have always been networks. But we need to expand data in ways where there’s market competition. We’re working on a number of things that will help that, and I think if we solve the patient getting the data and the population getting the data, we’ll nail the providers getting data from each other. Now if we get those three things, what do we do about it? It’s one thing to identify use cases, another to do something about it.”
Speaking of the Cures Act again, Rucker said, “The 21st-Century Cures Act is a pretty amazing law. When I was appointed to this job, I read the entirety of the Cures language, and there’s a lot of pretty smart stuff in there to empower patients and get things going. I want to talk about three things” in that connection, he said. “The first is information-blocking. There are two classes of ways Congress envisioned information-locking being prevented. One is penalties to providers; and then for EMR vendors and networks, that would come through the Inspector General. I think you’ll see in the rulemaking that we’re working on—Congress has defined information-blocking; we’re defining exceptions to information-blocking. But if we work together and work on these interfaces—I think there’s a good chance we can get away without making significant enforcement actions.” He added that the development of trusted networks will be a second important element in progress forward.
“The third thing that’s in Cures that’s maybe the most interesting is open APIs,” Rucker said. “The fascinating thing about that is, when you read that language, it doesn’t just say ‘open API’—it says, ‘open API without special effort.’ An open API just means you’ve exposed your function calls. In order to make things useable without special effort, you need to go to industry standards that people know, you need documentation, publication, some ability to test the code, and Congress put all that in. It’s open APIs without special effort: Congress did call out that this is really a patient empowerment thing.”
Another issue that Rucker mentioned, briefly, was the need to move to the analysis of data across very broad populations in U.S. society, something that remains challenging because of the fragmentation of health insurance coverage. “The population-level data is all still covered under HIPAA,” he said, speaking of the Health Insurance Portability and Accountability Act of 1996. “You still need a legal contract with you the provider and a payer, or a population health vendor you’ve hired, or a consortium you’ve gotten together, like PCORI [the Patient-Centered Outcomes Research Institute]—all that requires a legal HIPAA contract.” But that fact, he said, will continue to protect the privacy of individual patients.
Moving forward towards greater interoperability and usability will take time and effort, Rucker said, but he said he remained convinced that much will change in the coming years, some of it stimulated by the federal government, but a great bulk of it stimulated by consumer empowerment and the mechanisms of the free market. In the end, he said, “I’m pretty optimistic that we’re going to solve these problems. It is a very exciting time. We finally have the computers, the networks, we have enough knowledge about it, we’re in the mood to do it, we have a lot of learning on what works and doesn’t work—so I think we’re in an extraordinary position to use a lot of this technology” to drive forward towards interoperability.
Rucker sidestepped an audience question about the development of a national patient identifier, saying that biometric identification systems and algorithmic statistical investigation could eliminate the need for such an identifier.