From my perch as a moderator and reviewer for HIMSS2016, here’s a quick synopsis of key themes, issues and thoughts.
A few Interesting Presentations:
The first is a project titled Patient Identity & Digital Record Matching: A New Approach, developed & reported by the CEO & CIO of Tenent Health (https://www.tenethealth.com/), a large-scale healthcare network that manages approximately 80 hospitals, 475 outpatient facilities staffed by about 130,000 employees, six health plans and other services. Tenet has described use of a hardware token to provide identity verification across their system of care. In terms of workflow integration, the token is read to check the person in at their point of care, their data is updated and pulled up and the card also serves to manage billing and payment. Rather than being limited to the use of the technology at the Tenet facilities a key innovation is the integration of this token for identity verification by local banks, businesses such as health clubs and large retailers (Sam’s Club, etc.) and smaller businesses including service business. Their arrangement allows this token to be used like a (direct) charge card. It also carries a summary of the person’s healthcare information. Tenet’s vison is that unambiguous & secure healthcare identity should be able to serve for the majority of identity needs, providing a “value add” in the community.
Second was a project titled Five States, 700 Physicians & Four Best Practices for HIE was developed and reported by Avera Health (http://www.avera.org/) and the South Dakota Health Link (http://www.sdhealthlink.org/). Avera Health is a faith-based integrated healthcare delivery system located in South Dakota, Minnesota & Nebraska, and SD Health Link (SDLH) is the non-profit health information exchange initiated by the SD Department of Health that now provides services across five states (SD, NE, IA, MN, WY). The presenter described a partnership where the HIE provides technical and other support to Avera so that its facilities and providers can exchange healthcare data either by DIRECT messaging (standardized secure, encrypted messaging) or by point-of-care exchange (NWHIN query). SDHL developed and maintains a Health Information Service Provider (HISP) so that they can provide DIRECT support (push data) with no intermediary. They also have developed the infrastructure and maintain software to support provider query of other participating organizations (on-demand pull data) for patient information. It is rare that a healthcare organization develops its own HISP for DIRECT communication, but by doing so, SDHL is able to provide secure messaging services not just to Avera, but to healthcare organizations across the five states it now serves.
John Mattison, CMIO & Assistant Medical Director of Kaiser Permanente, gave a talk on the changing landscape of healthcare & HIT. I worked with John when I was CTO of a company providing identity verification & management in California, & he is nothing if not controversial, but often insightful. Mattison, who currently co-chairs the eHealth Workgroup of the Global Alliance for Genomics and Health (GA4GH) stated that population health is a “dead concept”, and that the days of one-size-fits-all care are over.). What I believe he meant is that we are moving to a state-of-the-art in healthcare where care will be personalized for all patients based on their social and clinical histories and genetic make-up; in this new world, population health will be much less important because all care will be individualized. I personally think that this transition will not come to pass for a long time, but even if Mattison is right, some elements of care will always have to characterized and addressed at a population level, which considerable mutes this pronouncement.
The Federal Agenda
Sessions by the ONC, CMS, HHS focused primarily on two things: first was the “new” interoperability pledge made by 17 HIT vendors, 16 large healthcare systems & 17 healthcare organizations &/or government agencies. The pledge was voluntary and stated that it proposed to: “promote patients’ access to their own electronic health records, eschew data-blocking and use federal standards to promote interoperability”. This is the fourth such effort to get HIT vendors to realistically support data sharing. Will it be any more successful than the previous three? Time will tell, but the industry’s record on this has not been good. Even with Cerner CEO Patterson stating that “It is unethical & immoral not to share (healthcare) data”, as well as If you are not interoperable in five years, you’ll be obsolete”, it is difficult to see a path to real interoperability in the foreseeable future.
In short-term, industry experts including vendors, providers and staff suggest that interoperability can be addressed either via the use of an integration bus, such as Intersystems, to do point-to-point connections between EHRs, the use of DIRECT messaging to exchange Continuity of Care Documents (CCDs or C-CCDs) or the use of HIE capability (also mostly CCD exchange, but evolving to query-based exchange). None of these “solutions” create an actual interoperability among EHRs or other HIT, but simply allow the exchange of limited data in a format (XML) that is difficult to assimilate into the actual searchable records of the target EHR. One possible solution to this that people is the new HL7 standard FHIR (Fast Healthcare Interoperability Resource). This is a highly granular, REST-based standard that has the potential to actually create interoperability among healthcare applications.
The second item on the Federal agenda was MACRA Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), Merit-Based Incentive Payment System (MIPS) and the reimbursement changes that will be put in place over the next 3-5 years. MIPS starts in the 2017 performance year, but it is hard to evaluate the difficulty (or ease) that Eligible Providers will have in complying with the program since the performance measures that will make up a large part of compliance are not finalized. What is clear that the program as currently defined is complex – with seven different reporting paths, four different measure areas (Meaningful Use, PQRS, Value-based payment modifier & clinical performance), different compliance requirements for each reporting path two of which (VBPM & clinical performance) are entirely new. Conference attendees expressed a healthy concern over the evolution of the meaningful use incentive program and a good deal of skepticism regarding the MACRA/MIPS program.
Approaches to analytics
Attendees seemed to be interested & excited over the increasing focus on population health as it appeared to give them a real focus for larger-scale improvement of care and outcomes. Many were uncertain, however, of what this would mean for them and their organization in terms of technology and organizational change. Conference themes supported their interest, if not necessarily solutions to the quandary.
I was able to sit down with IBM’s chief healthcare architect for about a 30 minute discussion of the direction that IBM is taking with Watson Healthcare. Does Watson do population health or healthcare analytics? As you may already know, Watson is primarily a learning system. A current effort in healthcare is that Watson has read tens of thousands of papers on cancer research as well as reviewing a very large amount of clinical (EHR) data including treatment plans & outcomes. Based on this corpus of material it used its deep learning capability to teach itself about cancer treatment & can now make recommendations on cancer treatment for specific cases. This is true in several diagnostic & treatment areas. Could Watson “teach” itself population health? What would that entail, since there are no specific cases for it to apply its knowledge to. It might be very interesting to see what Watson would think population health is, but IBM has not yet looked in this direction for Watson. Nevertheless, it is one of the most interesting new developments in the recent technology landscape.
Every EHR vendor as well as many other types of vendors was demonstrating population health and analytics applications. A very broad range of capabilities was demonstrated, ranging from deep analytic, visualization function, productive population analysis and characterization. Still, functionality demonstrated by almost all vendors included detailed reports on quality measures and population percentages for chronic conditions such as hypertension and diabetes. Some vendors allowed a drill-down on the details of these reports, and some vendors also provided on-line (active) guidance for analysis. My take-away, given the broad range of functions and features, leads me to suggest that those charged with selecting analytics &/or population health products consider the following:
- Make a list of the questions you need to answer and the capabilities you need in order to do so.
- Prioritize the list.
- Evaluate your current HIT products (EHR, etc.) to determine if they provide any of the capabilities that you need. Work with your vendor(s) to be able to utilize the functionality you already have.
- If your current product set does not provide the capabilities you need, evaluate analytic and population health vendor’s products to see what products do provide what you need. Make very sure (by actual demonstration with your own data) that the product you evaluate is compatible with your EHR (and other HIT products) and that it can both extract and share data with your in-use applications. This is essential.
Develop a test case, several is better than one, and have the vendor work with you to execute these tests. Use your own data and determine how easy integration and use of the new product will be. Work with the new vendor with respect to training as well as deployment. Involve your current vendors as well, if possible.
HIMSS16 emphasized several major directions in health information technology that health centers must be aware of and take into account in their planning and operations. From the Federal standpoint, the important topics were new payment models in the form of MACRA and MIPS as well as the focus on data integration in HIT applications. From a vendor and end user point-of-view, the primary topics were the role of analytics and population health in care planning and delivery as well as operational optimization and strategic planning. Health centers need to be addressing all four of these topics as they move forward in 2016 and beyond.