U.S. Senators and healthcare information technology (HIT) make strange bedfellows indeed. To quote Trinculo, the jester in Shakespeare’s The Tempest, “Alas the storm has come again! … Misery acquaints a man with strange bedfellows”. (Act 2, Scene 2)
In the wake of articles published by The New York Times, The Wall Street Journal and other major news outlets suggesting that electronic healthcare records (EHR) solutions are not living up to expectations, or worse, enabling fraud, (see Parity Research blog on the topic) a twenty seven page Whitepaper was published April 16th, 2013 by Senate Republicans entitled REBOOT: Re-Examining the Strategies Needed to Successfully Adopt Healthcare IT.
Authored by six Republican U.S. Senators, none with any significant IT experience and only one with a healthcare background, the paper aims “to foster cooperation between all stakeholders – including providers, patients, EHR vendor companies, and the Department of Health and Human Services – to address the issues raised in this paper, evaluate the return on investment to date, and ensure this program is implemented wisely.” (page 5, paragraph 2)
Healthcare IT Tempest
The “program” in question is the Health Information Technology for Economic and Clinical Health or HITECH enacted under Title XIII of the American Recovery and Reinvestment Act of 2009. The primary issue raised in the Senatorial paper is the lack of a “clear path toward interoperability” for electronic healthcare records (EHR) and the solutions that mange them within hospitals, across providers and even across state-run health information exchanges (HIE) – not to mention the billions spent on technology adoption.
The report, authored by Sens. Lamar Alexander of Tennessee, Richard Burr of North Carolina, Tom Coburn of Oklahoma, Michael Enzi of Wyoming, Pat Roberts of Kansas and John Thune of South Dakota, decries the “misplaced focus on use of technology within silos rather than interoperability.” (page 11)
“Unfortunately, the program as laid out by CMS (Centers for Medicare and Medicaid Services) and the Office of National Coordinator for Health IT (ONC) continues to focus less on the ability of disparate software systems to talk to one another and more on providing payments to facilities to purchase new technologies.
CMS’ failure to systematically and clearly address meaningful groundwork for interoperability at the start of the program could lead to costly obstacles that are potentially fatal to the success of the program.”
The Senators also address related concerns – what the paper refers to in separate chapters as “Lack of Oversight, Patient Privacy at Risk” and “Program Sustainability”. In part, they have concluded that while “clinical notes are recorded with increasing speed and ease, and other transformations offer the promise of increased efficiency, reduced costs, and improved quality of care… details of federal law and regulation may be inadvertently incentivizing unworkable, incoherent policy goals that ultimately make it difficult to achieve interoperability.” (page 27)
“Congress, the administration, and stakeholders must work together to ‘reboot’ the federal electronic health record incentive program in order to accomplish the goal of creating a system that allows seamless sharing of electronic health records in a manner that appropriately guards taxpayer dollars.”
The Senators assert that “transformations in health IT will significantly change how health care is provided in this country.” But until the program can be reexamined and evaluated – preferably through a detailed study conducted by an outside party – the Seantors are calling for a halt to spending “meaningful use” dollars set aside for providers to implement EHR solutions.
The Imperfect Storm
While the whitepaper brings up several valid points about lack of interoperability, potential misuse of funds and fraud, issues with security and long-term program viability, a lack of oversight and a rush to move smaller less well-funded providers through HIT adoption requirements to qualify for meaningful use, the paper fails to produce any viable suggestions to improve on what CMS and the ONC have so far put in place.
Halting the program to “recalibrate” (pages 1, 13) and conduct an in-depth study is not the answer – although that might make opponents of ObamaCare happy as the HITECH act is tied emotionally and essentially to the Affordable Care Act (ACA).
In addition, suggesting that HITECH and the ONC stick with their initial definition of interoperability is counter-productive. The paper quotes the ONC definition as “The establishment of standards that support the nationwide electronic exchange of health information (called “interoperability”) in a secure computer network.” (page 8, paragraph 3)
There are multiple dimensions to HIT interoperability and the healthcare ecosystem has to walk before it can run. To use an oil industry analogy, it makes no sense to focus all your efforts on the refinery when you haven’t yet figured out how to get the oil out of the ground. Lots of work needs to be done before a nationwide EHR standard can be implemented.
According to a recent survey conducted by Premier, which helps 2,000 hospitals across the country manage their back-office operations, “Thirty-two percent of respondents are unable to share data across the continuum of care.” (from Health Data Mgmt. article) Extrapolated across the 5,000 hospitals in the U.S., these findings would indicate that 1,600 hospitals can not effectively share EHR data between departments within their own organization. It is also highly likely that most of the remaining hospitals can only share a portion of their EHR data across the continuum of care.
Healthcare records come in many forms including handwritten on paper and a myriad of incompatible electronic formats. Top tier hospital groups with deep pockets have spent many millions bringing their historical EHRs on line and making them available to clinical and operational systems as well as newly implemented EHR solutions.
For the most part, these HIT leaders and innovators were motivated to make the interoperability investment within their own shops not because they were reacting to policy. On the contrary, they understood what the Senators’ whitepaper hints at: Interoperability helps improve quality of care and reduces cost.
Creating policy to achieve a nationwide EHR interoperability standard is doomed to failure. There are too many competing healthcare interests that influence policy including medical associations, technology vendors, payers, providers and big pharma. Better to establish interoperability guidelines and let the marketplace determine a de facto standard down the road.
The HIPAA privacy standard, while important and necessary, is hampering productivity and interoperability – at least the way it is so far being implemented. A recent survey conducted by the Ponemon Institute that focuses on productivity estimates that over $5 billion per year is lost due to the use of outmoded technology. The study also concludes the HIPAA regulations are an enabler.
At the same time, the less well-funded providers are struggling. Their IT departments are underfunded, understaffed and overworked, and they often use technologies that other industries, such as finance, replaced 15 to 20 years ago. There are several published reports indicating a severe shortage of healthcare IT personnel – which is no surprise since any highly qualified IT person can make more money and work with more advanced technology in many other industries.
Complexity + Chaos = $
As much as or more than any other industry, healthcare loves complexity and feeds off chaos. Healthcare is primarily reactive. Most people never see a doctor or seek medical attention unless they are already sick or experience a health-related crisis. Healthcare IT mimics this reactive condition. While ACA seeks to refocus both patients and providers on prevention and quality of care – which will ultimately lower costs – the prospect of less revenue in the healthcare pie may be anathema to providers, payers, big pharma, medical device manufactures, EHR solution providers and perhaps even some politicians.
Policies related to HITECH and the implementation of meaningful use are fueling the chaos by enforcing reactive behaviors from providers including the purchasing of mindbogglingly expensive EHR solutions. The push to implement EHR solutions is literally turning software entrepreneurs into billionaires such as the founder of Epic Systems – which last year found itself caught up in a potential lawsuit with rival Allscripts over a $303 million bid to supply New York City’s public hospitals with new EHR solutions.
As mentioned above, the Senators’ whitepaper refers to the suspected “Misuse of EHRs” which may facilitate “Code Creep” and “Actually increase health care costs”. (page 15) Two major points the articles written on the topic of EHR solutions abuse and the Senators’ whitepaper fail to point out are:
- EHR solutions are glorified billing systems. That’s what they do best. It makes sense that they would optimize the medical billing process – a less-than-perfect science to begin with.
- Fraud in the healthcare industry, including code creep, existed well before EHR solutions showed up. While EHR solutions might enable fraud, they also enable fraud detection.
Waiting on Interoperability Standards
The ONC’s Standards and Interoperability Framework, overseen by the Office of Interoperability and Standards has its work cut out for it. The framework gathers input from public and private sector sources aiming to build repeatable processes and best practices to help create standardized HIT specs. Simultaneously, a consortium of six EHR solution vendors, led by Allscripts and not including Epic, has created the CommonWell Health Alliance whose stated mission is to “provide a way for vendor systems to link and match patients and their healthcare data as they move from setting to setting, in a robust and seamless industry-wide data environment.”
While providers, and their patients, wait for all of these standards and the good intentions of software vendors to play out, meaningful use requirements are moving ahead. As stated by the Senators’ whitepaper, one of the biggest problems with meaningful use incentives is the absence of any interoperability accountability for EHR vendors. That needs to change.
Apparently there are no simple, cost-effective answers when it comes to healthcare IT and EHR interoperability. Or are there?
Achieving EHR Interoperability in Stages
Starting the interoperability exercise at the provider level where much of the critical unstructured patient data resides increases productivity and lowers costs related to managing and deriving value from health records and related documents while maintaining and improving compliance with HIPAA and meaningful use requirements.
Below are a few recommendations for policymakers and providers that can be achieved relatively quickly and cost effectively to help pave the way for critical intra-provider interoperability. When standards are finally in place and HIEs have matured, sometime down the road, providers will be prepared to take full advantage. In the interim, providers need to shift out of reactive mode when acquiring HIT solutions.
Recommended Policy Updates – Rather than spending more tax payer money on in-depth studies and delaying meaningful use requirements, HITECH and the ONC should;
- Raise the bar on interoperability for EHR solution vendors. Force EHR vendors to adopt or “OEM” technologies that support providers’ migration from old paper and/or electronic records to their new EHR system or to a central records repository or database that can be accessed by updated EHR solutions or by clinical, operational or analytics systems. Right now, Epic and other EHR vendors often recommend “tiffing” files, i.e., creating an image of a record. Such records can only be searched as metadata. Unless the record, which is mostly text, is indexed before the image is created, the data within that record is not accessible.
- The requirements for vendors qualifying for meaningful use dollars should be broadened to include non-EHR vendors that enable interoperability at the basic provider level. Most hospitals have multiple, non-compatible EHR systems in use throughout their environment. At present, however, the requirements for meaningful use are too narrow and the bar set too low for appropriate non-EHR solution vendors to qualify.
Recommended Provider Strategies – Aside from the relatively few healthcare providers that are leaders, that enjoy a relative abundance of resources and that have created a clear path to interoperability internally and for HIEs of the future, the vast majority of providers need to:
- Stop spending exorbitant amounts of money on EHR solutions that lack the basic functionality to interoperate with existing HIT infrastructures. Vendors are transaction focused and will sell whatever customers say they want. Buyers need to demand more functionality from EHR vendors before they can expect better solutions.
- Providers need a Healthcare Big Data strategy supported by senior management. IT needs a roadmap for implementing solutions that support meaningful use requirements as well as existing processes and workflows, while being affordable. Leaving the development of a Big Data strategy up to vendors does not lead to what’s best for providers.
- Given resource constraints, providers need to set aside concerns about cloud adoption and identify other opportunities to outsource IT operations, services and support. Also, IT needs to take an inventory of existing solutions in use throughout their organization and identify which solutions can be cost-effectively repurposed across departments as opposed to supporting a siloed approach to solution and technology adoption. A recent IBM Sourcing Study points to the many motivations, benefits and best practices for outsourcing and partnering with technology vendors and service providers.
Cost-Effective Interoperability: Recommendations and Vendor Enablers
Looking across the spectrum of solutions that can cost-effectively support health records interoperability at the provider level (once a strategic healthcare data plan is in place), here are several recommendations for dramatically improving interoperability – right now.
The following list of vendors is not exhaustive, just representative of solutions in their respective category available today to meet providers’ needs. Most of these products already have a significant footprint in the provider space.
Intelligent Imaging Solutions and Services are readily available to transform handwritten notes and paper into machine-readable text which can then be indexed, categorized and stored in various types of content repositories offering easy access for EHR solutions, operational systems, medical informatics or analytics tools. Two of the top suppliers in this area are:
A2iA has made a major commitment to the healthcare provider space. Its technology is used by a broad set of healthcare-related services and solution companies from BPO companies that turn paper records into usable electronic formats and medical coding vendors dealing with CDI and ICD-10 codes, to content management vendors that embed A2iA technology into their products to enable cursive handwriting recognition. For the most part, A2iA delivers its solutions through its partner network.
Parascript is best known in the healthcare arena for the technology it brings to the medical imaging field including its neural network and algorithmic-based proprietary pattern recognition and image analysis technology that helps, for example, radiologists track suspicious lesions. Its technology also supports handwriting recognition including signature verification. Parascript primarily sells through channel partners.
Document Transformation Solutions providers take any document, fax, email or other text-based data, such as a continuity of care document, that can be sent to a printer or included in a print stream and store it in a compressed format while leaving the text available for indexing or searching. Two of the top suppliers in this area are:
Crawford Technology partners with both EMC and IBM to support their customers’ document transformation needs. Better known in the healthcare ecosystem to payers, Crawford helps to manage claims documents received by insurers from providers. Its document archive solutions represent a valuable tool for regulatory compliance, long-term archiving, and physical print and distribution reduction.
DATAWATCH products are used by business professionals at more than 1,000 hospitals across the country. Its Information Optimization Platform (IOP) helps customers quickly and easily extract, manage, analyze and distribute critical data and metrics from existing reports and data without additional programming. DATAWATCH also offers an on-premise or cloud-based clinical informatics solution.
Document-Oriented Databases are highly scalable and schema-less which means virtually any document format can be ingested, indexed and searched. PDF or Word documents or encodings such as XML and JSON are stored in a compressed binary format, not shredded as text-based data needs to be for relational databases. Two of the more popular document-oriented databases are:
Mark Logic is the database of choice for many of the world’s largest healthcare organizations including a fraud detection solution for CMS. Mark Logic helps healthcare organizations streamline their information interoperability, improve search and analysis, and optimize drug and clinical information. Mark Logic offers a free express license or an enterprise licensing model. Its database also has an integrated search capability.
MongoDB is one of the most popular document oriented open-source databases. Because data in MongoDB has a flexible schema, collections do not force a particular document structure. Therefore, “documents in the same collection do not need to have the same set of fields or structure, and common fields in a collection’s documents may hold different types of data.” MongoDB offers full indexing support, querying and commercial support from 10gen, IBM and others.
Interoperability at the provider level is critical to the overall healthcare interoperability initiative. It’s where most of our health records live, either on paper or in electronic form. Up to 80% of our healthcare data is text entered free form or with little structure by physicians, nurses and other healthcare professionals. In order to mine that data for clinical, operational or research purposes, it is absolutely critical to make EHRs accessible to care providers and, to the extent practicable and appropriate, to patients.
Boiling the healthcare interoperability ocean by attempting to drive a nationwide standard will not achieve the desired results of improving care and lowering costs until the basic, foundational requirements of healthcare data management are first addressed at the local provider level. Many providers still rely on paper documents.
And until EHR solution vendors are forced, through a combination of policy changes and marketplace dynamics, to address their interoperability failings at the individual provider level, little progress will be made to transform healthcare records into a reliable nationwide resource.