Just before Christmas, the Office of the National Coordinator (ONC) issued its long-anticipated Health IT Patient Safety Action and Surveillance Plan for public comment. A major component of the draft is ONC’s not-so-gentle push on HIT vendors to get serious about reporting adverse patient safety event information, via affiliation with a Patient Safety Organization (PSO).

National Coordinator Dr. Farzad Mostashari, commenting a couple of days after the release: “We are saying to the vendors, ‘Step up and prove your ability to create a code of conduct that would be enforceable, that would bind you voluntarily to reporting safety events’… And what we’re saying is, ‘If you don’t step up, we can always look at more classic regulatory approaches’.”

This echoed a very similar message delivered by Dr. Mostashari to CEOs of more than a dozen top HIT vendors, at a D.C. meeting hosted on November 28 by the Electronic Health Records Association (EHRA) (see more about that meeting here): “‘Step up’ and agree to a ‘Code of Conduct’ setting forth basic principles and behavioral standards to protect patients, guard against fraud, and empower health information technology finally to revolutionize healthcare.”

I am proud to report that athenahealth is stepping up. On the flight home from that November 28 meeting, in fact, CEO Jonathan Bush talked about almost nothing but what such a Code of Conduct could look like, how to make it meaningful instead of merely symbolic, and how it could serve to coalesce industry innovators around a set of core principles to create true information fluidity that empowers both patients and providers, while safeguarding patient safety and reducing costs. Jonathan was very worked up about it.

The result of that in-flight brainstorm is the following draft that, given the season, might be called a proposed set of New Year’s resolutions for the HIT industry: 

Health Information Industry Code of Conduct

Proposed: To achieve the universally supported objectives of systemic cost reduction and quality improvements, members of the health information industry should agree to maintain, uphold and abide by a uniform set of high standards related to data portability, patient safety, freedom of choice, and meaningful, ethical use by health care providers of health information technology (HIT).

Resolved: The signatories hereto, representing innovative, forward-thinking members of the health information industry, agree that they and their respective companies will adhere to each of the provisions of the following Code of Conduct:

1. Empowering Data Portability and Provider Choice

In the event that any client opts to change to the electronic health record (EHR) of another signatory, we will, at our own expense, facilitate the intact transfer to the latter’s EHR of all of the provider’s clinical data.

2. Building a True Nationwide Information Backbone

We will build, maintain, and curate reliable interfaces on behalf of any qualified healthcare provider that requests one.

3. Protecting Patients

We commit to public reporting of adverse patient safety event information. Within one year of signing, we will affiliate with a Patient Safety Organization (PSO), report all patient safety-related events to that PSO, and work proactively with clients to identify and resolve the causes of any such issues.

4. Preventing Fraud

We will actively monitor, and report to clients, changes in provider billing patterns that could indicate up-coding or fraud.

5. Driving Meaningful Use

We will adjust reporting to accommodate government quality reporting programs, at no incremental cost to clients.

Next Steps

We started circulating this draft in Washington (including to Dr. Mostashari) a few days before the ONC’s draft surveillance report came out, and we were excited to see the degree to which our thinking matched theirs. Of course, these basic commitments and statements of principle go well beyond just our shared concern about protecting patient safety. They also address many of the other major issues frequently identified by industry stakeholders, provider and patient advocacy groups, and policymakers in Washington in connection with the exploding adoption of HIT across the country: information fluidity and interoperation between and among disparate systems; identification and prevention of fraudulent billing practices; and the continuing evolution of Meaningful Use standards.

Commitment to these provisions will require changes—some practical, some philosophical—in how our industry approaches the products and services that we provide. But the changes are necessary and, in many cases, overdue.

Over the coming weeks, we hope and expect to garner support from our peer companies to put these ‘resolutions’ into effect, kicking off 2013 as the year when HIT finally begins to realize its potential to revolutionize health care delivery in this country.

“I feel like I am in a time warp; at a meeting of record company executives 15 years ago….” Neal Patterson, Chairman, CEO & President of Cerner Corporation

Looking around the room packed with CEO-level executives from a baker’s dozen of the largest HIT vendors in the country recently, I saw that each expression asked the same question: “Did he really just say that??!!”

The occasion was a meeting requested by the Electronic Health Records Association, or EHRA, with National Coordinator for Health IT, Dr. Farzad Mostashari, and several senior ONC and CMS staff. Many of athenahealth’s major (software-based) competitors were represented: Cerner, Epic, Meditech, Siemens, sitting around a large conference table in the Health and Human Services offices. Also on hand was athenahealth’s own Jonathan Bush and executives from our plucky compatriots in the cloud.

A Quickly Apparent Agenda

There were three topics on the agenda: Meaningful Use (MU), payment reform/accountable care, and the catch-all “future direction of the health IT industry.” The true agenda, however, became clear within five minutes of the opening gavel. Our competitors came to D.C. to complain about Meaningful Use standards.

I’ve become a bit of a broken record on this point, I know, but it bears repeating: nothing underscores the fundamental difference between static software-based electronic health record (EHR) technology and athenahealth’s cloud-based services than the difficulty that the static system vendors have meeting the standards. Our 21st century technology can do it with relative ease.

And so one legacy system CEO complained that his customers “feel rushed” by the need to “install new hardware and software” to keep up with government standards.

Another jumped in and asked for a “staggered cooling-off period” of one year between MU stages (in addition to the already-implemented delays) to allow vendors to “catch up,” and added helpfully/hopefully, “I think I speak for all vendors here.”

That made Jonathan twitch a little bit.

Then a senior executive from Epic (EPIC!!) lamented that Meaningful Use is “killing innovation,” and that was just too much for Jonathan.

He asked me for a list of the Meaningful Use Stage 2 standards and, scrolling through them, incredulously asked the group to tell him which of the “SO EASY!” standards are difficult to meet. He then launched into a lengthy discourse on the difference between cloud-based services and static software platforms.

Barely taking a breath, Jonathan transitioned to our D.C.-facing message-of-the-month: Reform the law to allow for creation of a true two-sided market for exchange of health information, which will incentivize true information liquidity and empower real systemic reform. This discussion yielded what might have been the most encouraging aside of the day, when a CMS official acknowledged the need for “a system to monetize information exchange.”

You can be sure we will follow up on that one…

Candor on Interoperability

To the extent that there were any points of agreement between Jonathan’s remarks and those that preceded him, they were:

• Scrambling to meet sometimes arbitrary government standards DOES divert resources from innovations that customers really want
• MU standards are too prescriptive and do not allow enough flexibility to achieve desired outcomes in innovative ways
• MU Stage 3 (MU3) should be more about desired outcomes and less about mechanics
• “Interoperability” doesn’t exist in today’s reality

On that last point there was surprisingly candid agreement from some of the major players in the room. Although they didn’t admit that their companies are specifically guilty of the practice, the executives did concede that too much “interoperability” is geared toward communication within proprietary networks, and virtually none of it is outward-facing. Jonathan opined that MU3 should be purely about the exchange of information and “forget all the rest.” Then came that shockingly candid bit of self-awareness, from Neal Patterson of Cerner, one of the biggest, baddest software-based platforms in the business: “I feel like I am in a time warp; at a meeting of record company executives 15 years ago….”

He pegged the vibe exactly. We only needed cigarette smoke hanging over the table to complete the 20th century ambiance. That, and a conversation on the limitation of technologies still hobbling health care, but that the rest of the economy shucked at end of the 1990s.

A ’90s Flashback, With Biospheres

The same conversation dynamic carried over into the “Payment Reform/Accountable Care” portion of the program. After listening to a number of big-company CEOs talking about system consolidation and information lock as though they were good things, Jonathan again went off—this time deploying his “biospheres” speech. He talked about the top players protecting their “pavilions,” told the group that if they ever need a construction crane, they should just follow the “H” signs to find one, and said that the unintended consequence of consolidation and doc-lock is the “elephant in the room” on Accountable Care Organizations that nobody is talking about. In other words, “nonprofit” hospitals dump a lot of money into buildings that they then need to turn around and fill with patients. The “Pavillion” of 2012 is a large, static server-based stand-alone software product.

This triggered an excellent back-and-forth with the fellow representing one of the largest market players in the room, who in another moment of surprising candor admitted fairly openly that his company deliberately designs its systems to “interoperate” within closed systems, but not with the rest of the world.

One often hears the expression, “the first step is admitting you have a problem.” And some of the largest HIT vendors in the country admitted to big problems. Now if they’d just set about solving problems like true system interoperation instead of pushing incessantly to slow progress at the leading edge of innovation and locking doctors, patients, and information in proprietary silos. Then maybe we’d have a chance at a true technological revolution in health care. That’s what we’re in D.C. fighting for.

There were a few other stops on this trip to Washington. Extra credit if you can name the location of this picture…

This week the House of Representatives’ Science, Space and Technology Subcommittee on Technology and Innovation, held a hearing titled “Is Meaningful Use Delivering Meaningful Results?”

The five testifying panelists were learned and the subcommittee members engaged, but the hearing could easily have taken place in 1997.

Let me put that another way: An unknowing time traveler from 1997, sitting in the gallery through the entire hearing this week, would not have heard a single technological reference that would have struck him as curious or futuristic. Instead, speaker after speaker deployed metaphors tethered to 19^th and 20^th century technologies: Train tracks. Electrical connections. Plumbing?! Worse, these metaphors were used to describe not only the current state of health information technology (HIT) and EHR products, but also the panelists’ aspirations. It is no great revelation to say that HIT has lagged significantly behind the rest of the high-tech world, but it was troubling to see a panel of experts in the field rhetorically cementing that lag and labeling it as progress.

Subcommittee member Dana Rohrbacher (R-Calif.) asked an incisive question that goes precisely to my point. Observing that his wife’s smartphone can share information seamlessly with people all over the world, Rohrabacher wondered why government is spending billions of dollars to bring HIT only to a level of technological parity with the rest of the consumer universe. Noting incredulously that “I’ve seen it in real life myself,” he said that $20 billion (the amount Congress has budgeted for Meaningful Use incentives) is an awfully high price tag—especially during a persistent budget crunch—to incentivize a single sector to do what the rest of the tech world is already doing in every other market space.

Two doctors on the subcommittee drilled down further. As part of a larger question about the persistent lack of interoperability among health information systems, Dr. Andy Harris (R-Md.), an anesthesiologist, criticized static software’s inherent inability to catch drug interactions when crucial patient information resides outside of a proprietary network. Panelist Rebecca Little, an executive at HIE solutions provider Medicity, responded that sometimes “translators” are needed “in the plumbing” of health information exchange. While that is undoubtedly correct in the context of the anachronistic health information technology in prevalent use today, it is precisely wrong when looking to the future: we need to liberate information from the “plumbing.”

Speaking from his personal experience, practicing physician Rep. Dan Benishek (R-Mich.) bemoaned the sorry state of too many electronic health record systems in the marketplace, stating that they do not provide actual interoperability and cost too much money. Meaningful Use payments do not cover even implementation costs for most, and the technology too often “doesn’t do the job.” Noting the policy goal of improving access to quality care, Benishek said exasperatedly, “If the hospital goes broke, the access to care isn’t there either.” To which this government affairs VP at a cloud-based services provider, sitting at his desk outside of Boston, answered, “Amen!”

Now, let’s return to the title of the hearing: “Is Meaningful Use Delivering Meaningful Results?” After nearly two hours of testimony, the answer seems to be: “It depends who you ask.” On one hand, witnesses correctly pointed out that Meaningful Use incentives have resulted in a huge uptick in EHR adoption. Providers attesting to “meaningful use” are, by the government’s reckoning, “delivering meaningful results.” Res ipsa loquitur. On the other hand, the providers that Dr. Benishek mentioned, those spending too much money for systems that don’t “do the job,” might quibble with the government’s definition of “meaningful.”

EHRs that meet Meaningful Use standards but have slow workflows, lock up information in proprietary silos, interfere with doctor/patient interactions, or impose costs that exceed their benefits, neither helping struggling medical practices nor improving the health care system overall. This is the understanding that animates everything we do at athenahealth to provide cutting-edge, cloud-based HIT that delivers truly “meaningful results” to our network of more than 38,000 providers nationwide.

What comfort the HIT innovation community could take from this week’s hearing came in the combined understanding reflected in the questions posed by those three subcommittee members: Many EHR products cost too much money and impede (sometimes intentionally) interoperability; despite billions spent by the government and billions more budgeted, HIT continues to lag behind the rest of the tech world; and, perversely, some of those incentive dollars are perpetuating use of lagging technologies.

The challenge to HIT innovators is illustrated by the fact that we did not hear any understanding of the vast potential of cutting-edge technology to improve the health care system. While others continue to talk in inherently earthbound terms, we need to better communicate the limitless potential of the cloud, and advocate relentlessly for policies that allow and encourage continued innovation.

Adding some voices of innovation to these testifying panels will be a good start. And adding some of your voices of innovation right here on our blog can’t hurt either.

A recent post on The Health Care Blog caught my eye this week with an initial statement that health IT is a tool that, just like any tool, can produce excellent results when used properly —but can also lead to harm if used incorrectly.

Whether we’re talking about  a car, a piece of machinery, a stethoscope, or an EHR, correct use of a tool comes down to usability and training. It’s great to see a medical informatics thought leader like blog author Dr. William Hersh making this point.

Dr. Hersh and his team at the Oregon Health & Science University medical center just received a grant from the federal government to continue their electronic health record simulation research, which Dr. Hersh describes as “novel” in the health IT world. I agree that this research is important. Examining an EHR’s use in a simulation environment allows you to ascertain whether the right information is presented to the right person in the clinical workflow at the right time, and in the right way, so that the user interface is facilitating—not hindering—the delivery of quality health care.

However, the simulation approach is not exactly novel—we’ve been doing it for a couple of years at athenahealth. And while I agree that simulation research could provide “insights to improving the use of HIT in the clinical setting,” the true value of such research can only be realized through the cloud and cloud-based services. Why?

Here is what athenahealth sees playing out in the market, and why we think there is a better way:

1. The federal government is pumping millions of dollars into the health IT industry through the Meaningful Use program. This is encouraging thousands of hospitals and health care providers to implement software-based EHRs.
2. After spending hundreds of thousands (if not millions) of dollars and many, many months implementing massive software-based EHR systems, health care providers across the country are pulling their hair out in frustration as they try to climb the steep learning curve on a new IT system and transition their paper-based workflows into an electronic world.
3. As the cries of frustrated physicians and nurses grow louder, there is a focus on the poor usability of EHRs, particularly with some EHRs that are based on decades-old code and come with hefty price tags for updates that might fix that poor usability.
4. The federal government is recognizing that the Meaningful Use program is funding the continued existence of EHRs that do not, and technically cannot, respond quickly to the market’s demand for more usable products. As a result, the government is now funding a variety of usability research to help spur improved usability in EHRs. However, even if all of that research produces amazing findings with respect to usability, implementing those findings across the thousands of health care providers on software-based EHRs will take years. And the frustration and hair tearing will continue until then.

What is the better way?

The better way is measuring and studying usability across an entire client base that’s using the same instance of cloud-based software.

The better way is a vendor that proactively and continually strives to improve user interfaces.

The better way is immediately placing findings from usability studies into planning and development cycles.

The better way is implementing improvements across an entire client base as quickly as possible—not through years of piecemeal updates one client at a time.

The better way to continually improving usability is in the cloud.

At athenahealth, we’re already there.

Much commentary in the wider world today, Election Day+1, is focused on the fact that for all the billions spent, all the ads run, all the robocalls made, 2012 in the end turns out to be a status quo election. We have no change in the executive, no real change in either chamber of Congress, not even much of a change in the electorate.

Of course there is an inherent difference between a president’s first term and his second. In the second, with the looming specter of a re-election fight wiped forever from his personal political horizon, the president is afforded the chance both to be more magnanimous and more ambitious.

The Obama administration’s agenda with regard to health information technology (HIT), especially toward EHR adoption, has been clear and unambiguous, and we expect it to remain so. How exactly the second term agenda will differ from the first, either in focus or intensity, remains to be seen. However there are a few predictions that we can make with a high degree of confidence:

• The Meaningful Use (MU) incentives program will continue. With their genesis in the Stimulus Act—broadly opposed by a significant cadre of Republicans—those incentives faced the very real possibility of reduction or elimination had Gov. Romney won. As it is, the HIT policy committee meets today with a walk-through of the MU Stage 3 draft and request for comment (RFC) high on the agenda. We expect to see that RFC in the near term, and hope that on more certain political footing the Office of the National Coordinator (ONC) reasserts itself in the effort to drive MU standards higher and to implement more aggressive timelines for meeting those standards than we saw in the Stage 2 rules.
• At the same time, persistent media attention to questions about the costs and benefits of government supported electronic health record adoption, continued concern about whether Meaningful Use is producing true interoperability, allegations of billing fraud facilitated by use of HIT, and anecdotal claims of HIT-related risks to patient safety mean that the Congress will continue to aggressively question the administration about the Meaningful Use incentive program. This starts November 14, just a week following the election, as the House Committee on Science’s Subcommittee on Technology and Innovation convenes a hearing titled “Is Meaningful Use Delivering Meaningful Results?” We have strong points of view on each of these important issues (stay tuned to this blog), and look forward to inserting ourselves into these conversations early and often on behalf of our tens of thousands of care givers, for whom “Meaningful Use” has in fact been meaningful. We will also continue to encourage policymakers to confirm that the billions spent on incentives are in fact incentivizing adoption of transformational technologies, not serving as life support for technologies that otherwise would fade into the sunset. We will also keep pushing for the policy changes beyond just monetary incentives that will truly create a context for technological transformation of the health care system, such as the creation of a legitimate market for the open exchange of health information.
• Finally, we expect to see some clarity on the long simmering issue of potential regulatory oversight of HIT. In the FDA Safety and Innovation Act of 2012, Congress strongly encouraged Health and Human Services Secretary Kathleen Sebelius to convene a work group consisting of a broad set of industry stakeholders to inform a proposal for an oversight framework that appropriately balances patient protection with the policy imperative of encouraging innovation in HIT. We strongly believe that such a workgroup will be invaluable in formulating a rational oversight framework and we have taken every opportunity in our Washington-facing interactions to build support to encourage the secretary to take Congress up on that suggestion. With a closely contested election pending, it was understandable for the secretary to defer her decision. Now that the election is in the rearview, we hope to see that work group convened. In the meantime we’ve been working hard in conjunction with other stakeholders to build consensus for a risk-based framework. We will continue that work and look forward to participating in what we expect will be much more deliberate and focused conversations in the coming weeks.

The world didn’t change yesterday, overall or with respect to HIT policy. But it would be a mistake to assume that everything stayed the same. Elections are always clarifying; they blow away the thick haze that cloaks Washington in the months leading up to November. These are just a few of the pressing issues facing HIT and the health care system overall. As always, athenahealth is excited to jump into the fray and work to solve the big problems on behalf of the care givers we serve and the innovators we represent.

Here we go…