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Thursday, April 25, 2013


I read and reviewed Dr. Sweet's fine book a year ago, and have subsequently corresponded with this delightful, wonderful physician and author. I cannot wait to meet her.


I think we already knew this, but it was posted by CMS today. If you're an EP eligible for maximum Stage 1, Year 1 payment in 2013, your $15,000 incentive potential has now been reduced by $300 (2% sequestration reduction). It will take new overriding legislation to undo the sequester law.


Missed our connecting flight. Our flight from SFO was late. Then, to get to our connector gate, we had to exit Security and go back through. TSA found my scurrilous 6 oz bottle of water down in my camera bag as it went through the scanner. I got pulled aside for The Schtick.

No problem. The office is now wherever I am. All pretty much wireless. Even use my iPhone as a WiFi "hotspot" to connect online when I have to. I'll just make use of my time while awaiting a later flight.

From InformationWeek HealthCare:

Interoperability Depends On EHR Vendors: AHA
Ken Terry, April 26, 2013 08:56 AM
The American Hospital Association (AHA) does not want the federal government to impose more regulations on healthcare providers to encourage health information exchange.
It would, however, like the government to demand more from electronic health record (EHR) vendors to advance interoperability at several different levels, according to an AHA letter to the Office of the National Coordinator of Health IT (ONC). The AHA sent the letter in response to the ONC's request for information (RFI) on how to increase interoperability...

The Money Shot, I guess...

Glossing over the core problem. They continue:
Electronic information exchange is one tool among many that providers use to achieve the goals of improved health and the best possible health care. Payment policy should incentivize those end goals, not specific means to achieve them. New payment mechanisms such as value-based purchasing, accountable care organizations (ACOs) and bundled payment models incentivize better care coordination and reduced fragmentation of care. The AHA supports these new payment and delivery models, and hospitals around the country are engaged in their implementation. We do not believe it is productive to add specific information exchange requirements to these projects, as the mechanisms of exchange may vary by project, and the specification of requirements could result in unintended consequences, including limiting innovation and posing a reporting burden. 
A key principle behind these new payment and delivery models is to incentivize the right outcomes, while allowing flexibility in determining how they are achieved. These new models are encouraging the movement of data from individual silos that support individual transactions and clinical encounters toward integration of information to support collaboration among a health care team, while allowing local considerations to shape the care delivery approaches taken...

"Payment policy should incentivize those end goals, not specific means to achieve them."

I could not disagree more with the latter part of that sentence. Moreover, one precisely needs means that comprise the mechanics of "incentives." Absent "means," incentives are nothing but empty platitudes, a nullity. Now, none of that observation argues inexorably in favor of government regulation, but regulation of some sort there must be. And, given that government is by far the single largest payer, the "payment policy" of government should explicate the "means" (standards) that produce the "goals."

Is it really that difficult to grasp?

The AHA letter continues, with the customary Motherhood-and-Apple Pie, Continue-to-Miss-The-Point red herrings.

The AHA urges ONC to focus on removing the barriers to data exchange and sharing best practices in order to support the acceleration of the payment and service delivery redesign initiatives currently underway...

Fine. I got your "removing the barriers" right here.


One. Then stand back and watch the Market Work Its Magic in terms of features, functionality, and usability. Let a Thousand RDBMS Schema and Workflow Logic Paths Bloom. Let a Thousand Certified Health IT Systems compete to survive. You need not specify by federal regulation any additional substantive "regulation" of the "means" for achieving the ends that we all agree are desirable and necessary. There are, after all, only three fundamental data types at issue: text (structured, e.g., ICD9, and unstructured, e,g., open-ended SOAP note narrative), numbers (integer and floating-point decimal), and images. All things above that are mere "representations" of the basic data (e.g., text lengths, datetime formats, logical, .tiffs, .jpegs etc). You can't tell me that a world that can live with, e.g., 10,000 ICD-9 codes (going up soon by a factor of 5 or so with the migration to ICD-10) would melt into a puddle on the floor at the prospect of a standard data dictionary comprised of perhaps a similar number of metadata-standardized data elements spanning the gamut of administrative and clinical data definitions cutting across ambulatory and inpatient settings and the numerous medical specialties. We're probably already a good bit of the way there given the certain overlap across systems, just not in any organized fashion. 

Think about it.

Why don't we do this? Well, no one wants to have to "re-map" their myriad proprietary RDBMS schema to link back to a single data hub dictionary standard. And, apparently the IT industry doesn't come equipped with any lessons-learned rear view mirrors.

That's pretty understandable, I have to admit. In the parlance, it goes to opaque data silos, “vendor lock,” etc. But, such is fundamentally anathema to efficient and accurate data interchange (the "interoperability" misnomer).

Yet, the alternative to a data dictionary standard is our old-news, frustratingly entrenched, Clunkitude-on-Steroids Nibble-Endlessly-Around-the-Edges Outside-In workaround -- albeit one that keeps armies of Health IT geeks employed starting and putting out fires.

Money better spent on actual clinical care.

More to come...

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