Search the KHIT Blog

Thursday, February 6, 2014

Meaningful Use 2013 review, ONC Working Group Stage 3 draft report, and discussion of KP's book "Connected for Health"

CMS just released the 2013 cumulative participation and incentive payments report. $19.24 billion paid out thus far. In tabular summations,

446,295 registrants on the EP side. 323,293 EPs paid to date (excluding Medicare Advantage).


More on Slide 6 shortly ("supports new model of care...").


There is interest in loosening the attestation requirements -- possibly providing for alternative paths for MU-seasoned EPs and EHs to be "deemed" to have effectively complied with the aims of the Meaningful Use program in Stage 3 in lieu of having simply complied in pass/fail fashion with every required criterion.

Judy Faulkner, MS – Founder & Chief Executive Officer – EPIC Systems Corporation

A few things here, I’m a little confused about deeming. Do people get to do deeming in some things and not others or is it deeming across the whole thing? Do you substitute deeming for doing MU3? So, in other words if I’m really good in orthopedics do I get to deem for orthopedics? But if I’m not hot in diabetes do I not deem there? Do I have to be good in everything?

And even within them in orthopedics maybe I have really good hip results but not so good spine or in diabetes I’m really good in adults but not so good in pediatrics. How do we handle that? Is the definition of doing deeming meaning you have to be passing everything or not everything?

And what about the things in Meaningful Use 3 that have nothing to do with quality, clinical quality measures? What about things like keeping certain data elements? What about things like interoperability requirements or sending things to registries, or patient engagement things? So, I guess I don’t understand really is deeming, you pick this and this, and this, and you get your choice or is deeming, it replaces MU3?

Then how does an organization know its high-performance, maybe they all think they are or some of them do and how can they measure that and again, you get down into well pediatrics versus adults or which part of ortho? And so that’s my second question.

My third question is we were kind of thinking of it as for the larger well known high-performing organizations, but if they can substitute deeming for Meaningful Use, and I’m not arguing one way or another I’m just thinking it through, then shouldn’t that be available to others who may not fall into that category but still are excellent in this piece or that piece?

The fourth thing I have is does deeming mean that vendors need to create two sets of things? One thing is for all the measuring of performance for Meaningful Use and the other thing is for measuring all the deeming evaluations that need to be done because that’s going to be significant?

And then the last thing I have is, and I have some analysis of all the SGRP number things and there’s a lot in there I would recommend that we focus on that have to be things such as what requires standards that says the EHRs should do this but really the standards aren’t there to do this, because I think we can actually get into more of a mess if in fact we don’t put the standards in first which is the Maslow’s hierarch, I think, bottom set first you have the standards and then you apply them to what you’re doing.

Then if we say to all the vendors go do this but there are no standards to do it against and all we’re doing is creating stuff that later on the vendors won’t be able to interoperate well. So, there’s quite a few things that I think were in there that didn’t have the standards first.

And another thing I think we have to look at too is when is it not an EHR. So, for example there was something on labs, what was it, EHRs must have the ability to identify abnormal lab results. Well, the lab systems define what’s normal and abnormal not the EHR. So, is it clear when something is – when we should be saying take from the lab systems rather than do itself. So, there’s a lot of those subtleties in there that especially the setting first of standards that I think have to be addressed.
This all bears watching, I would think. Another long process is set to ensue.

One has to wonder about the attrition impact of significantly reduced remaining incentive reimbursement funds (even should Congress fail to cut the money further).


Ms. Faulkner is the Health IT vendor CEO some EHR critics love to hate. Some see her being a member of the ONC HITPC (Health IT Policy Committee) as a blatant conflict of interest. Her company's platform ranks #1 in terms of Meaningful Use attestations thus far, and some wags call the MU initiative "The Judy Faulkner Corporate Welfare Statute." Epic was widely lambasted last year during HIMSS13 for refusing to Play Nice with the Commonwell Health Alliance. And, they have had their share of implementation failures. See, e.g., "Another NC hospital falls to Epic EHR implementation costs."
Wake Forest Baptist Medical Center isn’t the only North Carolina hospital struggling with poor credit ratings and huge revenue gaps after attempting the installation of an Epic EHR system.  Its neighbor in Greensboro, Moses Cone Memorial Hospital, just received a “negative” outlook from Standard & Poors (S&P) due in part to the $130 million spent on purchasing, implementing, and maintaining their new Epic infrastructure...

Epic Systems is the largest EHR vendor in the country by number of meaningful use attestations, and is a popular choice for hospitals.  But horror stories about skyrocketing costs are nearly as plentiful.  Besides Wake Forest’s woes, which include cutting 950 workers from its payrolls and rescinding merit-based raises for those employees who were left, the company has been implicated in the closure of the emergency room at St. Andrews Hospital in Boothbay, Maine, due to its overwhelming financial burden...
Given that my REC caseload was all small-shop outpatient primary care EPs, she and her company were only dimly on my radar; I had no kick-the-tires, hands-on experience with Epic.

Scanning the transcripts of her contributions to the HITPC meetings leads me to conclude that she's largely getting a bum rap.

In particular in light of the book I'm now reading.

This excellent book recounts the history and upshot of Kaiser-Permanente's decision to deploy the Epic platform system-wide. I will provide below an extended excerpt I read in using Dragon Dictate (I hope I caught all of the mistakes). But, first, it helps to set it up with the slide deck from outgoing KP CEO George Halvorson's Keynote Address to the NYec 2013 Conference I covered back in November.

(Requires JavaScript capability to display.) Nearly 150 slides setting forth the history of the case for the Kaiser-Permanente course of action and ethos, and its result. Well worth your time to review all of them.


Start with the end in mind

When an organization makes a strategic investment of the size of KP HealthConnect, it had better have a good understanding of its strategy at the beginning. The primary goal of KP HealthConnect was lofty: to transform care and service delivery. What did that mean? I learned from my experience as an operating executive importance of developing a shared vision. In this instance, what was the organization's vision of healthcare in the future? Even before the software contract was signed, the process to develop a shared organizational vision was begun.

As in all major Kaiser Permanente initiatives, support and leadership of the Permanente medical group was critical to success. I would work closely with a Permanente Federation physician executive who would engage and represent the eight independent regional Permanente medical groups. I knew and respected Andy Wiesenthal, the associate Executive Director for Permanente Federation, who had extensive experience from leading the Colorado E HR development and CICS. Together we would provide leadership for KP HealthConnect .

I relied on my intuition is a pediatrician, my experience as a healthcare executive, and my knowledge of quality improvement to develop the process. To me, quality improvement means data-driven and patient focused decision-making, respect for front-line knowledge, and profound knowledge of systems thinking. My job was to identify and frame the important questions and issues and then design and facilitate a process that engage the right people with the right information to develop the right answers and solutions.

The Blue Sky Vision

In the first part of the process we brought in a group of people to develop the key themes. I wanted the wild and crazy thinkers in the organization — the ones that make us a bit uncomfortable, but we are smart enough to keep them around. There were the folks who are always pushing at the edges. We cross-cultivated those 16 people with seven outsiders. The reason for the outsiders was to avoid groupthink, because I was concerned that Kaiser Permanente was a very internally focused organization,. These guests represented expertise and technology, healthcare policy, economics, alternative delivery systems, and self-care.

The themes that emerged from what we called quote the blue sky vision" process — the name suggested open-ended Vista — were developed using a technique about which I was in the initially skeptical. Facilitated by both Robert Bittman, from the Institute for the future, and graphic facilitator Tom Benson, small teams wrote actual skits which they acted out for the rest of the group. It was very entertaining, but it was also eye-opening. Even though the team had totally different care delivery settings to visualize — the emergency room, chronic care, acute care, home, and so on — the themes that emerged were the same. They reflected the organization's aspirations, if not actual practices. They felt right and touched a nerve in a positive way.

I didn't know beforehand what those principles are themes were going to be. I was an observer at the back of the room. Strategic vision actually lives within an organization. Processes like this, if done well, will surface, articulate, and codified them.

The assignment was in tension only broad in nature. The object was to create a Kaiser Permanente model for healthcare delivery by 2015 to guide the deployment of the integrated EH are. There were only two constraints put on the group: the assumption that Kaiser Permanente would be a viable organization delivering healthcare in 2015, and that affordability of services was a consideration. The year 2015 was selected for reason. Planning 12 years out took our technology readiness concerns and other common short-term barriers to major change out of the equation. Conversely, the timeframe was short enough to ground participants in developing achievable care delivery models.

As with healthcare experts across the nation, there was a diversity of views among the blue sky participants on the future of the healthcare industry and the specific implications for Kaiser Permanente. Some painted a dark picture of uncontrolled infections sparked by bioterrorism and a collapse of healthcare financing due to severe economic depression others were more optimistic seeing a continuation of the significant improvements in overall health care in the past 50 years. Participants were I'd asked to identify the major trends affecting the healthcare industry. The group cited trends that are common to many discussions about health care's future. The list included continuing cost pressures on both employers and providers, changing demographics affecting consumer trends and workforce availability, pursue a perceived infinite consumer demand for the latest technological services regardless of cost, and the continuing advances of medical knowledge that will turn many fatal diseases into chronic illnesses. The year was 2003, but it could have been today.

The process was framed to elicit multiple art alternatives for care delivery, but what emerged from the group was a single, dominant model that placed the consumer or patient at the center. Prompting that consensus was a shared sense that many consumers — especially those with the means and choices — would demand a central role in managing their own care. An aging baby boomer population would put greater demands on the health care system than any generation before them, the group concluded, thanks to medical advances that would allow them to live longer while managing multiple chronic diseases. In addition, an increasingly diverse patient population with a wide variation in language, religion, culture, technology-based communication skills, ability to pay, and interest in alternatives to the traditional delivery model would require customized treatment.

This new paradigm would require the patient in the caregiver to reassess their roles and responsibilities. For the patient, it would mean going beyond choosing insurance coverage to selecting individual sets of services, both in terms of medical care and wellness activities. For the clinicians and staff, the changes would require a fundamental shift in the way they view their relationship with the patient. Instead of the role of definitive expert, they would become coach and facilitator. The Blue Sky Vision concluded that in 2015 a successful healthcare organization would recognize that the true primary care provider has always been the patient and his or her network of family and friends. The patient's home would be the center of early diagnostics and service, with caregivers serving as advisors on service options, clinical efficacy, genetic profile influence, and cost considerations.

The blue sky vision, they further concluded, could be achieved with technology that already existed, including long-standing technologies such as the telephone. The tricky task was to avoid falling too easily into the trap of uncritical adoption of technology and neglecting the hard work of leveraging that technology to achieve real change in care delivery.

For themes composed this new vision of healthcare delivery in the future:

  • Home as the hub: the home and other nontraditional settings would grow significantly as locales of choice for care delivery, and a patient's care delivery team would expand beyond the physician and other traditional caregivers to include other community and family resources.
  • Integration and leveraging: medical services to combat disease would be integrated with wellness activities to enhance overall quality of life as well as prevent and stem the onset of disease. Information technology would provide the vehicle to enable the leveraging of specialized clinical resources and increase patient and family involvement in care.
  • Secure and seamless transition: technology would allow the caregiver to provide better-informed and more efficient care to each patient. The computer would not replace human interaction, but in which it by fully availability of integrated longitudinal patient information coupled with the best knowledge and recommendations science could offer.
  • Customization: patients would become true partners in their health. Customer centric care would be at the patient's convenience and customized to their specific health status and personal preferences, leading to a deeper understanding by patients of the care they are receiving and a stronger relationship with their clinicians.

Once the four themes were identified, another set of Blue Sky participants — these from the operational side of the organization — took up the assignment of identifying the range of practical and actionable steps and technologies that would change processes and mobilize the Kaiser Permanente workforce to achieve significant progress on the Blue Sky Vision within five years (by 2008). The space to participants consisted of about 10 of the original insiders from the first group for continuity, supplemented by a new group of our operational leaders. It was made very clear to the second group that their job was not to change or prove the themes that the first group had developed. Their job was to identify how to put the Blue Sky Vision into practice. They discussed operational implications for Kaiser Permanente across five categories: business and clinical processes, technology, information and knowledge management, facilities, and people.

Their operational imperative was to make this new era of care delivery as simple, seamless, and intuitive as possible for the patient. It recognized the patient as a leader and/or partner in deciding his or her care and the home as the center for much of the care delivery. It also recognized that in the future, caregivers would need to adapt to the patient's preferences for receiving information either electronically, by telephone, in person, or all three, depending on the nature of the information. And they would need to share, if not relinquish, the reins in deciding on the patient's healthcare path.

It also meant more than lip service to the age-old effort to move away from the departmentally siloed approach to medicine. In this new world, geographic as well as departmental and professional boundaries would be eliminated, and gathering and viewing data would not be enough. Interpreting and leveraging real-time and longitudinal information would be required to meet the specific needs of patients, whether they were in our facilities or at home, school, or work.

Once the Blue Sky Vision and its key tenets were codified, they were reviewed and discussed with the Board of Directors and the organizations key leadership groups, including Halvorson’s national leadership team and presidents and medical directors of each Kaiser Permanente region. The themes resonated, especially “home as the hub." The KP HealthConnect team would use these themes to guide the implementation.

In almost all other spheres of business and industry, electronic information systems coupled with the Internet have driven fundamental shifts in how business is conducted. Healthcare should be no different, but that has rarely been the experience with health IT.

We knew that KP HealthConnect could be the platform to achieve the blue sky vision. With the immense changes required of clinicians and staff just to implement the EE HR, could we also make fundamental changes to care delivery? It would be the only way to avoid adding cost and complexity to the system, but it is usually where organizations lose energy. That would be the key to achieving the Blue Sky Vision the a KP HealthConnect, and we would need to stay focused.  [Louise Liang, MD, pp. 12 - 16]

Flipping to the final chapter:
Unleashing the power of computerized data

[George Halvorson, pp 214 - 221]  Computer supported care is going to have the very same kind of "jump shift" impact on care delivery as each of the earlier major medical breakthroughs — like discovering that germs cause disease or that antibiotics will kill germs. When the toolkit changes medical care changes. The medical toolkit for care information is about to make a huge change. Care will never be the same, and it will be a lot better in ways we can't even anticipate.

One of our senior leaders at Kaiser Permanente likes to say that introducing complete, real-time data to care delivery is like opening up the Internet to commerce and communications. We can't possibly anticipate all of the paths this new toolkit will take us down.

The Internet is an evolving toolkit. The web is changing in complexity and functionality every day, in a world and a culture of continuous creativity and innovation.

Health IT will explode in the same way. In-house con activity that is being piloted today will be perfected tomorrow. Medical research projects that historically have been set up to run for a limited period and that involve relatively few subjects in today's paper medical record data environments will be transformed into ongoing, virtually perpetual projects involving complete data on huge populations of subjects.

Both better research and better care will result.

Using Kaiser Permanente's new health record database and linking it electronically to older, historical patient data, we have recently learned that high cholesterol levels in 40-year-old men doubled their chance of having Alzheimer's disease in their 60s (Solomon and others, 2009). We combined old medical information in our historical files with the new Kaiser Permanente health connect medical record and discovered an important correlation that no one had even suspected. When we add DNA data to our data file, we will be able to better identify exactly which people with high cholesterol are more likely to have Alzheimer's. Care will become much more personal because we will know so much more about each person.

We are just now getting access to some very powerful information — learnings that can only be acquired with longitudinal data and data about entire populations of people. Small sample sizes and truncated data sets are the number one curse of traditional medical research, and a huge expense for individually and manually collecting each piece of paper-based data is the second major curse.

Both the curse of too little data and the curse of the cost of data gathering can be eliminated by complete, longitudinal, and real-time electronic data about patients and care. You don't have to send teams of nurses physically into a paper or computer file to spend years manually sorting through individual charts to gather population data — as they did for the famous and invaluable RAND study of medical practice consistency (McGlynn and others, 2003). The RAND study took nearly a dozen nurses working for a couple of years to do the one time care status portrait for about 20,000 people. That is one of the best studies in the world on variability in medical practice and the use of recommended practices. That's the good news. The bad news is that the study is too expensive to update to see if anything has changed.

In the new world we are headed into, that basic study can be done electronically for much larger populations with a lot more data for a lot less money — and then updated weekly, or even hourly. The new database involves years of longitudinal tracking that can turn a research snapshot into a moving picture.

One of the next major breakthroughs in learning will definitely involve DNA. Linking DNA to an electronic medical record for large population of people will yield golden research findings that will save lives and improve care delivery in multiple ways. Care will be much more effectively personal when our caregivers have much better data about the rights, needs, chemistry, genetics, and care needs of each person.

Again, like the explosion of highly creative commercial users we see constantly emerging on the Internet, the ability of the best creative minds in healthcare to plumb the new data and find important linkages that no one suspected will be critically important for enabling continuous improvement for care delivery and the process of care.

Glimpses of the tip of the iceberg

Safety will also improve for patients when the data sets are more robust dangers invisible to the naked eye will be seen clearly by the electronic eye. We have already seen the tip of that iceberg.

A pre-KP HealthConnect electronic database had already raised the flag on a number of safety issues. For instance, we were I able to identify a disproportionate and totally unexpected number of Vioxx-related deaths. Kaiser Permanente pulled Vioxx out of our formulary more than six months before the rest of the country — alerted partly by our publicly announced decision — did the same. The old Kaiser Permanente database also identified real problems over time for number of patients with certain heart stents, resulting in new care protocols for many stent patients.

The old Kaiser permanent a database on joint replacements and joint surgeries also identified important differences in success rates for various devices and approaches to those surgeries. That research which took advantage of the newly implemented KP HealthConnect, has also changed care practices within Kaiser Permanente, and is changing care in the rest of the country, as well.

Moving beyond the data vacuum

Computerized data and support should not be a new idea for healthcare. Other industries have skilled data analysts who do incredibly effective process improvement work very routinely as a matter of course in running their businesses.

Healthcare has never had that systematic process improvement mentality, culture, or skill set, despite the fact that there are millions of very smart people in healthcare. But consistent care improvement has not been on their agenda. Why is that? The lack of a continuous improvement culture in healthcare has been caused in part by a lack of real data about performance, outcomes, results, and caregivers. No one in any industry can do continuous improvement in a data vacuum.

So the new data set for healthcare will help both research and operations. It will support better and more focused day-to-day care. This is already happening. With the health of KP HealthConnect, Kaiser Permanente regions had the highest scores in the country on eight HEDIS overall quality measures in 2008. Every Kaiser Permanente region also had the highest scores in their local markets in just about all of those categories.

How did that happen? As Louise Liang pointed out in the opening chapter of this book, Kaiser Permanente did not have eight first-place overall scores five years ago. Each of those wins was assisted by KP HealthConnect and its panel management tools and patient focused support systems that give nurses and physicians the reminders and prompts needed to deliver highly consistent overall, continuously improving care in those care categories.

Forging a connected world

The learning from those successful outcomes of consistent computer supported care should not be limited to the people and patients of Kaiser Permanente.

The entire country and the rest of the world need their own versions of KP HealthConnect. Creating "virtual Kaiser Permanente's" should be a major policy goal for American healthcare. What does that mean? It means that all caregivers in America need to be connectable and connected relative to the patients they share. That should be a very basic functional goal of healthcare reform in America. All caregivers in America need to know that they have all of the needed data about each and every patient — past and current data about every test, treatment, and diagnosis for each patient.

All caregivers would also be better served if all doctors had electronic conductivity with their patients. Connections happen in other areas. Patients tweet each other about their daily lives — and then have to communicate on paper or face-to-face with their physician. All caregivers who share a patient should have conductivity with each other to provide team care to each patient. And patients should be electronically connected to their doctors and their healthcare information. With today's computer technology, that is entirely possible.

Virtual Kaiser Permanente's can and should be created. They can be defined, designed, developed, and then implemented with the patient's as the focus of the entire healthcare system and the healthcare database. We should have a national health agenda that enables the creation of team-based, well-connected care.

The good news is that the proven and measurable success of KP HealthConnect and team care at Kaiser Permanente significantly increases the likelihood that similar systems will be created. When the world learns that the total KP HealthConnect value equation includes cutting the number of heart failures in half or cutting the number of asthma crises by a third, that learning will help people set goals. That data will give purchasers of health care and new expectation about what their patients should expect and receive from their care teams. Without those successes, care improvement in other settings is less likely to happen. There is no reason to reorganize and connect care just for philosophical or ideological reasons. But when team care actually saves lives, the electronic connectors that enable team care will become embedded in a functioning business model in other care sites as well. The success of KP HealthConnect and its support systems is a reason for other care organizations and other health plans to follow in that path.

Realizing the Blue Sky Vision

Our own member surveys show that patients love the new electronic toolkit. In the year after secure messaging between physicians and patients was first introduced at Kaiser Permanente — supported by KP HealthConnect  — 1 million patient contacts occurred electronically through secure messages instead of in person.

A year after that, 3.6 million such contacts happened, saving patients the time and inconvenience of having to drive to a care site to exchange basic care information with a caregiver in a face-to-face encounter. In 2009, Kaiser Permanente will respond to more than 6 million secure email messages. And new members are signing up for that and other online services every day.

Patients would now rise up in anger and rebellion if Kaiser Permanente decided to stop doing e-visits. E-Connectivity works so well because with KP HealthConnect on their desktops, Kaiser Permanente caregivers have at their fingertips so much data about their patients that indeed visit or telephone visit is a sensible way — even sometimes a superior way — to deliver certain kinds of care or information.

Beyond the clear convenience of EE visits and telephone visits, patients are accessing and their personal health record, my health manager, in record numbers for all sorts of help — information on the flu, interactive programs for weight loss, lab tests, and medication refills. Our experience suggests that these patients are more satisfied with their care, and that may ultimately lead to better health outcomes.

The future of computer supported care

The future of healthcare is one of the infinite possibilities, as the Blue Sky team envisioned at the start of the KP HealthConnect planning and implementation process.

Homes will increasingly become sophisticated care sites. Eve visits will be blended with visual electronic connectivity tools and in-home medical monitoring devices to make a wide spectrum of care more timely, more immediate, more interactive, and much more convenient.

"Care everywhere" will continue to evolve as a care concept, and Kaiser Permanente will be just one of many organizations pioneering multiple levels of connectivity and data sharing with other healthcare organizations.

Three – or four – way virtual conversations, which shared medical imaging, such as x-rays, between patients, primary care doctors, and other specialists are now possible. Virtual second opinions can already be part of the normal framework of care delivery. These kinds of consults are much safer and easier to do when the caregivers all share electronic health records (EHRs) with complete information on the patient's test, lab results, scans, and diagnosis.

Team care will be enhanced hugely. Real time virtual consult with a chronic disease patients primary care doctor, specialist, and related therapists will become standard practice — with the patient participating in the process. Kaiser Permanente is even now piloting these kinds of consults, and the early evidence suggests they work really well.

Think of the contrast. In the "old days,” a doctor would say, "I think you may need a specialist for the next phase of your care. Let me write you a referral to Dr. Smith. You should call her office to set up an appointment. Here's her address. Tell her I told you to call."

The patient would then leave the care site, go home, call Dr. Smith's office, and set up an appointment with a specialist at some future time at another care site.

Too often, in the world of paper medical records, a patient seeing a new Dr. brings no past or current information about his or her care or diagnosis. In the best case, the patient would carry a written referral file with paper copies of some key notes from past care sites. And the new care site would almost always start all over with all tests.

That's the old world. For people who don't get their care from electronically connected provider organizations, such as Kaiser Permanente, Mayo, Geisinger, Intermountain, health partners, group health of Puget Sound, and a very small number of team care organizations, it's actually not the old world. It's today's world.

The new, connected world will be entirely different. In this new world, the first doctor might say, "we need an expert opinion here. Let me get Dr. Smith on our computer system and we can do a consultation right now. Dr. Smith also has your full medical record on her screen, so we don't need to send or redo any test or scan. Let's see what we can learn, together, right now, with you here in the room."

Specialty consults can now be real-time and virtual, occurring via computer in the primary care doctors exam room — with a printout of follow-up instructions given to the patient on the spot and a secure in message sent as a reminder and reinforcement.

Team care is possible today, and through KP HealthConnect it is happening today. Team care at Kaiser Permanente cut the death rate from both major forms of heart disease by 73% in our Colorado region (sand half and others, 2008), and it cut the number of broken bones from osteoporosis in older patients by 37% in another project (Dell and others, 2008).

Making the right thing easy to do

Conductivity is good and team care is even better. The reason Kaiser Permanente spent nearly $4 billion putting KP HealthConnect in place is that we believe passionately in team care and we know that it takes a computer to fully connect the team. Computers can connect caregivers outside of Kaiser Permanente to our caregivers, as well. The two most fundamental learnings of KP HealthConnect just need to be applied to other settings that want to use computers to support care:
  • Learning one: have all of the information all of the time.
  • Learning two: make the right thing easy to do.
Both of those points are actually profound lessons. They seem simple. They are, in fact, elegant. In today's world of computer conductivity, both of those strategies are possible in multiple settings if the people deciding healthcare policy in Washington, DC understand and appreciate the importance and the wisdom of each of them and set up expectations for care and connectivity accordingly.

If the right thing is hard to do, it won't get done. EHR projects in a number of other sites have failed completely because they made the right thing hard to do. That's a mistake. The right thing to do needs to be supported, not impeded, by the design of the system and process. Computers are not magical. They are tools.

Tools need to be used in the context of an agenda, a strategy, and a focus on creating value.

People do not realize how much low hanging fruit exists in American healthcare today. Care costs are not evenly distributed. 75% of all healthcare costs come from patients with chronic conditions (Centers for Disease Control and Prevention, 2009). 80% of those costs come from patients with comorbidities — multiple diagnoses that involve multiple positions (Robert Wood Johnson foundation in partnership for solutions, 2004).

Our own internal data suggests that about 1% of patients incur about 35% of all costs, and 10% of patients incur about 80% of the costs. So we don't need to improve care support for most patients. But if we do a really good job on care and can keep just half of that one percent of high-cost patients from entering that expensive, dire need status, we could cut the costs of total care by billions of dollars, and we could make care outcomes a lot better for Americans in the process.

We need to target better care for these patients. We need to set collective goals for care improvement — and then we need computer-based tools to help us achieve those goals.
My last book, Healthcare Will Not Reform Itself (Culberson, 2009), listed the 10 mandates that people designing a health IT system should follow. Interestingly, those same 10 points describe the characteristics of the ideal American healthcare database: (1) patient focused; (2) complete; (3) accessible by all relevant parties; (4) current (real time, if possible); (5) easy to use; (6) linked to care improvement programs; (7) accessible to patients as well as caregivers; (8) transportable (when people change health plans or caregivers); (9) interoperable; and (10) confidential.


The future of computer-supported healthcare is blindingly bright. We can't begin to imagine how many ways complete care data and meaningful connectivity will improve care, care delivery, and the science of care.

It is a good road to be on. KP HealthConnect was a great investment for Kaiser Permanente to make. The people inside Kaiser Permanente who put the largest nongovernmental IT project in the world successfully in place deserve our great gratitude — and the people who are now very creatively using that new system and its supplementary systems to make care better are earning the gratitude of the world. We have a lot to learn — and the learning will define us and make us better at being who we are and doing what we do.

Be well.

That is key. As far as Health IT is concerned, it simply goes to:
  • Features;
  • Functionality (including -- critically -- "interoperability"), and;
  • Usability.
All of which go to "effectiveness."

Now, having reviewed George Halvorson's NYeC Keynote deck and read the foregoing "bookends" excerpts, dwell for a moment on Slide 6 from the MU Working Group Stage 3 proposal.

One of my favorite sayings is
"If you waitin' on ME, you backin' up."
Meaningful Use Stage 3 is slated to ensue in 2017. Kaiser-Permanente has not been waitin'. Acquire and study "Connected for Health" for an interesting, detailed look into how a leading organization has successfully gotten ahead of the curve.

YouTube: George Halvorson's Perfect Health Care Plan


Will there even be a stage 3?
February 07, 2014 | Anthony Brino

On Friday, Valentines Day, the ONC’s Meaningful Use Workgroup is submitting draft recommendations for the third phase of the EHR incentive program to the Health IT Policy Committee. So far, they’ve developed a number of ideas that have consensus, but clinical quality measures may not be as easy to include in digital systems as previously thought, and Congress may end up stepping in.

While health IT stakeholders mull on the potential challenges of stage three over the next year, Congress may end up coming back into the process with new ideas — and redesign the entire system for how Medicare pays and incentivizes physicians...


Reports are that Congress has arrived at a permanent Medicare "SGR Doc Fix" via H.R. 4015. Recall that Meaningful Use Stage 3 is now set to commence in 2017 (see the Working Group summary above in this post).

Well, this is curious (from the H.R. 4015 bill -- props to David Harlow*):
Repealing the Sustainable Growth Rate (SGR) and Improving Medicare Payment for Physicians’ Services...
Consolidating Current Law Programs into a unified MIPS

Payments to professionals will be adjusted based on performance in the unified MIPS starting in 2018. The MIPS streamlines and improves on the three distinct current law incentive programs:

  • The Physician Quality Reporting System (PQRS) that incentivizes professionals to report on quality of care measures;
  • The Value-Based Modifier (VBM) that adjusts payment based on quality and resource use in a budget-neutral manner; and
  • Meaningful use of EHRs (EHR MU) that entails meeting certain requirements in the use of certified EHR systems.
Sunsetting Current Law Incentive Program Payment Implications

The payment implications associated with the current law incentive program penalties are sunset at the end of 2017, including the 2 percent penalty for failure to report PQRS quality measures and the 3 percent (increasing to 5 percent in 2019) penalty for failure to meet EHR MU requirements. The money from penalties that would have been assessed would now remain in the physician fee schedule, significantly increasing total payments compared to the current law baseline...
*Prepared by the House Committees on Energy & Commerce and Ways & Means and the Senate Committee on Finance Staff
Emphasis mine. Uh, OK... Well, the penalties commencing in 2017 are the "stick" part of the MU Carrot and Stick arrangement. By 2017 there will be precious little MU incentive money left on the table. I'd say the ROI calculation has just gotten materially worse with this news.

Stage 3 MU may well be stillborn -- should this bill actually pass and become law, with these specs intact.

Physicians will get an extra month to tell Medicare that they achieved meaningful use of an electronic health record (EHR) system last year, helping them qualify for an incentive payment and avoid a 1% penalty in 2015 in the process.

The Centers for Medicare & Medicaid Services (CMS) announced today that it is extending the deadline to attest to EHR meaningful use in 2013 under Medicare from February 28 to March 31, with physicians having until 11:59 p.m. EST to submit their performance data.

More to come...

No comments:

Post a Comment