We all know that interoperability must be solved, but what’s the first step we need to take? Doug Fridsma believes it’s in changing the definition. “We need to stop thinking of it as a ‘utopian place’ where data can freely flow.” Rather, it should be viewed in a much simpler and more practical way — as “incremental added functionality.” In this interview, the CEO and president of AMIA talks about why interoperability wasn’t baked into Meaningful Use, why he thinks FHIR has great potential, and why patient access has become such a big priority for his organization.
Fridsma also reflects on his time with ONC, discussing some of the difficult decisions that had to be made and why he believes a “front-loaded incentive program” made sense when it came to Meaningful Use, and talks about the work AMIA is doing to advance the field of informatics.
- About AMIA: “We’ve seen a fairly dramatic change in priorities.”
- Health IT as a stethoscope
- Informatics vs health information management
- EHR 2020 – “It was meant as a repair manual for IT.”
- AMIA’s accreditation & certification efforts
- The push for patient data access: “Information empowers patients.”
- Blue Button initiative – “These are rights that patients have.”
LISTEN NOW USING THE PLAYER BELOW OR CLICK HERE TO SUBSCRIBE TO OUR iTUNES PODCAST FEED
As a field, informatics is beginning to mature. It isn’t defined just by what you know; in fact, it’s increasingly being defined by what you do.
Because of the rapid adoption of EHRs, there are a lot of folks that profess to have knowledge in informatics, but what they really understand is health information management. They understand health IT, but not the underlying science of how to extract and use that information in those systems.
Making sure we have access to that information empowers patients, and I think it provides opportunities for entrepreneurs to begin to develop new applications and new services that can help patients manage that information and integrate it more effectively into their care.
The biggest barrier is that many institutions and EHR vendors see patients’ data as an intellectual property asset that can be monetized. And so when you give patients the ability to easily take it out and to give it to someone else, it diminishes the ability of EHR vendors and others to be able to monetize that information.
These are rights that patients have, and I think we as physicians or as providers, shouldn’t question that. Even if people don’t exercise that right, that doesn’t mean that they don’t have it.
Gamble: Hi Doug, thank you for taking some time to speak with healthsystemCIO.com.
Gamble: I’d like to start by getting a little bit of a background on AMIA — what the organization does and what are its ultimate goals.
Fridsma: AMIA is a professional organization that represents informatics professionals at all stages and in all flavors of informatics careers. Historically, we came out of an academic tradition. There have been a lot of researchers, scientists and educators who are really trying to advance the field of informatics, but I think over the course of the last couple of years, we’ve seen a fairly dramatic change in both the composition and the priorities of the organization.
The organization remains committed to evidence generation and that includes the scientific work and papers and things like that, but increasingly, our membership is composed of professionals that are much more applied in their work. We have chief medical information officers, some CIOs, and others that are really trying to leverage all the new information technology that’s out there and use informatics as a way of unlocking potential.
We’ve found that, as a field, informatics is beginning to mature. It isn’t defined just by what you know; in fact, it’s increasingly being defined by what you do. We’re getting a lot more professionals that are out there, boots on the ground, really trying to tackle some of the hard problems of collecting, analyzing, and applying information and knowledge to the care of patients.
Gamble: You talked about the evolution in the focus — has that resulted in changes in the organization, whether it’s leadership or just trying to get that broader scope?
Fridsma: Some of it has happened organically. Ten years ago, AMIA started down a road to develop a medical subspecialty in clinical informatics. And they were successful in establishing that as a clinical subspecialty in which you could get board-certified in 2013. Since 2013, about 1,500 physicians have been board-certified in clinical informatics. Many of those folks are assuming leadership roles across health systems, and many of them see AMIA as their professional home. Oftentimes there is participation in vendor meetings about the products and services they have installed in their health systems, or they go to HIMSS to understand the trade shows and see what’s out there right now. I like to think that people come to AMIA not to see what’s now, but to see what’s next. They’re focused not on a specific product, but on the basic understanding of how to use those products to improve care and care delivery.
The analogy I like to use is that health IT is like a stethoscope. It’s an instrument that you use to diagnose and care for patients, but you have to understand cardiology to be able to interpret and use the information you get from your stethoscope and to be able to apply that to clinical care. Informatics is the science and specialty that underlies the effective use of health information technology.
Gamble: Okay. So what are the key areas where you’re focused right now — what are you looking to gain or push forward?
Fridsma: There are a couple of things. One is this notion of making sure that we are able to recognize individuals for their skills and expertise. Because of the rapid adoption of electronic health records, there are a lot of folks that profess to have knowledge in informatics, but what they really understand is health information management. They understand health information technology, but not the underlying science of how to extract and use that information in those systems.
And so part of what we want to do is assure health systems that the people they hire have the skills and expertise they say they have. The medical subspecialty is a first step in that direction, but we have other plans for providing ways to recognize people at all different levels for their skills and expertise.
In addition to that, we’ve been doing some policy work to really take a look at information technology in health systems. For example, a few years ago we published a report called EHR 2020. That wasn’t meant to be some futuristic look at how information technology should be used, but really a repair manual, if you will, for information technology that’s out there. And so we have groups that are working on issues of interoperability, usability, workflow integration, some of the policies that drive those activities. All of those things I think are important aspects of how we represent that community of CMIOs and others.
Gamble: When you talk about being able to recognize individuals for expertise, are you talking about some kind of certification
Fridsma: Yes, it’s about accreditation and certification. We want to make sure that people who get a degree in informatics come from accredited programs. We’ve updated what the accreditation requirements are in the course of the last year or so, as well as professional recognitions through certification. We have the clinical informatics medical subspecialty. We’re going to be updating the core content of that in the next year as well to help it reflect the current state, and we’re working to develop additional certification options for folks that either are no longer practicing MDs and want to be able to be recognized for their informatics expertise, or who haven’t gone to medical school but are computer scientists, nurses, pharmacists, or others that have expertise in informatics and would like to be able to demonstrate that as well.
Increasingly, we’re seeing more and more job postings that are asking for folks to have clinical informatics as a board specialty. We want to make sure that the broad scope of folks out there — not only those that are board-certified, but those that have other kinds of expertise — can get recognized for that.
Gamble: And when you talk about policy efforts, I imagine there’s a bunch of subcategories. Can you give an overview of what you’re really looking at from a policy perspective?
Fridsma: We put together a set of policy principles, and that includes patient safety, interoperability, research applications, and a few others. And when there are notices of proposed rulemaking or other things like that, we look at those and see if we can provide some advice and expertise.
For example, with 21st Century Cure Act which was passed back in December, we’ve been strong advocates for patients having access to their complete record in a computable format. We think that’s important from a safety perspective, because patients can help correct errors that might be present in the medical record. We think it’s important from an innovation perspective because things like precision medicine need to be driven by having access to information. We also think it’s important to have apps and other ways of managing health, but access to data is oftentimes is the rate-limiting step. And so making sure we have access to that information empowers patients, and I think it provides opportunities for entrepreneurs to begin to develop new applications and new services that can help patients manage that information and integrate it more effectively into their care.
That’s just one example. We’ve also commented on some of the CMS rules that they have around quality payments — how do you calculate those things in an electronic format and what are the ways that you can do that most effectively? We’ve attended a number of different meetings with the Office of the National Coordinator around information blocking and interoperability, as well as usability, so we’ve had a relatively active profile there. I used to work for the government and a lot of my friends still do, and so we leverage those connections to help us provide some input and feedback from our members into the regulatory and policy processes.
Gamble: Right. So, a few things there I want to follow up on. When you talk about making patient records available, that sounds like it should be a no-brainer, but there’s opposition to this. What are your thoughts on some of the high level leaders who are opposed to it, either because they say patients don’t need all of the information or managing it is difficult?
Fridsma: Many people cite technology barriers. I think those are easy to overcome. Many of the standards are already out there in existence, and organizations are certified to provide a basic framework for having that entire record made available. The 21st Century Cures Act doesn’t say it needs to be standardized. It just says it needs to be computable, which means it’s not going to be a PDF, but it could be a free text. It doesn’t have to be complicated in that regard.
There’s a whole host of things including many of the precision medicine and the Cancer Moonshot activities that are going to require having access to comprehensive medical records to mine that information in a big data way, and that’s how we’re going to learn about new associations using the EHRs that are out there.
And so there are opportunities that we need to take advantage of. I think when we say things like, ‘patients don’t need it’ or ‘they don’t want it,’ that tends to be a pretty paternalistic view. Take, for example, things like the Blue Button, which was an initiative ONC launched to enable outpatients to click on a button and be able to download a copy of their medical record. The VA was the first to instantiate it, and within the first year, they had a million veterans that downloaded a copy of their medical record. So to say that patients don’t want it or wouldn’t care about it, I think underestimates what patients really could do.
We also found that once there was access to that information, there was an ecosystem of app developers and entrepreneurs that said, once we have this data, we can integrate it with lots of other data and provide value to patients that didn’t exist before. We had companies that started and said, ‘we have ways of managing your Medicare Part D information and integrating it with your Blue Button activities and giving you a much more comprehensive view of the care you’re receiving, what the network of providers looks like, and a whole lot of other things.’ So in some sense, without that data, that kind of entrepreneurial spirit and innovation can’t occur.
I would say that perhaps the biggest barrier is that many institutions and EHR vendors see patients’ data as an intellectual property asset that can be monetized. And so when you give patients the ability to easily take it out and to give it to someone else, it diminishes the ability of EHR vendors and others to be able to monetize that information. The modifications that were made to the HIPAA regulations in 2012 said that patients should have access to an electronic copy of their medical record when such records are available. The 21st Century Cures Act went the next step to say every patient should be able to have access to a computable copy of their medical record. These are rights that patients have, and I think we as physicians or as providers, shouldn’t question that. Even if people don’t exercise that right, that doesn’t mean that they don’t have it. Once it becomes easier, I think more and more people are going to have the opportunity to see the value.
The last thing I’ll say is with the travel industry, it used to be that travel agents were the ones that controlled your access to airline reservations and hotel reservations. Making that data publicly accessible has created a whole new set of ecosystems out there and has done so to the convenience of the traveler. And so working in those early systems was not something that a traveler would ever do, but once you made it accessible to others, they found simple and easy ways to present that, and it became easier for folks to be able to interact. I fully expect the same sorts of things to happen with health care as well.