Dr. David Blumenthal
I had a brief chat with Dr. David Blumenthal last week that basically covered four areas:
- Transparency at the ONC
- HITREC and communities of shared learning
- Personal Health Records and possible certification
- Rural practices and Critical Access Hospitals
Regarding transparency, which is something I’m fairly passionate about and have seen some improvements on at the ONC, Dr. Blumenthal said, “Trust is such an important factor in the management of sensitive information that it has to be attended to in everything we do. I think that being open is one way to create trust.”
He also spoke of the frustration he had felt previously as an academic working in the scientific community where openness is not always encouraged and there is a culture of “secrecy in science” that can have an adverse effect on the industry and relationships. “I have come to believe strongly in openness as a way of making progress, a way of attracting the best ideas, a way of collecting the best information, and a way of maintaining the trust of one’s constituents and stakeholders.”
Speaking about the HITREC, I referenced Anthony Guerra’s discussion with Joshua Seidman, acting director of the Meaningful Use Division in ONC’s Office of Provider Adoption Support. I was trying to get to what the vision for these communities of shared learning would be and how the REC’s would operated in a collaborative way within the HITREC framework. He said, “There is a very strong strain in using collaboratives to advance best practices.” He added, “we are blazing new trails in a lot of areas, and there are not a lot of good precedents for what we want to do, whether it’s in health information exchange or promoting adoption in our very special healthcare system. So we need to find ways to move learning rapidly around the community.”
They had their first meeting of RECs a couple weeks ago and they placed a high priority on developing a community of members. “There was a lot of spirit of sharing and a lot of excitement about sharing,” he said. The HITREC has five or six contracts that are being administered through the AHRQ. When I asked if those contracts were awarded, he said he didn’t believe they had been yet, but they are just a matter of days away.
Regarding the certification of PHRs, which had been briefly mentioned during the ONC webinar on the Certification NPRM, and on how PHRs fit into the overall strategy of the ONC he said, “This area of work is still under development. We want to make the systems we develop open to innovation and progress so we want to make sure there is plenty of room for PHRs to interact with the electronic health records that we certify. We are not tasked right now with certifying personal health records. The ultimate purpose of certification is to allow providers to be meaningful users.”
Since the meaningful use requirements include making electronic copies of a patient health record available and many healthcare consumers may be wanting to use a PHR, “There has been a lot of discussion for 2013 of requiring electronic health records to be able to share patient’s information, if requested, with their personal health record. But we haven’t regulated on that yet and we won’t for some time. In the mean time I don’t sense a groundswell of interest in the certification of personal health records.”
“At this point we have no plans to certify personal health records,” he said. When I asked about how PHRs may fit into the overall strategic plan for the ONC he mentioned a recent management group meeting where they presented on their strategic plan, which he claims they are intensively working on now. “Patient engagement is an important part of that plan and I think it will include a place for the personal health record.” He left open the future possibilities for how market forces might shape the evolution of the how our health system will organize health information, and PHRs will likely have a role to play. “We don’t want in any way to inhibit the development of personal health record.”
Speaking about challenges to promoting the adoption of electronic health records in small rural practices and critical access hospitals he identified some disparities in ethnicity, race, broadband availability, EHR adoption and the ability to raise the capital necessary for implementation. “We have targeted with our Regional Extension Centers small practices and underserved areas. We are going to be pushing our Regional Extension Centers to give good service to small providers.” Referencing the simpler version of the NHIN, which is being worked on through the NHIN Direct project, he said this is “so that providers who don’t have all the resources that are available to large systems will have a means of exchange.”
As far as the hugely important issue of being able to fund these projects, which is difficult for any hospital system, but virtually impossible for small independent facilities, he recognized that this is a big area of concern. “Critical access hospitals tell us that they are having trouble finding the money to get started,” he said. “The meaningful use paradigm makes money available to meaningful users… but it doesn’t front load all the available resources that some critical access hospitals say they need.”
This is something that there is no immediate solution for and may require additional steps, so they may need to “circle back and see what needs to be done, but we’ll do everything within our authority to try to minimize disparities.”
You can listen to the entire conversation on my blog:
http://ahier.blogspot.com/2010/03/discussion-with-dr-david-blumenthal.html
Brian Ahier says
Getting the resources to fund “meaningful use” upfront is going to indeed be a challenge for many hospital systems and physician practices both large and small. There are vendors rapidly moving into this space that allow you to possibly finance your projects, even in these uncertain economic times.
Winthrop resources has a strong partnership with Dell/Perot Systems for financing ARRA related projects and offers a wide array of different vendors:
http://www.winthropresources.com/
And for small practices that are choosing GE Centricity an attractive financing option might be GE’s Stimulus Simplicity option:
http://www.gehealthcare.com/usen/hit/hitech_act.html
There are other opportunities out there as finance companies jump in to try to get a slice of the ARRA pie. I’d be happy to provide some additional information if anyone is interested…
Jimmy Weeks says
Your interview causes me to take pause and visualize our peers in those small, rural communities where they may be fortunate to have a couple of file and print servers running on 10BaseT connecting a handful of PCs. For them, the timeline of MU must be completely overwhelming in impossible to meet.
We consistently hear of the giants who have invested hundreds of millions of dollars on systems and technology to enable PACS, EMR, BMV, PHRs and clinical dashboards. The trade publications are full of success stories, which hopefully demonstrate to others that the impossible is reachable.
As we all know, the initial system purchase is just the beginning. The routine care and feeding of the technology is a never ending challenge. The thought alone must be daunting to these rural areas.
It may be time for someone to take a Michael Moore style road trip to these rural sites and give everyone a dose of reality. Let’s hear from those who are far more challenged with funds, resources and connectivity. Let’s hear from the MD who is still billing on 3×5 cards and the rural hospital that is operating totally on paper with little or no automation.
My assumption is their stories might be quite humbling and give us all some insight in to the realities of meeting MU.
Thanks again for sharing!
Ferdinand Velasco says
Brian,
Thank you for providing this excellent summary of your conversation with Dr. Blumenthal and your untiring efforts to advancy transparency in the decision-making process surrounding healthcare reform in Washington. I also share Jim’s perspective on the challenges that face many providers in early stages of adopting health IT.
In retrospect, it’s quite apparent now that the complexity of the meaningful use regulations is out of proportion to the time between when they were first published in the Federal Register and when they are to expected to go into effect (October 1, 2010 for eligible hospitals applying for Stage 1 MU.) While we wait for ONC and CMS to process the comments they’ve received and for the final rules to be published, the clock keeps ticking.
I commend Dr. Blumenthal’s committment to transparency. The issue, however, isn’t one of trust. The real concern now is one of execution: Are the federal agencies able to deliver what’s needed to achieve the intent of HITECH in time? Let’s hope so!
Paul Roemer says
I enjoyed reading your interview with Dr. Blumenthal. Clearly he and the members of his team are working very hard on a number of difficult and rather diverse issues.
I have been wondering, how does one tell the story of EHR to someone who has no understanding of EHR? Not the story about the EHR system in a physician’s office, or the ungainly one in a hospital. The story to which I refer is the story of the national rollout of EHR and the drive for interoperability.
For me, the question of how to tell the story in a way to make it understandable raises a number of other questions. Is there a story, or is it a collection of short stories written by different people, guided by different principles and goals? Is there a plot? Does the story come together in a natural manner?
Sticking with the story theme for a moment—who are the main characters, do they relate to one another? Does it come to a meaningful conclusion, in fact, does it conclude?
Look at the various antagonists—EMR, EHR, PRH, Meaningful Use, Certification, HIEs, RECs, the N-HIN, interoperability, the ONC, CMS, ARRA, standards, vendors, and PR. I am sure I missed several.
Imagine if Random House allocated millions of dollars to publish and market a book which had yet to be put to paper. No plot, no outline. What if they hired a dozen writers, each with their own areas of expertise—and lack of expertise—and crossed their fingers.
Would they be more successful if they offered penalties and incentives to the writers—a garrote and stick approach? What if they changed the rules after the writers started? What if they left undefined numerous areas of rules, rules which will impact the story, and told the writers to keep pushing ahead?
I do not see how the national EHR rollout story comes together. Now or some distant tomorrow—at least not under this approach. Is the approach viable? Having a few disparate successes does not make me a believer. Call me a cock-eyed nihilist.
Once every so often, an announcement is made that another single hospital reached Stage 7. One among thousands. Why do I view this from the vantage point of a glass half-empty? For me, the existing approach is one of guidance and facilitation. There are no long lines of providers trying to beat the others to the front of the EHR line. There have been several hundred million dollar do-overs.
If we circle back to the providers for a second, three of the largest causes of failure include the arbitrary setting of go-live dates without knowing what needs to be done or can be done in that time frame; second, letting IT and the vendor drive and manage the project; third, not getting users to define what they need and then having IT replicate those needs. IT does not need an EHR.
As I look at the government’s national rollout of EHR I see the same three problems. Who are the government’s users? Doctors, clinicians, and hospitals. There are fixed dates, many having undefined requirements. These are causing some providers to dash for the cash. Who is driving the rollout—the government’s users, or the government. They way the rollout is structured, the users have all of the responsibility and little of the authority. This is a government led IT project. Where are their users? They are running their practices and hospitals. They have one ear open towards, reform, another to the garrote and stick project rollout approach, another to EHR, and yet another to their business model. They have run out of ears.
Brian Ahier says
One development since the interview is the supplemental funding for RECs to support Critical Access and Rural Hospitals. This is supplemental funding, so when awarded it would be incorporated into their existing cooperative agreements. I think this may be only a drop in the bucket of additional resources that are going to be necessary to pull this off.
More on the funding announcement at:
http://ahier.blogspot.com/2010/04/additional-funding-for-recs-to-support.html
Paul Roemer says
Grab a soft-drink—this one is rather long. Please forgive any formatting mistakes–it looked good in Word.
I have never been one who thinks hit-and-run critiquing is fair. It is too easy to throw metaphorical tomatoes at an idea with which you disagree. As such, perhaps instead of just being critical of the national EHR rollout plan, here are a few ideas which may be worth exploring in more detail.
It just occurred to me that the ONC’s role, the Office of the National Coordinator, is just that—coordination. Who or what is the ONC supposed to be coordinating—among its various functions, or the providers? There are the coordinators, and its constituents—the uncoordinated. I know at least one provider who already spent $400 million on its EHR. They didn’t get coordinated. I asked one of their executives who played a major oversight role in the implementation, with whom they worked at the ONC. She was not even familiar with the acronym.
I don’t think providers are looking to be coordinated—they are looking to be led. I also think they are looking to be asked and to be heard. They are looking for answers to basic questions like; why should we do this, what is in it for me—this has nothing to do with incentive dollars?
It often seems like the ONC has developed many solutions seeking a problem, filling their tool bag in the hope they brought along the right one. This is where I think we see a good portion of the disconnect. It is better to say we know where we are going, but getting there slowly, instead of, we don’t know where we are going but we are making really good time.
People don’t buy drills because they need a drill—they buy them because they need—say it with me—holes. Providers need holes, not HIEs and RECs.
You understand the pressures you face much better than do I. Has anyone from the ONC asked you if they should reconsider their plan, their approach, their timing? Chances are good that you are not implementing EHR and CPOE because you have a vision or a business imperative of someday being able to connect your EHR to Our Lady of Perpetual Interoperability. CIOs and their peers are not spending eight or nine figures because you want a virtual national healthcare infrastructure. The C-team is investing its scarce resources to make its operation better, to reap the rewards of the promise of EHR.
The ONC is spending its resources towards a different goal, a virtual national healthcare infrastructure. The two goals do not necessarily overlap. I am reminded of the photo showing the driving of the Golden Spike—the connecting of the Union Pacific Railroad to the Central Pacific Railroad—the final link of the Transcontinental Railroad that in the 1870’s allowed Americans to cross the US by rail. What would have happened had the two railroads worked independently of each other? They would have built very nice railroads whose tracks would never have met, tracks dead ending in the middle of nowhere. Even if they almost met, say got within a few feet of each other, they would have failed.
There are those who see the work of the ONC as a real value-add. I dare say that most of those are not hospital CIOs or physicians. Both groups define value-add and success differently.
This is not to say that providers would not accept all the help they can get. However, providers want the help to be…what is the word I am searching for—helpful—to them, to their issues. The ONC’s mission will not work until the providers successfully deliver what the ONC needs from them. How many providers must be Stage 7, Meaningful Use, Certified compliant for the virtual national healthcare infrastructure to work? Fifty percent? Eighty? Who knows.
So, the providers own the critical path. It is all about the providers, bringing fully functional EHR systems to hospitals and physicians. The numbers I have seen do not paint a promising picture. The critical path is in critical condition. Ten percent hospital acceptance and a sixty percent failure rate. Let’s say those numbers are wrong by a factor of three—thirty percent acceptance, and a twenty percent failure rate. Even those numbers do not bode well for ever achieving a virtual national healthcare infrastructure under the current plan. Subtract from those figures—supply your own if you would like—the churn figures—those hospitals that are on their second or third installation of EHR. Something is amiss.
In a more perfect world the ONC might consider shifting course to something aligned with the following:
• Segment its mission into two parts; one to build a virtual national healthcare infrastructure, and two, provide hands-on support individual hospitals’ and providers’ EHR initiatives.
• Standards
• Standards—I wrote that twice because it is important to both missions
o Let us be honest, the largest EHR vendors do not want standards. Why? Because if all else fails, their standards become the standards. They don’t phrase it this way, but one can assume, their business model calls for them to do what is best for them.
o The vendors do not want to open their APIs to the HIEs
• Do not set dates for providers which to be met require meeting rules which do not yet exist. If the government wants providers to meet its dates, the government must first meet some of its critical success factors—standards, for example.
• Mandate vendor standards for however many vendors make up ninety percent of the EHR install base for hospitals. Give vendors 18-24 months to agree to a set of standards and have them retrofit their applications.
• Use a garrote and stick approach on the vendors. Create a standards incentive program, heck, underwrite it. Pay the vendors to develop and get on a single set of standards—this will have a much more positive impact than REC and PR money. Many will say, especially those who have an incentive for this not to happen, this cannot be done. Of course it can.
• Processes. EHRs are failing in part due to not enough user involvement, not enough user authority and governance. There is no usable decompositionable process map of how a hospital functions. No Level Zero through Level Whatever You Need. No industry standard, mega-diagram, boxes and arrows, which can be laid on a table or hung on a wall that shows, “This is what we do. This is how it all ties together.”
• I am building this process map, along with a colleague. Why isn’t the ONC? It will not match you hospital. It may not match anyone’s hospital. What it will do is give someone a great base from which they can edit it. Why is this important? Because it will enable the users, IT, and the vendor to overlay the EHR application to show:
o which business and clinical areas are impacted
o the process interfaces
o duplicated processes
o processes with no value-add
o which other facilities have similar and differing processes
o where change management resources must be focused
o what needs to happen if an acquisition is made
The ONC must move from coordinating to leading. To do that they need the authority to mandate the execution of some of the items listed above.