With many key words and tricky phrases, the PCAST report essentially proffers six tenets, which either state the obvious or introduce entropy by suggesting the solution to the problem is found in more technology and standards.
With that said, let’s review the six tenets and then come to a conclusion.
1. HHS’s vigorous efforts have laid a foundation for progress in the adoption of electronic health records, including through projects launched by ONC, and through the issuance of the 2011 “meaningful use” rules under HITECH.
This is certainly true. HHS’s recent vigor surrounding EMRs has clearly kicked up a great deal of dust and arguably initiated an increased rate of adoption and some minor behavior modification surrounding the use of EMR technology. It would be disingenuous of me in this blog to fail to point out that the lion’s share of activity has been spawned by the prospect of financial reward, or minimally financial subsidization. Unfortunately, such top down financial incentive is provided at the sole discretion of the government – a government challenged with many things, most notably in this context deficit reduction. Financial sustainability in a free market is therefore critical.
2. In analyzing the path forward, we conclude that achievement of the President’s goals requires significantly accelerated progress toward the robust exchange of health information.
This too is certainly true and in our humble opinion rather self-evident. With the introduction of an information technology “digital revolution” designed to capture patient health information in a manner consistent with this century’s manner of processing data, the need certainly exists to exchange, aggregate, share and analyze the data. Keeping the data locked up in silos renders its digitization quite valueless. Health information exchange (as a verb, not a noun describing a network) is, in fact, the cornerstone for properly leveraging digitally captured and available patient health information (dare we throw in the semantically interoperable tricky phrase?).
3. National decisions can and should be made soon to establish a “universal exchange language” that enables health IT data to be shared across institutions; and also to create the infrastructure that allows physicians and patients to assemble a patient’s data across institutional boundaries, subject to strong, persistent, privacy safeguards and consistent with applicable patient privacy preferences. Federal leadership is needed to create this infrastructure.
The notion that additional standards are needed is a bit odd given the number of standards developed over the past 20 years - standards offered by numerous well-meaning technologists and clinicians. In my humble opinion, this tenet introduces unnecessary entropy and suggests the problem we face in healthcare is largely one solved by technology. That’s just wrong. There’s plenty of standards and technology that can be brought to bear on the information challenges in healthcare. Amidst the entropy such a suggestion creates, the real issues that must be addressed are overlooked; we must align incentives with behavior to encourage symbiotic information technology deployment to improve care and reduce costs. The problem is one of behavioral economics, not technology.
4. Creating the required capabilities is technically feasible, as demonstrated by technology frameworks with demonstrated success in other sectors of the economy.
While ruminating on the PCAST report, I thought about a famous Albert Einstein quote, “make everything as simply as possible, but not simpler” (emphasis added). In other words, distilling this problem to some simple issue regarding technology frameworks that have been deployed to streamline information flow and improve service quality in other, different industries fails to recognize that healthcare, as an industry, is quite different from most industries guided by the free market. Healthcare, certainly at the provider level, is inherently benevolent, for example. Selling cars is not. Investing money is most certainly not. People don’t choose to get sick. People choose to purchase cars, stocks, bonds, widgets, etc. I strongly advise readers of this blog to be careful of superficial analogies. A misinformed analogy applied to a problem has potentially dangerous implications.
5. ONC should move rapidly to ensure the development of these capabilities; and ONC and CMS should focus meaningful use guidelines for 2013 and 2015 on the more comprehensive ability to exchange healthcare information.
As with tenet number two above, this is good and quite obvious. Dr. Blumenthal has been quoted for over six months suggesting the bar will be raised for HIE in Meaningful Use Stage 2 and Stage 3. Given the realities in which providers operate, long product development cycles, and complex installation and testing activities that are needed to deploy technology upgrades in their facilities, enhanced exchange of what is available digitally is appropriately suggested and well-timed – get the EMRs to some level of exchange capability (driven by ONC’s Standards and Certification rules), then give providers a year or two to meaningfully deploy the exchange capabilities proffered.
6. Finally, as CMS leadership already understands, CMS will require major modernization and restructuring of its IT platforms and staff expertise to be able to engage in sophisticated exchange of health information and to drive major progress in health IT.
What does this really mean? CMS already spends significant dollars on their IT modernization and maintenance. I believe the directive sets or should set CMS up to redirect behaviors within healthcare such that securely sharing digitally available healthcare data and turning such data to specific action is a goal worth pursuing. The key, however, is behavior modification driven by aligning the incentives of a complicated environment that includes many players, some driven by self-interest and some by benevolence, all sitting on top of a consumer base that for the most part have little choice when it is time to “purchase” care.
At the end, the report makes certain recommendations, most of which we’ve heard before. Create, formalize and propagate standards, set up measures that will instrument and illuminate production-level utilization of information technology, health information exchange, and align Federal agencies and their IT systems to support such an industry infrastructure. There are even a couple of holdovers from ARRA, like pushing forward comparative effectiveness, surveillance, research within FDA and CDC, and yet another nudge to get VA and DoD to step up their interoperability.
I like this recommendation in particular:
“Direct … efforts under the Patient Protection and Affordable Care Act toward the ability to receive and use data from multiple sources and formats.”
I don’t like that it is tied to the debacle that is PPACA, but the underlying advice is crucial. We need to establish incentives and economic devices that alter how business decisions are made in healthcare, reduce the self-service biases that exist, and empower our citizens to engage in and share more responsibility for their healthcare. Expect friction with socialistic norms and capitalistic principles. But today’s behaviors in healthcare are rarely rewarded for sharing information, and are not incented to use shared information.
My PCAST recommendation: regardless of the standards, technology, or implementation choices, move healthcare providers and our nation’s patients to weave themselves into our burgeoning healthcare information technology and exchange fabric, to participate, use, and benefit from the electronic flow of data. Focus on incenting this behavior, and we will have moved the dial on our nation’s healthby improving care quality while simultaneously reducing costs – the quest for the healthcare industry’s holy grail will be complete.