HIEs EHRs and CIOs Day 3 at Harvard

Day 3 kicked off early with a talk on Health Information Exchanges by Julia Rose Adler-Milstein which in light of the article released that week in the Annals of Internal Medicine by the speaker on the adoption of HIEs in the USA was very relevant. I guess that is the beauty of being at Harvard, an article gets published on Monday and on Wednesday the author is talking to you about it. The big issue is the sustainability of HIEs and to date they have been basically grant funded. Only 1/3 of operational HIEs are currently covering their own costs. With the advent of the HITECH act there is now some incentive for providers to be involved, based around Meaningful Use funding which is believed may positively affect their sustainability.

The second speaker was Karen Bell the chair of the Certification Commission for HIT in the USA. One thing that continues to amaze me is how many people involved in HIT in the USA are actually medical doctors. She made some very interesting points. Whilst culture change is recognised as a major issue, we cannot discount the technology issues, and it is important to keep both in mind. The other issue that arose was that much of the HIT program in the USA is economic stimulus based, and it has different timelines and goals than clinical improvement people. Certification is all about provider assurance and protection, and in the USA there are over 700 products currently certified. The other issue is interoperability and the holy grail of data portability. The basic federal compliance is meaningful use, but products need to do more than that, so CCHIT also certifies for enhanced functionalities above and beyond meaningful use. Very open discussion about the issues and the need for standards.

This was followed by a panel of 3 CIOs from Boston Children’s, Boston Medical Centre and Newton-Wellesley Hospital talking on their experiences on driving quality and safety using IT. An interesting thing is the length of tenure of these folk; two have been CIO for 15 years and the other 10 years. The need for behavioural and cultural change came up again, but it was interesting that they saw meaningful use as a driver to produce this cultural change as it unites the disparate parties involved. A question arose on how the meaningful use stuff disrupted their flow, as they were all actively doing stuff before HITECH came around. Timing was the major issue; they had to change their priorities to make sure they had access to the stimulus funds. The key issue was the link between demand management and governance. How do you chose what can be done versus what needs to be a done. How they managed new projects was interesting, prioritisation was based on need and costs, and those most likely to be done were needed but cheap. Another interesting comment from one of the CIOs was how they wished they were not best of breed as it is now causing them huge issues. The idea of best of suite came up as an option, but there is strong push towards consolidation. Cloud computing came up, and it was interesting that one of the CIOs pointed out that healthcare is a more employee friendly industry, and some decisions are being driven by the effect of going to the cloud would have on their staff.

An issue I raised was what the interaction there was between the CIO and the CMIO. The one medical CIO admitted that for 5 years he did both roles, but realised that there was a need to separate the two roles, and now they have a formal CMIO who interacts directly with him. For the non medical CIOs there was a comment that the role of the CMIO is probably one of the least well defined roles in their organisation, and the reporting mechanism tends to drive their activity.

After lunch the next module starts focusing on Continuous Improvement through HIT. It is being run by Dr Blackford Middleton, another health informatics luminary. The scenario was painted of the issues we face, on the background of financial turmoil, and legislation which is not designed around sustainability. One of the issues is that clinical information is very expensive, because we get it via very expensive means, physicians and healthcare providers. We need to find a way to do it more cost effectively. He spoke about the Clinical IT vision, with common consolidated information for all patients, with consistent decisions support, identification of high risk patients and patient access. He spoke about ruthless standardisation as a way forward.

Tim Ferris from the Massachusetts General Physicians Organisation spoke on clinical leadership for high performance medicine. He started off with the 20 “no brainers” for high performance medicine, including things like patient and physician portals, virtual visits, incentive programs, quality metrics and more. His group has 100% adoption of EHR, which is very impressive in the US, and is now focussing on getting 100% of their patients actively online. They are working on defining episode process standards, with IT playing a pivotal role. He dived deep into how they developed their stroke care plan, and looked at how they drove the change within their group.

The day ended with dinner in the Harvard Faculty Club, very swish, makes me feel like a Harvard educated expert, well at least Harvard educated J