Friday, May 20, 2016

A Multi-Stakeholder Discussion in Washington

On Thursday, I spent the day in Washington with a group of government, provider, and developer sttakeholders convened by the Institute of Healthcare Improvement.      We operated under Chatham House Rules, so I can summarize the discussion but not identify any of the participants or their specific statements.       Below are three questions we discussed and the observations we made:

1.  What worked in CMS and ONC rules (HIT related regulations)?
*Meaningful Use  provided a foundation of basic electronic record functionality
*We enhanced systemness thinking and created learning groups to address vulnerabilities in discconnected systems
*We made safety improvements and enabled analytics
*We enhanced patient engagement and dispelled several myths
*We automated quality measurement processes and recorded social determinants of healthcare
*We encouraged EHR optimization
*We enhanced  Interoperability for public health transactions, eprescribing and entry of vocabulary controlled data (problems/meds/allergies/labs)
*We incentivized new entrants into the marketplace
*We enabled standardization of workflows
*We found that CMS was a good listener
*We began to engage post acute providers
*We caused infrastructure to be upgraded (to support EHR implementation)
*We enabled remote access to records
*We created an ecosystem for home care devices  and wearables to become relevant
*We taught stakeholders that clinical automation is not an  IT project
*We began to focus on the user experience

2. What didn�t work or could have been done better?
*Products were rushed to market and they were not as usable or as intuitive as we�d like
*We did not achieve a consensus on national priorities - where we want electronic records to be in 5 years
*We did not include behaviorial health providers
*We did not enable team communication
*We did not enable substitutable apps that can be shared across vendors
*We required too much non-valued data entry
*We often digitized the  paper world
*We ended up with regulatory complexity
*We required too many clicks, causing a loss of patient focus
*Once the foundation was laid we did not have time to digest the changes, interatively improve and innovate
*Certification consumed too many development resources
*We hired scribes as a workaround to overwhelming  data entry requirements
*We required documentation to satisfy legal and regulatory concerns rather than patient care needs
*We demanded Interoperability without first building enabling  infrastructure
*IT service levels did not always align with clinical requirements
*We underestimated the burden of the impact of HITECH on providers and developers
*We made patient engagement too hard
*We did not turn data into information, knowledge and wisdom
*We focused on compliance instead of joy in the workplace (or joy for the patients)
*We did not enable the marketplace to meet customer demands
*We focused on billing rather than clinical workflow
*We tried to do too much, too soon

3.  How do we shape the future based on lessons learned?
*IHI  Leadership Alliance/EHR workgroup should submit a comment letter about  MACRA/MIPS to CMS
*Reconciling the tension among Developers, Government , Providers, Patients   will required  argreement about who is the user/customer, what is success, what is considered a good outcome
*Instead of just Interoperability we need to think about the functionality needed for a collaborative work and a more uniform  user experience
*We need to build Infrastructure enablers - a catalog of constrained standards, a national patient identifer (or private sector solution i.e. CHIMEchallenge/Commonwell/Surescripts/CareEverywhere), a national provider directory, a trust fabric, uniform consent policies among states
*We need to align economic incentives among stakeholders
*We need to consider the impact of the emerging consumer driven digital ecosystem
*We need to recognize that the EHR is not the center of the universe and enable other tools such as EHR agnostic warehouse solutions
*We need liquidity of claims data
*Documentation/coding rules need  to enable team-based care by all clinicians
*We need education to dispel fear of HIPAA and enable a culture of sharing

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