Key learnings are now emerging from the meaningful use process under the HITECH (Health Information Technology for Economic and Clinical Health) Act, learnings that are particularly timely as the U.S. healthcare system evolves forward towards what will soon be a post-meaningful use future, even as healthcare IT leaders are faced with the reality of the need to revision physician documentation, said Douglas B. Fridsma, M.D., Ph.D., president and CEO of the American Medical Informatics Association (AMIA), and who had worked in the Office of the National Coordinator for Health IT (ONC) for five years, from November 2009 through October 2014, including as the Chief Science Officer at ONC from June 2011-October 2014.
Dr. Fridsma, who joined the Bethesda, Md.-based AMIA a year ago in November 2014, delivered a keynote address Tuesday at the Health IT Summit in Beverly Hills, held at the Sofitel Los Angeles at Beverly Hills, in Los Angeles, and sponsored by the Institute for Health Technology Transformation (iHT2, a sister organization to Healthcare Informatics, under the corporate umbrella of parent company Vendome Group, LLC). Expounding on themes he has been sharing recently with healthcare audiences, Fridsma said that, in his perspective, five key learnings are emerging from the meaningful use process, even as it moves into Stage 3 MU and beyond.
Doug Fridsma, M.D., Ph.D.
First, Fridsma said, “Framing matters. Sometimes, you get the right answer to the wrong question,” he said, going on to stress that, in his view, “The bottom line is that health information technology isn’t architecture; it’s city planning. It isn’t that we’re going to have to build some ginormous building that everybody’s going to live in; it’s about city planning, knowing the right zoning laws, figuring out the right building codes for safety, figuring out the right infrastructure for water and electricity and all those things. So it’s an ecosystem in which people will build interesting things inside interesting buildings that we want to live in.”
The key point within that first point, Fridsma told his audience, is that “Governance matters; how you make decisions around federated systems is very important,” and, extending out the metaphor of urban planning, he said, “City planning is decentralized in its control.” What is evolving forward in healthcare IT, he stressed, making his second point, is a “socio-technical system. And that means that people are part of that system, they don’t just interact with the system.” Most significantly, he said, U.S. physicians are inevitably going to express their desires, preferences, dissatisfactions, and grievances with the ways in which healthcare information technology evolves forward, and given the cultural factors involved, the forward evolution of IT in healthcare will necessarily be iterative.
Many people in U.S. healthcare have expressed frustration over the gradual, iterative aspects of the industry’s IT evolution, but the reality, Fridsma said, is that the development of IT will necessarily be incremental, and as a result, he said, “Since we will learn as we go. So in health IT, you’ve got to start with little bites and learn from each of those experiences. So this notion of modularity is really important.”
Fridsma’s fourth and fifth points had to do with the broad context of IT evolution in healthcare. The reality, he said, is that regional and individual-market differences in healthcare will mean that “You’ve got to tolerate differences in semantics and sophistication” among clinicians and other end-users, and patient care organizations, across the U.S. “You’ll have rural physicians who barely have EHRs, and work via dial-ups. You’ll always have some folks ahead of the curve, and some behind the curve. That’s true of systems, too,” he added. “You’ll have legacy systems and new ones, and you’ve got to figure out a way to allow that heterogeneity to exist, even as you make things interoperable.”
Finally, he said, healthcare leaders will have to come to tolerate normal failures, for example, understanding and accepting that data security breaches will occur, and that “Nothing is entirely secure. So we need to focus on risk and recovery,” rather than believing that all breaches can be prevented from occurring in the first place. The reality for those would move the U.S. healthcare industry forward, he said, is that, “If you’re a leader in this field, your job becomes one of orchestration rather than command and control,” given the city planning type of governance involved in healthcare IT in the U.S.
Referencing the recently released “Report of the AMIA EHR 2020 Task Force on the Status and Future Direction of EHRs,” Fridsma made a major pitch for rethinking physician documentation. “We have to simplify documentation,” he told his audience. “Right now, doctors are just checking the box for everything. But our argument [at AMIA] is that modern medicine is a team sport, and everybody’s voice should count, and it shouldn’t fall to one individual [individual doctors] to do it all. We need to distribute the load, and to simplify it. ICD-10 could be a really good thing or a bad thing for documentation, depending on how CMS handles it,” he added. Significantly, the legacy process of “SOAP”—the historical way in which physicians documented in paper medical records, with the subjective, objective, assessment, and plan elements of documentation being taught in medical school, may need to be rethought, given the need for physicians to quickly be able to identify and isolate key data and information points in what is increasingly becoming a “note bloat”-overstuffed electronic documentation format in electronic health records.
In the same vein, Fridsma noted that the AMIA report, released earlier this fall, beyond advocating physician documentation reform, also called for simplifying and focusing regulatory mandates, encouraging innovation, particularly through new APIs (application program interfaces), and keeping the patient at the center of all development efforts.
With regard to AMIA’s role in spearheading change, Fridsma said that “The first thing is that we have to, within the health IT and informatics community is that we need to show physicians what they can do. If we can hit people emotionally with what they can do, we can change things. Success is when people stop talking about interoperability, and start thinking about the goal,” he said.
And, he added, ultimately, “EHRs are not going to be the most important health IT in the future. And the reason that I know that,” he said, is that this is not the first time medicine has had to adopt new technology. Between 1906 and 1912 in JAMA”—the Journal of the American Medical Association, he noted, “there was a whole set of articles about ‘the physician’s automobile,” which went into great detail about the various features of emerging cars, based on the fact that physicians were early purchasers of cars, both because they had the income, and because they used their autos to make house calls. “What happened in 1908?” he asked. “Henry Ford developed the model T,” and created the assembly line-manufactured car. “And it stopped being about the physician and started being about the consumer. So somebody is going to develop the model T” in information technology, he told his audience, “and it’s going to transform the way consumers interact with the healthcare system, and then we’ll stop talking about electronic health records, and we’ll just talk about health records.” And in that context, he said, “patients are going to be the biggest innovative force in health IT,” as consumerism and the explosion in consumer-outfitted devices move the focus of attention to patients/consumers and away from providers and their orientation.