Gregory Maciag

Encouraging Standards Development

This is an excerpt from a Q&A with Marc Probst, vice president and CIO of Intermountain Healthcare:

Q: What kind of leadership can policymakers or professional associations provide that would help in the rollout of all these [health IT] initiatives?

MP: Standards. If we had standards around the patient identifier, if we had standards around transported data or even data standards, all of this would still be difficult, but much more straightforward. Interfaces would be easier. Security would be easier. We didn’t address those upfront, but I think we’re at least getting around to that discussion. Policymakers could have set standards and that would’ve made it much easier.

[Professional associations] are trying, but I think they’ve tried for 30 years to get standards in place. I personally think it’s the government’s role to step in and solve this problem.

Probst's view of the immediate benefits of standards is correct, and if I detect some frustration in his words then I understand that too. I can't comment in detail on the last 30 years of development in health IT, but I know the structural changes driving connected IT in health today just weren't there in earlier times. In the insurance industry, we've been connected for hundreds of years. When we say data is the lifeblood of the industry, we're not kidding. That wasn't formerly obvious in the health professions where the lifeblood is, well, blood.

As data collection, management, exchange, and analysis become more central to healthcare delivery and innovation, the need for standards becomes more acute. I believe industry associations are best placed to produce and promote relevant standards, because standards must be generated by and for the people who need them. Government's role is to encourage, facilitate, and connect groups where necessary – and maybe bang a few heads together.  CIO Q&A

 

Standards Essential to Health

Failure to implement data standards in health care could be fatal – that's the judgment of the Harvard Business Review. Thomas C. Redman and Donald Nielsen note that computerization is delivering real benefits in health care, notably from aggregation of data. They cite a serious interaction between Paxil and Pravastin that was only discovered through analysis of newly aggregated data.

But elsewhere they see a “crisis” caused by non-use of standards. First, a lack of patient identifiers makes patient records incomplete and frustrates complete data analysis. Second, non-use of standards for health attributes can lead to poor or incorrect care.

As the authors say, “Without [standards] it is simply too easy to translate 'mild systolic flow murmur' into 'underlying cardiac disease,' 'wheeze" into 'asthma,' and mild reactions to specific drugs into allergies. These sorts of misinterpretations were all too common without computers, and electronic medical records have done nothing to reduce their severity or number.”

Every sentence of this article is highly quotable. I hope it has the impact it deserves.

Harvard Business Review

Patient Data

The healthcare sector is considering how to include patient-input data in electronic health records (EHRs). The idea is to use existing document standards.

Seems obvious enough. We should think of patient input as a kind of form-filling. Items on forms need to be standardized and verifiable. They need to be recognized by collaborating systems.

I guess that in the future large amounts of patient data will be automatically generated and delivered to analysis and workflow systems by personal devices. Various health factors will be monitored and relayed without our ever having to look at the readings, let alone transcribe them into a system.

Patient-input can be presented as patient empowerment. But it's also about downstreaming work. The more the customer does, the less clerking the organization has to do. That's been one side of self-service from the supermarket through the ATM and beyond.

The difference (an difficulty) here may be about nuances. In order to allow a patient to enter, say, symptoms, we'll need to present them with a set of possible symptoms to check. This may encourage people to check more symptoms than they would have done unprompted. It will also mean that the degree to which the symptom itself is causing distress will be masked, meaning that a piece of potentially important data is lost. Call it the light and shadow – the subtleties of human communication that physicians use in the diagnostic process. So maybe patient input will be limited to basic items rather than nuanced ones.  EHR

Healthcare Standards

Ross Koppel, professor of sociology and medicine at the University of Pennsylvania, is concerned that the transition to digitized healthcare records is neither efficient nor cost-effective. He says: “The problem is that a lot of the software out there is really clunky, is not user friendly … and the structure of the market is such that the vendors of these programs are not as responsive to the needs of clinicians as they should be.”

According to Adam Ludwig at Technonomy, Koppel goes on to say “the high cost and protracted implementation time of digital record-keeping programs leave hospitals little flexibility to make improvements based on feedback... One solution, he suggests, is for the government to push harder to enact data standards and oversight.”

Koppel's analysis highlights a couple of important aspects of data standards. First, industry standards are always faster to apply when compared with creating specific workarounds between incompatible systems. Second, the time lags involved in refining or evolving proprietary standards to meet changing business needs are unacceptable. And third, well managed industry standards integrate responses to the changing business environment through their maintenance and improvement processes.

The key to the solution is indeed standards. But the sector needs to look to itself for leadership. Healthcare providers must agitate for standards implementation. They don't need government to tell them what they know they ought to do.

By the way, in case you're in doubt as to whether there are really lots of data flows in healthcare, take a quick look at slide #8 in Kathleen Connor's presentation at  X12 & HL7.  Here is the Koppel mention in Techonomy

Health Data Standards

The American Health Information Management Association (AHIMA) has issued a call for unified data standards in health information. AHIMA “says it's prepared to work alongside vendors, insurers, providers and the federal government to develop needed industry-wide governance standards for health information technology”.  Modern Healthcare

Big Data for Healthcare

The Institute of Medicine is calling for a “Knowledge Network of Disease”. By bringing together diverse data on health, new discoveries can be made. Healthcare can get smarter, faster, and more evenly distributed.

Reporting on developments in The Atlantic, David A. Shaywitz highlights the tension facing all data aggregators: whether it's possible to create a single, coherent and correct data model, or whether it's better to use a more ad hoc approach. He quotes system biologist Eric Schadt: “The grand data model of everything in biology has been tried over and over again and ultimately it comes crashing down because once you lock in a model, you constrain the types of questions you can ask of the data. The information half life is short, and we know and understand so little about what the data can actually tell us that we don't really understand the questions that ultimately will be the most useful.”

How do we build a knowledge structure when we don't know what we want to know? It's a problem we face in business too.   However, the problem can be attacked in an incremental way. There are levels of detail at which healthcare professionals will agree. They'll agree that there's such a thing as a patient, for example. They are also likely to agree on the major biological systems and organs. They will also probably agree on a core set of signs and symptoms.

There will be a point at which interested parties can no longer agree on definitions of items or relationships. But that doesn't mean the modeling approach should be abandoned. We have to tolerate fuzziness and ambiguity at the depths and fringes of our knowledge structures. That's how we learn.

As healthcare data sets become larger, researchers will use analytics to discover new types and constellations of facts. These discoveries will sharpen the resolution of the outlying fuzzy areas. So the model will become more detailed and more effective in response to its use in the field.

The idea that standards need to be all-or-nothing is one of the myths of information management. Standards exist to facilitate  action, not constrain it. You don't have to have a grand data model. But you need a model.   Instead of thinking that a model or standard “locks in” users, we need to manage standards as evolving tools that learn from users as well as supporting them. Standards must lock step with the communities they serve. Database for Medical Knowledge

Standards for Value in Healthcare

Boston Consulting Group have released a new study into how various countries collect clinical data so they can improve health care while cutting costs. Looking at how the US could do better, BCG's Simon Kennedy zeroes in on the lack of data standards: “So many terms to describe the same medical event creates a lot of problems in the heterogeneity of the data. It would be nice if we could have a standardized medical nomenclature around the practice of medicine in the United States with much stronger data standards.”

Getting high quality healthcare with minimum costs is called value-based healthcare. BCG rank the sharing of high-quality data in their top four must-haves. I note also that one of the other requirements in the top four is for a “national infrastructure”, by which the report authors mean standards for processes and platforms.

It's good to see recognition of the role standards play at the meeting point between effectiveness and efficiency. Standards can bring both excellence in quality and parsimony in expenditure. They can also help to propagate best practice throughout a sector, raising service levels for all.

US Healthcare Needs Data Standards

Technology and the Healthcare Value Gap in the USA

The piece was prompted by a conversation between a health services researcher and the head of health information technology of Taiwan’s Bureau of National Health Insurance, which administers Taiwan’s single-payer national health insurance system. By that time, virtually all of Taiwan’s claims were billed electronically. Economix

Goals & Tools

Good quote on health IT from Kaiser Permanente president and CEO George Halvorson: “The goal is the care [...] The technology is a tool. [...] A lot of people put medical records in place but don't have a goal, don't have a particular strategy to use them, and if you just put the medical record in place and don't use it for anything, care doesn't get better.”

Halvorson also refers to process improvement guru Edward Deming, saying that savings follow from improvement activity, while targeting savings instead of improvement usually leads to reduced quality. So, it's better to focus on reducing the incidence of broken bones among seniors than on reducing the cost of broken bones. This way, care will be improved and savings made.

I'd develop the argument somewhat. The healthcare sector is becoming increasingly complex and collaborative. This means that medical records have to serve many goals throughout the collaborating community. A good standards process can ensure that record structures are designed to serve all the goals of the sponsoring community. In fact, good standards can even help to enable new goals by providing enhanced clarity over the nature and structure of the information at play in the domain. Standards are a powerful way of promoting business strategy over short-term, silo thinking.

 Information Week

 

IT is Healthcare's Biggest Challenge

If state healthcare exchanges survive the Supreme Court challenge to health care reform, the election and state tea party activists, health policy experts are worried they could still be brought down by a much more mundane problem: information technology

Politico

Xchanging and Healthcare

In late 2010, the UK Government gave a public commitment to increase spending on the NHS by 0.1% year-on-year throughout the lifetime of the current parliament. But there are already doubts about whether this promise is being delivered.  More fundamentally, critics would argue any additional funding may not necessarily benefit healthcare because of organisational bureaucracy and inefficiency.

The NHS is the largest public sector health organisation in the world but most healthcare in the western economies is similarly dependent on government funding which will become increasingly pressured as tax receipts decline during the course of the economic downturn.  Other developed countries fund their healthcare through a variety of public and private insurance programmes – with varying degrees of efficiency and success in terms of healthcare outcomes.  READ MORE FROM  Xchanging

Electronic Health Records and EHR Standards

Arjen Westerink asks: “What it will take to encourage EHR [electronic health record] vendors to develop truly interoperable EHRs?” Collaboration and competition seem to be irreconcilable forces. “So far, there is little financial incentive to support true interoperability, and if anything, many vendors see some level of proprietary distinction as desirable – creating barriers to customer defection,” he writes.

He asks whether government should stimulate standards or whether the industry should wait for standards to emerge. The problem with this, as I see it, is that the industry can't hang around waiting for either eventuality. In particular, I don't believe that industry standards emerge by themselves any more. The kind of de facto industry standard that we used to see in, say, punch cards, was driven by closed intellectual property - patents and copyrights. That's not going to happen in healthcare data standards, and any organization nurturing the idea that it can produce a proprietary standard that will be taken up by the industry is kidding itself.

Data professionals in the healthcare industry need to get together and create standards. They need them for the growth of the industry. Trying to establish islands of dominance is not a tenable strategy. To do so is to fight yesterday's battles instead of building a bright tomorrow. Interoperability is coming – so bring it on.

Health Management Technology

Electronic Medical records

An artcile written by Chris Taylor talks about electronic medical records.  In it, he says: "There are few more personal, passionate, and political topics than health care. The reasons for this are clear: Health care spending has reached 17% of the U.S. GDP, outcomes are worse (partly due to  American lifestyle issues in my opinion) than in other developed countries, and an attempt to fix the system through the Affordable Care Act (ACA) now sits in the hands of the U.S. Supreme Court. But regardless of ACA's legal prognosis, the Pandora's Box of true health care reform has already been opened — and it happened before most of us realized."

Download The Health Care Reform That Can't Be Stopped 

Just 1 Campaign - Healthcare Standards

Just-1 is the name of a new campaign to promote the use of the 13-digit Global Location Number (GLN) in the healthcare sector. The idea is that just using this one simple standard will bring major benefits to the industry – and to patient safety: “Just one validated GLN is all a hospital or healthcare provider will need to begin issuing purchase orders electronically under the GS1 standard.

GLNs may then be encoded in a GS1 bar code and used to identify ship-to, bill-to and purchased-from information, among other functional data and locations. This will help bring healthcare providers up to the same standard of efficiency and accuracy already achieved in other sectors of the economy, such as retail and grocery stores.” The code can also be used to identify other entities including parties and devices.

Successful data standards grow from the urgent needs of the communities they serve. The major business benefit of any standard lies in the acceptance of its core elements. The 80/20 rule plays a part here, in that a small number of elements tend to supply the larger part of the benefits. However, success in the core area also leads to reprioritization of more peripheral areas. Once organizations in healthcare are working happily with the GLN, they'll come to see value in other standards as well.

HSCA President Talks Standards