By Clinical Informatics News Staff 

April 30, 2014 | This Monday and Tuesday, the second annual Medical Informatics World Conference convened in Boston to discuss trends and best practices in health information technology. Medical Informatics World has grown in attendance and commercial clout since its debut last year, a reflection of the healthcare industry's burgeoning interest in information technology as a gateway to controlling costs and improving outcomes. As Sachin Jain, Vice President and Chief Medical Information & Innovation Officer at Merck, observed in his keynote address Monday morning, "If we had a conference like this 10 or 15 years ago, there would be five people here. It really does feel like the best time to be an innovator in healthcare."

A Field Outgrowing the EHR 

The discipline of health IT remains tied to the ambiguous reputation of electronic health records (EHRs) and Meaningful Use regulations. The wholesale transfer of medical data in the U.S. from paper records to EHR systems has touched the basic practices of clinicians nationwide, a trend accelerated by the incentives for EHR adoption in the Affordable Care Act. Monday's keynote speakers showcased the promise of an electronic data management environment within the hospital setting, while speaking frankly to the frustrations that many providers still face in adapting to EHRs.

John Halamka, CIO of Beth Israel Deaconess Medical Center in Boston, represented an institution that has weaved its EHRs into a complex and variegated IT ecosystem. He shared a number of creative new programs this embrace of health IT has enabled, including the adoption of Google Glass in the emergency room, transmitting patients' EHRs directly to physicians' headsets for active use during visits. A more far-reaching IT tool at Beth Israel Deaconess is I2B2, which collects anonymized information on patients' conditions, interventions, and outcomes, so that physicians can rapidly reference past interventions to see which have been most successful, without going through hoops to access private patient data.

Yet Halamka also gave voice to common concerns about interoperability between providers; the limitations of electronic notes, which check off basic clinical data without allowing physicians to record a narrative thought process; and poor incentive structures around how the government regards meaningful use of EHRs. He drew a round of applause when he called for an incentive structure that rewards the achievement of important health outcomes, without punishing the failure to meet more granular milestones.

Speaking from the government perspective, Jacob Reider, Acting Principal Deputy National Coordinator of the HHS Office of the National Coordinator, acknowledged the limitations of EHRs and the federal Meaningful Use incentives, while painting an optimistic picture of EHRs evolving toward greater ease of use and more direct impact on patients. "The document-centric EHR, which hasn't let go of the metaphor of paper, is holding us back," said Reider. He noted that EHRs capture static documents in order to meet the reimbursement needs of payors, rather than recording a linear stream of health data that can help both clinicians and patients to make consequential decisions. Sachin Jain also foresaw an evolution in EHRs, commenting that the next generation of physicians will be digital natives who will not need to be retrained to work in electronic environments. Jain likened EHRs today to the early days of online banking, when Quicken users simply transcribed their receipts into digital fields — hinting that the ubiquity of online banking today will gradually be mirrored in healthcare.

EHRs, and other digital records of sensitive data, continue to raise privacy and security concerns, a reality reflected in a new track at Medical Informatics World this year, on "Information Security and Privacy in Healthcare." Yet there is also a growing consensus that this is not a primary worry of patients themselves. As Mark Davies, a health information consultant for the U.K.'s National Health Service, observed in Tuesday's closing keynote, when his patients watch him enter their data into his computer, they're often alarmed to learn that their data isn't being shared with wider systems that could improve their care.

Increasing Focus on the Patient 

For a large number of speakers and attendees, data capture at the point of care is no longer the vanguard of innovation in health IT. Instead, direct outreach to patients through digital media is providing more flexible, specific tools to affect outcomes.

Joseph Kvedar, the Director of the Center for Connected Health at Partners HealthCare, presented a series of small-scale experiments in reaching patients through mobile applications. These innovations could be as tightly focused as encouraging patients to use sunscreen, by sending them phone messages that included both weather reports and sunscreen reminders — a method that showed greatly improved compliance over weather reports alone. Kvedar encouraged providers to borrow techniques from the ad industry, including small, unpredictable rewards for sticking with a product, and subliminal messages that reinforce good health behaviors. "We can make health addicitive," he said. "Mobile is a perfect platform for that."

John Schmucker, a lead developer in the Virtual Practice Project at Massachusetts General Hospital, reinforced the idea that new IT tools are most likely to generate results in the short term if they are narrowly targeted to specific problems. The Virtual Practice Project has implemented virtual visits at Mass General, through which patients discuss mainly chronic conditions with their doctors through structured email questionnaires, saving physicians time while offering patients easier access to routine care. Patients in the program have been significantly more likely to agree to long-term, regular evaluation and management programs with their physicians. Crucially, says Schmucker, the project has concentrated on a few diseases at a time, and made minimal disruptions to physicians' workflows, to encourage rapid and comfortable adoption — in contrast with the broad restructuring of practices under EHR implementation.

Patient-empowering tools can also be natural extensions of EHR systems. O'Neill Britton, Chief Health Information Officer at Partners HealthCare, encouraged providers to let patients provide data for their EHRs from home. Family history, for example, is often misremembered if the data can only be captured at the point of care. Giving patients access points at home can be seen as a quality control measure, which not only opens the door to more data, but also improves the reliability of existing data.

One ambitious patient outreach effort built on top of an EHR system comes from Kaiser Permanente, which has enrolled nearly half of its patient population of 9.3 million in the kp.org health portal. Terhilda Garrido, Vice President for HIT Transformation & Analytics, and Michael Kanter, Medical Director of Quality & Clinical Analysis, gave insights into Kaiser Permanente's success in achieving high levels of patient engagement with kp.org. While the portal gives targeted access to popular EHR elements like lab results, it also draws patients in with novel tools that Kaiser Permanente could not previously offer. These include the ability to make appointments and refill prescriptions online, a secure email environment that opens a direct line of communication with physicians, and a health encyclopedia where users can look up unfamiliar terms to learn more about their lab results or diagnoses.

Garrido and Kanter stressed that the value of kp.org has not been limited to the new tools added to the system. Instead, convincing patients to participate in kp.org has also increased utilization of existing programs. Patients can access their lab results without kp.org, but through the patient portal, Kaiser Permanente found patients would sometimes consult their results repeatedly over the course of several days, suggesting that easy online access fostered a more sustained interest in one's health metrics. Patients also referred more often to their personal action plans: personalized guides to health behaviors that are otherwise only made available during office visits.

Expanding Interests 

While the speakers and attendees at Medical Informatics World showed a growing focus on IT tools that offer direct control to patients outside points of care, they also represented a field that is restless and expanding. Health IT experts and advocates are constantly finding new applications for information infrastructures.

Sandy Aronson, Executive Director of IT for Partners HealthCare Center for Personalized Genetic Medicine, contended that genetic diagnostics has pioneered a virtuous feedback loop for clinical data, where each new data point improves both future diagnoses and previous patients' care; he suggested that similar systems could be implemented in fields like pathology and cardiology. Bryan Sivak, CTO of HHS, revealed a number of government programs to foster IT innovation, offering increasing freedom to both federal employees and external contractors to experiment with new digital tools within HHS programs. And in yesterday's closing keynote, Adam Landman and Eric Goralnick of Brigham and Women's Hospital in Boston related their experience responding to the Boston Marathon bombings in 2013, and how bottlenecks encountered during that event led to new IT protocols in the emergency room that could be replicated nationwide.

The ambition and diversity of health IT programs visible at Medical Informatics World underscores the need for venues where innovators in this emerging field can meet and share ideas. Conferences like this are likely to grow and multiply in coming years as members of the healthcare industry increasingly see health IT less as an obstacle to smooth operations at the point of care, and more as an opportunity to experiment with new models of care that empower patients and impact costs and outcomes.