By Aaron Krol 

May 8, 2015 | “Imagine for a second that you are a professional racecar driver,” Jason Burke told the audience at the 2015 Medical Informatics World Conference this week. Chief Information Officers, IT vendors, clinicians, and standards advocates had gathered together in downtown Boston to discuss the state of the IT systems that form the nervous system of modern healthcare centers, and Burke, like many of his fellow keynote speakers, was pulling no punches.

“You show up to the biggest race of the year, and your team has been working on this new car,” he continued. “You notice that on the dashboard of this vehicle there are 87 different gauges. So you look at your pit crew chief and you say, ‘I notice there are a lot of new gauges here. Can you point me to where the speedometer is?’ And the pit crew chief says, ‘Well, we didn’t have room to put the speedometer in because the race track requires us to install these 87 gauges… These gauges give you a continuous feed of what is going on with your vehicle, on a 45-minute delay.’

“We’re doing that today in healthcare, every single day,” he concluded. “It needs to be disrupted.”

Burke, who serves a unique role at UNC Health Care as Senior Advisor for Innovation and Advanced Analytics, was frustrated with an issue that would recur throughout the conference: the large and growing web of metrics used by providers and government to measure patient care, which play major roles in the financial incentives of the U.S. healthcare system through programs like Meaningful Use, which funds care centers based on the capabilities of their electronic health record (EHR) systems.

Two trends, both positive on balance but saddled with complications, have converged to create this problem. First, there is the increasing digitization of healthcare, as the large majority of providers have now adopted EHRs. Second, there is the slower transition from fee-for-service to value-based care models, a profound change in priorities that is still in its infancy.

As Jonathan Weiner, Director of the Center for Population Health Information Technology at the Johns Hopkins Bloomberg School of Public Health, observed at the conference, these two trends go hand in hand. He pointed to a study of those care centers that are experimenting with new value-based models, where providers and physicians are reimbursed less on the basis of the services they provide, and more on the basis of how much patients’ health outcomes are improved. “Transformation of healthcare and reform is synonymous with having not only an EHR, but an EHR that meets Meaningful Use,” Weiner said. “If you look at the accountable care organizations, the patient-centered medical homes, the pay-per-performance, it’s almost synonymous with having a high-end EHR.”

Yet the speakers at Medical Informatics World were far from seeing Meaningful Use and other top-down quality assurance programs as unalloyed goods. “Meaningful Use has become a big impediment,” declared Steven Stack, President-elect of the American Medical Association (AMA), who believes that the program increasingly penalizes providers for not meeting obscure requirements rather than rewarding them for making the most of digital records. He added that his organization is continuing to negotiate with the federal government over changes to the program.

The rapid adoption of digital systems has confronted healthcare with an unprecedented volume of data, and that data is more standardized, more sharable, and more available than ever before (though big improvements are still needed on all three counts). As a result, it’s much easier for providers to track large numbers of metrics about their patients, clinicians, and practices — and be held accountable for improving those metrics.

Yet there have been few efforts to narrow down the universe of possible features of care that can be measured, either to those that most directly reflect the quality of the patient experience, or those that make the biggest difference to health outcomes.

“What we call ‘quality measures’ are really representations of good clinical practices,” said Burke — practices like hand washing or administering cancer screens. These are important, but miss the big picture for which providers should truly be accountable: whether they are providing the best value to patients. “We should not get confused that quality, as we’re framing it, is some kind of analytically driven, evidence-based way of driving higher performance.”

Phil Polakoff, a national healthcare consultant, put it simply. “From my point of view, there are way too many metrics,” he said. “I only have three: functional status, morbidity, and mortality.”

Expanding Access 

Health IT might seem like too narrow and technocratic a field for high passions, but the speakers at Medical Informatics World were zealous and at times emotional. That’s because the stakes are high in a national healthcare system with unsustainable costs, wide inequalities in health outcomes, growing epidemics of chronic disease, and far too many preventable medical errors. Intelligent use of information technology, especially with coordination and cooperation across providers, could play a role in alleviating all these problems, yet professionals in the field have frustrations with vendors, regulators, and hospital administrators alike. 

Stack was especially irked at the idea that physicians’ widely documented dislike of EHRs is a sign of technophobia or conservatism. “It would really be a misrepresentation to say we do not embrace and adopt technology,” he said, after noting that, while most doctors are unhappy with their EHRs, an AMA survey found that over 80% were against returning to paper records. “We use technology as voraciously as any and arguably more so than most. EHRs are technology that were not ready for prime time and do not work.”

The lack of interoperability between EHRs at different providers has been one of the biggest knocks against these products, although this year many of Medical Informatics World’s speakers sounded optimistic that incentives are aligning to bring the meaningful exchange of data closer. But Stack was also concerned that the data collected in EHRs is unreliable, difficult for clinicians to use during care, and too rarely contains the most important information about patients. “You’ve got doctors using this incredibly expensive, incredibly unfunctional technology, printing off 70-page documents and faxing them to other people,” he said. “It is perfectly legible and utterly incomprehensible. There is so much garbage in those things that most of us feel the record is not a useful tool in most of the provision of care that we do.”

Burke has been especially focused on these issues in his work at UNC, where his team implements predictive models that try to comb through the data UNC collects for the most relevant metrics to improving health outcomes — in essence, surfacing the speedometer on his racecar and making sure it’s visible to doctors and administrators. That work calls for a lot of rigorous data collection, but it doesn’t mean that every data point needs to be presented to clinicians or actively monitored for “quality.”

A keynote panel meets on Wednesday, May 5, at the Medical Informatics World Conference in Boston. From L: Phil Polakoff; Stanley Huff, Chief Medical Informatics Officer of Intermountain; Steven Stack; and Jason Burke

The speakers were also at pains to emphasize that health IT is a broad and expanding field. “EHRs are one type of digital health or health information technology,” said Stack. “They are not health information technology.” He pointed to telehealth as another type of tool that could make a substantive difference in patients’ lives, particularly those who live in rural areas or for other reasons find it difficult to meet with their physicians.

John Halamka, CIO of Beth Israel Deaconess Medical Center, was equally enthusiastic about mobile health, explaining that middleware like Apple’s HealthKit development platform was making patient-gathered data far more accessible to providers. With an environment like HealthKit, hospital CIOs no longer have to implement one-to-one interfaces with each type of device they want to draw data from, and Apple handles many of the privacy and consent questions. Now that it’s relatively feasible for doctors to connect with their patients’ digital scales, activity monitors, or glucometers, the bigger question is how this can have a useful impact on care.

Halamka, who serves as an informal advisor to Apple, is also intrigued by the Apple Watch. Halamka’s mother, he said, takes three medications and sometimes forgets a dose. “So if she wears an Apple Watch, and the watch has taptics, it taps you and says, ‘It’s 2:00. Here’s a picture of the med you should take,’” he suggested. “And then once you take it, you tap the watch and say I’ve taken it, and you now have closed-loop medication administration records where the patient is involved in medication compliance.”

New Threats 

While Halamka was animated about new technologies that bring data collection closer to the patient, part of his keynote address took a darker turn. One of his major responsibilities as CIO is protecting Beth Israel Deaconess’ IT systems from cyberattacks, and the pace and nature of these attacks has become radically more threatening in recent years.

Halamka told the audience that his hospital network, along with several others in the Boston area, had recently encountered a dedicated denial of service attack from Anonymous, whose primary target was Boston Children’s Hospital. “As CIOs of course we all prepare our Internet borders for the usual kinds of Internet malfeasance, but distributed denial of service attacks from hacktivists wasn’t one of the things we put into our initial disaster plan,” he said. “We’re seeing organized crime, state-sponsored cyberterrorism. You wouldn’t believe the kind of strange stuff we’re seeing.”

This theme was underscored by Stephen Warren, CIO of the Department of Veterans Affairs, who revealed that his agency blocked 1.2 billion malware attempts this March alone. The data available in health centers is growing more valuable at the same time cyberattacks are growing more sophisticated. Most of the responsibility for combating attacks will fall on CIOs and their departments, but, Warren said, other members of the care system need to be aware of digital vulnerabilities. Technicians, for example, sometimes expose computerized medical devices to the Internet, all but guaranteeing they will be infected with malware.

“The majority of medical devices are XP-based. We don’t talk about it,” said Warren. “XP is an operating system that Microsoft hasn’t been supporting for a year. What we have found is, if you put an XP device on the Internet, within seven seconds it’s compromised.”

Despite the high security demands of his job, Warren was most eager to share the VA’s experience modernizing the way it works with medical records. The agency’s EHR, VistA, is widely admired as one of the most clinician-friendly systems in service, but recent efforts have focused on smoother communication with outside systems generally, and the Department of Defense specifically. (For more on interoperability in military health, see “In Defense Department’s Health IT Overhaul, a Crossroads for American Healthcare.”)

To this end, the VA has embarked on several big EHR innovations simultaneously. One insight was that the most important factor is often not whether data can be transferred between providers, but whether clinicians can view the most relevant patient data in another provider’s records. The VA has already implemented a system that allows physicians in both the VA and DoD to see each other’s records without moving the data, and is working on a wider rollout to third parties.

The agency has also committed to Blue Button, an initiative to let patients personally download their own records, which Warren admitted was “very primitive when it started.” Today, however, he says, “the scope of the data is larger and larger, and now we’re reaching the point where we’re going to add images into it… The idea is that as an institution it was not our right to withhold [patients’ data], it was our obligation to give it back.”

One project Warren mentioned, an integration with Walgreens pharmacies, also hinted at ways to expand the discussion about medical data beyond sharing between providers. “When a veteran goes into Walgreens and gets their flu shot, it shows up in the VA’s medical record,” he said. That kind of routine extension of the digital system into patients’ daily health activities could help build a much more informed, and informative, view of overall health than care centers currently access.

The Medical Informatics World Conference will meet again next year on April 4th and 5th at the Seaport World Trade Center in Boston.