Halamka: 'Get rid of Meaningful Use'

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 - John D. Halamka, MD
John D. Halamka, MD, CIO and CMIO, Beth Israel Deaconess Medical Center, Boston

BOSTON—A provocative trio of Boston-based thoughtleaders closed out AMIA’s iHealth 2015 Conference on May 29 discussing the current state of health IT.

“Expectations for a 10-15 minute doctor visit are miserably low,” said Isaac Kohane, MD, PhD, co-director of Harvard Medical School’s Center for Biomedical Informatics. He discussed how Netflix not only knows each customer’s entire ordering history but that of all individuals with similar tastes. “Furthermore, it can predict with a great deal of precision, the next movies you’re likely to order. Contrast that with the average healthcare encounter. You’re lucky if your doctor even remembers your last visit let alone all your visits.” Physicians certainly can’t remember many of the patients with a similar experience. He said patients are lucky if their doctor remembers “the correct half of his or her medical training that’s still valid.” 

To bring the Netflix experience to healthcare, “clinical leaders are going to have to care,” said Kohane. “Thousands of doctors accepted the HITECH Act without thinking too hard about what they would have to do. When things get hard, they’ll start complaining. The only party with no blame is the patient.”

Whether strep throat is going around a given geographic area is be a key piece of information to determine whether a child has the condition, said Ken Mandl, MD, MPH, chair of Harvard Medical School’s biomedical informatics and population health. But, EHRs don’t bring that information to the point of care. He was an author on a 2009 paper that reimagined EHRs to be more like iPhones because they are “tremendously powerful.”

Opening APIs and having EHRs expose these APIs allows customization for end users as well as letting innovators can get to scale, he said, citing Netflix as a great example.

This kind of intelligence is used in every other industry Mandl said. If healthcare could combine the limited data in EHRs with data from outside, whether from Twitter or other geography-based source, “the opportunities are immense,” Mandl said. “The opening up of data at the point of care is going to be very important.” An effective doctor-patient encounter will remain important but bringing in outside data to fill gaps will allow clinicians to put it all together in “new and powerful ways.”

If you believe the media reports, said John Halamka, MD, MS, CIO of Beth Israel Deaconess Medical Center, “all the vendors have chief information blocking officers.” He also said that a reading of the 21st Century Cures Act shows “there is no adult supervision left in Washington.”

Another problem facing healthcare, Halamka said, is the “crazy patchwork of privacy laws across the states” that prevents interoperability.

Change requires enablers, he said, such as economic incentives to share and consistent privacy laws. Also, unlike the federal government, the informatics community produces two-page papers that don’t require a PhD to read. “The API to Cerner, Epic and MEDITECH should be like the API of Google, Facebook and Amazon. They shouldn’t be any more complicated. Why should healthcare use complex standards different from Netflix?”

When asked how to make healthcare more efficient and lean, Halamka said, “Get rid of Meaningful Use. Give us a set of outcomes and challenge us. Give us an outcome to achieve and let us create the digital innovation to do that.”

Mandl said Meaningful Use has a structural problem in that the standards were designed by committees. Having public committees responsible for all kinds of processes almost ensures “that you cannot have the right outcome because it has to be diluted and there has to be consensus.”

He also joked that “it’s problematic for a software shop to get the requirements for their software after it’s been deployed. That’s not a very good sequence for developers.” A sense of a market and customer demand were complete left out, he said. “Clearly, the current configuration does not produce the right market for good solutions.”

The ecosystem created by the ACA has become a more powerful motivator than Meaningful Use,” said Halamka. He said the EHR as it exists today could be replaced by Facebook and Wikipedia. Care teams could share their preferences and observations and coordinate care. This proposal was rejected by federal officials but he said he was told that a shadow medical record that uses a medical Wiki and is edited, curate and signed by a physician of record and then copied and pasted into an EMR would be fine.