Military Health System Reform

Reforming the Military Health System – CNAS

Posted by timmreardon on 02/23/2015

Posted in: Data Science, EHR Interoperability, Global Standards, Health Care Costs, Health Care Economics, Health IT adoption, Health Outcomes, Healthcare Delivery, Healthcare Informatics, Innovation, Integrated Electronic Health Records, Military Health System Reform, Mobile Healthcare, National Health IT System, Patient Centered Medical Home, Patient Portals, Primary Care, Quadruple Aim, Quality Measures, U.S. Air Force Medicine, U.S. Army Medicine, U.S. Navy Medicine, Veterans Affairs. Leave a comment

Article link: http://www.cnas.org/reforming-the-military-health-system#.VOs6o8k5C03

Report link: https://healthcarereimagined.net/wp-content/uploads/2015/02/reforming-dod-healthcare_021015.pdf

By Heather Caspi | February 19, 2015 DOD EHR Choice

What’s in an EHR? As the Department of Defense prepares to select a new electronic health record system, some are advocating that it go with an open-source solution—not just to benefit of the DOD but to use the $11-billion program to benefit the healthcare industry at large.

Why it matters to the DOD

In a new report released by the Center for New American Security titled “Reforming the Military Health System,” the authors argue that the selection of a closed, proprietary system would trap the DOD into vendor lock, health data isolation and a long-term contract with technology that will age rather than evolve.

Co-author Stephen L. Ondra, a former senior advisor for health information in the White House Office of Science and Technology Policy, tells Healthcare Dive that an open-source solution could more easily adapt to meet future modernization and interoperability needs, and could more creatively be tailored to the DOD’s requirements.

Ondra says most commercial EHR systems are developed around the fee-for-service revenue cycle, a model that is not particularly relevant to the DOD and its healthcare system. He says an EHR for the DOD should be focused on the clinical care management aspect of these programs, which would require lengthy and expensive modification.

He argues that a proprietary system would be inadequate as it would leave the DOD with a single vendor’s solutions. “You don’t have some of the creativity and innovation that an open source system would have because you’re limited to a single vendor’s view and skills,” Ondra says.

In addition, he notes, proprietary systems have less incentive to provide interoperability solutions because their business model aims to lock people into using that particular system.

“I think the commercial systems are very good at what they do,” Ondra said. However, “they are not ideally designed for efficiency and enhancement of care delivery, and I think the DOD can do better with an open source system both in the near-term, and more importantly in the long-term, because of the type of innovation and creativity that can more quickly come into these systems.”

Why it matters to everyone

Whoever gets that $11-billion award is going to have a lot of money to develop EHR technology—and whether they are serving an open or closed solution will determine whether the innovations remain stovepiped from the rest of the industry, notes report author Peter L. Levin, a former chief technology officer at the Department of Veterans Affairs.

“If the DOD were to choose to go with a closed, proprietary system, it has the potential of stifling innovation in the rest of the industry,” Levin says. “If they go with an openly-architected, standard space and modular system, then really in a very simple way, they are spreading the innovation resources around.”

“Instead of concentrating it all in one place and letting that vendor own all of the innovation, they’ll be able to nourish and support the various components that comprise these complicated enterprise resource platforms in a way that will not only be beneficial to the DOD and the country in the long run, but will tremendously benefit the country and other kinds of innovations now,” Levin said.

Levin adds that the same arguments for the DOD to select an open-source EHR system apply to private healthcare systems as well. He asks consumers to imagine if they could only talk to people with same phone carrier, or only go to gas stations for their particular make of car.

He argues that private hospitals and private payers have been unwittingly supporting the continued isolation and segmentation of the commercial solutions.

“Healthcare suffers tremendously in terms of cost and outcome because of these isolated systems,” he says, “and that’s just as true for the private sector as it is for the public sector.”

Ondra adds that the DOD’s choice will set an example from which both open and closed source providers could learn.

“I think that a major government contract would send the message that the current systems, as good as they are, are not fully meeting the needs of clinical care in a way that is efficient for the provider,” he says.

“Going to an open source for the DOD gives the opportunity to have rapid development of things that are more helpful to care delivery, more efficient for the provider, because the customer then is the deliverer of care, and not the finance department of a care delivery system,” Ondra said.

Article link: http://www.healthcaredive.com/news/how-the-dods-choice-of-ehr-will-impact-providers/366180/

The Office of the National Coordinator for Health IT has released for public comment its shared nationwide roadmap for interoperability.

The roadmap’s goal is to provide steps to be taken in both the private and public sectors to create an interoperable health IT ecosystem over the next 10 years, according to ONC.

One of the main focuses on the roadmap is to enable “a majority of individuals and providers across the care continuum to send, receive, find and use a common set of electronic clinical information at the nationwide level by the end of 2017.”

In addition, the roadmap is also linked with President Barack Obama’s recently announcement Precision Medicine Initiative, which aims to increase the use of personalized information in healthcare, ONC announced.

“HHS is working to achieve a better healthcare system with healthier patients, but to do that, we need to ensure that information is available both to consumers and their doctors,” HHS Secretary Sylvia M. Burwell said in the announcement. “Great progress has been made to digitize the care experience, and now it’s time to free up this data so patients and providers can securely access their health information when and where they need it.”

Along with the roadmap, ONC also released a draft of 2015 Interoperability Advisory Standards, which “represents ONC’s assessment of the best available standards and implementation specifications for clinical health information interoperability as of December 2014.”

The roadmap is garnering praise from industry leaders, including from the College of Healthcare Information Management Executives. CHIME said in an annocement that is “welcomes” the Interoperability Standards Advisory today as part of the roadmap.

“This is a much-needed playbook for each and every health IT professional,” CHIME President and CEO Russell P. Branzell said in the announcement. “Now, healthcare providers and health IT developers have a single source of truth, with an extensible process to align clinical standards towards improved interoperability, efficiency and patient safety. While we have made great strides as a nation to improve EHR adoption, we must pivot towards true interoperability based on clear, defined and enforceable standards.”

The draft road map stems from, and is a more robust version of, a vision paper published in June by ONC. The ultimate goal of ONC in developing the road map is to build a continuous learning health system. The interoperability roadmap is also part of the ONC’s overarching Federal Health IT Strategic Plan, which spans from 2015 to 2020.

“As a draft, this roadmap needs the input from knowledgeable, engaged stakeholders and, in particular, areas where important actions or milestones may be missing,” according to ONC.

To learn more:
– here’s the roadmap (.pdf)
– check out the Interoperability Advisory Standards (.pdf)
– read the announcement

Article link: http://www.fiercehealthit.com/story/onc-unveils-interoperability-roadmap-public-comment/2015-01-30?spMailingID=11587394&spUserID=Mjg0MDEwMzE2MzkS1&spJobID=424244809&spReportId=NDI0MjQ0ODA5S0

Compiled by Neil Versel, Contributing Writer

While health providers praise the ONC’s interoperability vision, they’re demanding increased standardization and an accelerated roadmap to achieve the Triple Aim.

Interoperability was supposed to be a centerpiece of Stage 2 of the Meaningful Use (MU) EHR incentive program, but hospitals and physicians practices nationwide are finding out just how hard it is to achieve that goal. Through the end of August, a mere 25 hospitals and 1,277 eligible professionals had attested to Stage 2 on the Medicare side of the program, according to CMS.

A KLAS Enterprises report, released in October, found that although 82 percent of the 220 providers interviewed thought that they were at least “moderately successful” with interoperability, a mere 6 percent said they were at an “advanced” level. And just 20 percent were “optimistic” about health IT vendors’ efforts to collaborate on interoperability.

In the same week, the Office of the National Coordinator for Health Information Technology submitted its annual report to Congress, highlighting some of the problems. “Electronic health information is not yet sufficiently standardized to allow seamless interoperability, as it is still inconsistently expressed through technical and medical vocabulary, structure, and format, thereby limiting the potential uses of the information to improve health and care,” the report said.

Days later, ONC released an update of its proposed 10-year roadmap to interoperability, a document that will be finalized in 2015. Like the earlier draft, this version put interoperability front and center on the office’s three-year agenda, while harnessing this information to improve care and lower cost was part of the sixyear plan. This effectively pushes a main goal of Stage 2 into the third stage of MU, which will not start before 2017, and suggests that the bulk of the nation’s healthcare providers won’t achieve the “Triple Aim” until after the incentive money is gone.

Building Interoperability Around APIs

ONC’s Health IT Policy Committee and Health IT Standards Committee also approved recommendations from a task force of an independent scientific advisory group known as JASON (not an acronym, but a reference to a character in Greek mythology) to build interoperability around application programming interfaces (APIs). Together, the moves have gotten mixed reviews.

“Credit to ONC for the vision,” said Russell Branzell, CEO of the College of Healthcare Information Management Executives (CHIME). “We just need to find a way to do it faster than a 10-year plan.”

Branzell wondered how hospitals are supposed to balance the longer-term vision for interoperability with an MU timeline that penalizes noncompliant providers starting in 2015. “There still are some pieces fundamentally missing,” Branzell said.

He believes there should be “clearly enforceable standards” for patient matching, as well as “specific data standards that are enforceable down to the nomenclature number.” Not having standards — standards that are kept current — adds to the complexity of health information exchange by offering too many choices that are not always compatible with each other, according to Branzell.

The CHIME chief continued, calling patient matching “the cornerstone of not only effective patient exchange but also patient safety.” He would like at least a standardized patient matching requirement, if not a national patient identifier; a national ID has been politically taboo since at least 1998, even though the original 1996 HIPAA statute called for one.

Branzell praised the API strategy, while also indicating he was a proponent of the Fast Healthcare Interoperability Resources (FHIR) standard for data exchange, something created by Health Level 7 International. (Branzell is a member of the HL7 advisory board.)

The API idea is proving popular at the policy level. At a Washington, D.C. healthcare conference put on by U.S. News & World Report in October, Micky Tripathi, founding president and CEO of the Massachusetts eHealth Collaborative; Jennifer Covich Bordenick, CEO of eHealth Initiative; and Steven Posnack, director of ONC’s Office of Standards and Technology, all spoke in favor of greater availability of APIs in healthcare. After all, it has become common for facilitating interoperability in so many other industries.

“Kendall Square [in Cambridge, MA] and Silicon Valley are laughing at us,” said Tripathi.

Tripathi mentioned other interoperability vehicles, including secure messaging following Direct Project protocols, point-to-point query and retrieve — usually by organizations using the same EHR vendor — and record aggregation with data normalization. Central repositories, he said, “are the dinosaurs that are going to go away.”

Later, at the same event, then-National Health IT Coordinator Dr. Karen DeSalvo, said that EHRs would have limited impact on the quality of care in the absence of greater interoperability.

In the real world of healthcare, providers are getting creative, though some still want more clarity from Washington or from the health IT industry. Gulfport (MS) Memorial Hospital replaced its legacy EHR with a Cerner system that went live in June. Three months later, CIO Gene Thomas said that his most difficult task was migrating data to Cerner.

“This could have been avoided if all vendors had been told to adhere to the same formats,” Thomas said. “The lack of standards in healthcare is a problem.”

Addressing HIE Via Common Vendor Platforms Memorial Health System in Springfield, IL approached interoperability in what CIO Dr. David Graham called a “reverse way,” with private practices bringing data to the organization’s primary care group. Like so many other providers, Memorial is building a health information exchange among nearby organizations that have a common vendor, in this case, Allscripts Healthcare Solutions.

Memorial has been rolling out the Allscripts TouchWorks EHR at its own clinics this year and is installing an Allscripts interoperability platform called FollowMyHealth. The precursor of FollowMyHealth, called Jardogs, was incubated at the Springfield Clinic, a partner of Memorial Health System, prior to Allscripts acquiring the technology in early 2013.

Another partner, the Southern Illinois University School of Medicine, also is transitioning to TouchWorks for ambulatory clinics, Graham said. “We are competing practices using the same database and the same instance of TouchWorks,” he said.

Memorial also collaborates with a federally qualified health center (FQHC). When that safety-net facility refers patients to the Springfield Clinic or the SIU School of Medicine, information from a NextGen Healthcare Information Systems EHR flows into a common portal that care managers can access to reach out to high-risk patients, Graham said.

“The other benefit of it is that then you can put that data in front of the physician,” Graham said.

It’s not full interoperability, but it’s a start.

Adding Mobility To The Interoperability Equation

A much larger healthcare system, San Francisco-based Dignity Health, has made interoperability a major component of a massive IT program. Dignity Health, formerly known as Catholic Healthcare West, was the launch customer for AirStrip One, a product from San Antonio-based AirStrip Technologies that delivers data from EHRs, patient monitors, and medical devices to clinicians on their mobile phones and tablets. Dignity also made an unspecified investment in AirStrip in August.

“We’re fairly early with AirStrip One,” said Dr. Davin Lundquist, Dignity’s CMIO for population health. In the fourth quarter of 2014, the multistate health system was implementing the product in the Central Coast region of California. “In parallel with this, we are exploring care management, video visits, and other ways to engage patients,” Lundquist said. “You need to come at it from lots of angles.”

AirStrip OB, an obstetrics module, is in nearly every one of Dignity Health’s hospitals, and the health system also has begun using AirStrip’s cardiology product. “What we are envisioning is that we will get AirStrip in the hands of all of our physicians,” said Lundquist, a family physician in Camarillo, CA, who practices about one day a week. He expects to have secure clinician messaging within the apps as well.

There are a lot of physicians to reach. Dignity Health has approximately 1,200 employed physicians and 2,000 to 3,000 “clinically integrated” aligned physicians among its total medical staff of more than 10,000, according to Lundquist. “Our health system, like many others, relies on independent physicians to support our work,” he said.

Meanwhile, Dignity is about two-thirds of the way through migrating its hospitals to a Cerner EHR from an older system. Dignity Health Medical Foundation in California and several practices in the Phoenix area all run an Allscripts EHR, though Lundquist said there is “some variability” among those Allscripts installations.

Dignity has built a private health information exchange on the MobileMD platform, technology that Siemens bought in 2011 and now is in the process of selling to Cerner as part of the latter’s $1.3 billion acquisition of Siemens’ health IT business. More than 7,000 physicians across all of Dignity’s markets are connected, according to Lundquist. “In most cases, that allows them to access hospital information,” he said.

However, most of the data flow is one-way, though some employed physicians do have bidirectional exchange with Dignity Health hospitals. According to Lundquist, this is more a legal issue than a technical one. “Who owns it? Does it become part of the [patient’s] legal record? Do you become an HIO?” he wonders.

Dignity Health’s system connects with many national, standard HIE connections and exchanges data with the UC-Davis Medical Center and, according to Lundquist, is exploring a relationship with UC-San Francisco. He expects Dignity to participate in some fashion in California’s statewide HIE known as the California Integrated Data Exchange, or Cal INDEX.

Physicians seem to welcome the efforts, as long as HIE fits workflow and makes practitioners more efficient. “I haven’t seen any resistance from physicians when we give them data,” Lundquist said.

Eventually, he would like to push alerts to clinicians to encourage early interventions with high-risk patients. “There needs to be a benefit to the doctor and the patient for them to do something outside their traditional workflow,” Lundquist said.

“Obviously, it’s important to integrate as much clinical data as possible,” said Lundquist, who reports to both the CIO and to physician integration team leaders. That is easier with employed doctors than with independent physicians, who have all sorts of EHRs at various levels of implementation and sophistication. “Some small vendors don’t even have strong CCD outputs yet,” Lundquist said, referring to the Continuity of Care Document format required in Meaningful Use Stage 1. (Stage 2 replaces CCD with an HL7 standard called the Consolidated Clinical Document Architecture.)

The Best Is Yet To Come

Stage 1, which about 90 percent of hospitals and 70 percent of individual clinicians in the U.S. have met, was about getting EHRs in place. With that in mind, CHIME’s Branzell is optimistic. “We have a lot of exchange going on in a lot of places that wasn’t there 4 to 5 years ago,” he said.

“We’re building a house. We’ve got a beautiful foundation now,” Branzell said. “But you can’t live in a foundation.” Right now, the nation’s healthcare organizations are “just starting to put up the walls,” he added.

“Huge gains in efficiency and safety were not supposed to come until post-Stage 3,” Branzell said. That will be in about 2020, or the sixth year of ONC’s new 10-year vision. “It’s not all doom and gloom,” Branzell said.

Article link: http://www.healthitoutcomes.com/doc/the-ongoing-health-it-interoperability-struggle-0001?sectionCode=Articles&templateCode=Single&user=2423280&source=nl:42136&utm_source=et_6231164&utm_medium=email&utm_campaign=HCIT_2015-01-15&utm_term=0009EE33-ABCE-4D02-9B3C-4F32FFAA82BE&utm_content=The%2bOngoing%2bHealth%2bIT%2bInteroperability%2bStruggle

by Margalit Gur-Arie 12/15/2014

The distinguished JASON group of anonymous scientists and academics that provides consulting services to the U.S. government on matters of defense science and technology, just published a sequel to the 2013 best seller, “A Robust Health Data Infrastructure”. The new report is titled “Data for Individual Health”, and it has two purposes. The first and foremost purpose is to backtrack on the searing criticism leveled at government efforts to promote health information technology, which evoked much angst and indignation earlier this year. The second purpose is to expound upon the exact nature of personal data required to feed the robust infrastructure laid out in the first JASON report, complete with illustrations and examples of breakthrough benefits to humanity, such as helping city planners design bicycle paths. Yes, bicycle paths. And if you didn’t know that the number one health care problem in this country is the layout of bicycle paths, then you are a Luddite, and luckily your generation will soon be dead.

After dutifully observing that only a tiny percentage of Americans use medical services of any kind, JASON is informing us that the government agencies that funded its work “specifically” asked the group “to address how to bridge, on the national scale, to a system focused on health of individuals rather than care of individuals” [italics in the original]. It seems that the overdetermined triple aim of health care reform, better health for populations, better care for individuals, at lower per capita costs, is finally being reformulated into a solvable optimization problem by removing the unprofitable constraints on caring for the sick.

As was the case with the previous JASON report, the group was briefed by a diverse array of researchers and technology experts, including the great new hope of health, our most beloved, innovative, tax evading, and slave labor supported, Apple Inc. The content of briefing sessions is not available to mere mortals, but one in particular is rather enlightening in its title: “Disrupting the Status Quo: Putting Healthy People First”. Never since the dawn of medicine, from Hippocrates, to Florence Nightingale, to Mother Teresa and today’s Doctors Without Borders, have we experienced greater disruption in the status quo.

Similar to the first JASON report, the second offering is chockfull of technical recommendations for the “collection, assimilation, and exchange” of quantifiable “data streams” emanating from living things, whether in traditional medical surroundings or as people go about living their healthy lives. There is nothing earth shattering in the JASON findings or recommendations, but some finer points may be worth mentioning anyway.

Phenotypes – After providing us with a crash course in genomic sequencing and the workings of RNA and other protein molecules in the first report, JASON argued that the “biomedical research community will be a major consumer of data from an interoperable health data infrastructure”, hence the government “should solicit input from the biomedical research community to ensure that the health data infrastructure meets the needs of researchers”. In the second installment, JASON is reiterating its obviously very strong interest in genotype-phenotype relationships and their assimilation into the IT system they are recommending we build. Luckily, some of the JASON briefers happened to hail from academic centers renowned for grant funded genomic research in general, and efforts to “develop algorithms and methods to convert EHR data into meaningful phenotypes” in particular.

In Vivo – I have to admit that compared to run of the mill interoperability papers, which deal with unconscious patients in the ER, or people irritated by having to fill out paper forms, the JASON report is much more interesting. Here is another supercool futuristic development that we absolutely must consider when creating an IT infrastructure to collect data for health related research, which is essentially the main concern of the JASON group. It seems that the Defense Advanced Research Projects Agency (DARPA) is working on in vivo nanoplatforms. Something about “ultra-small scaffolds inserted directly into the body” and “fluorescent nanospheres that are functionalized to detect biomarkers of interest”. The purpose seems to be “continuous physiological monitoring for the warfighter”. We do of course want to support our troops, so these cute little nanites must also be part of our robust health data infrastructure.

FHIR – In this report JASON is taking an unequivocal stand behind a new HL7 standard for clinical information exchange, the Fast Healthcare Interoperability Resources (FHIR), which is actually pretty neat, and has been in development for approximately three years. FHIR is envisioned as a replacement for the C-CDA, which replaced the CCD, which replaced the CCR, which replaced an array of HL7 2.x messages. JASON is recommending that government “policies should make it advantageous for one or more leading EHR vendors to be the first to propose such standards”. Lo and behold, two days after the JASON report was published, a group of leading vendors and institutions, several of which briefed JASON, and some who are helping the government implement JASON’s recommendation, launched the Argonaut Project for precisely this “advantageous” purpose.

FDA – For some reason the JASON report is engaging in a lengthy and strangely passionate litigation of the 23andMe (a DNA analysis service) tiff with the Food and Drug Administration (FDA) from a year or so ago, concluding with a recommendation that the FDA should take a “more nuanced approach” to its regulation of apps that could be construed as “practicing medicine”. The FDA regulatory authority over medical software has been in the crosshairs of corporate lobbyists (tech, pharma, telecom, etc.) for a couple of years now, with a variety of bipartisan deregulation bills introduced, or almost introduced, unsuccessfully in Congress. Coincidentally, two days after the publication of the JASON report, Senators Bennet (D-CO) and Hatch (R-UT) introduced the MEDTECH Act, the most serious attempt so far to restrain the FDA’s regulatory abilities.

Non-profits – JASON is recommending that non-profit organizations, either those that are disease specific or general in nature, “should be encouraged to assess their goals with respect to health data streams, and to provide “stamps of approval” for applications (apps) and other consumer tools”. In other words non-profit organizations should leverage the trust of their communities to monetize their members’ health data. JASON also recommends that private foundations should help the government by creating cash prizes to entice entire communities into participation in data wellness games. This is brilliant thinking, which leads me to hypothesize that at least one of the JASON members must be a Nobel laureate in marketing.

In this era of “transparency”, where every dollar from every pharmaceutical company or government agency, paid to every doctor and hospital, comes under relentless public scrutiny, why should JASON be exempt? Shouldn’t the JASON reports be accompanied by full disclosures of conflict of interest, both for JASON members and the various briefers whose pet projects populate every page of every report? Where is the media when a group of secretive researchers and private corporations are steering almost 20% of our economy towards endeavors immediately beneficial first and foremost to themselves?

When you read the JASON reports back to back, you are left with the impression that the group’s overarching goal is to create an international distributed repository of genetic materials tied to individual, environmental, behavioral and disease specific manifestations for all people on this planet. There is no doubt in my mind that a structure of this type and magnitude can facilitate an infinite number of perhaps beneficial research projects, and maybe even an IPO here and there. But if taxpayers are expected to fund the infrastructure for such expansive research, shouldn’t they be asked, or at the very least clearly informed?

And why rob the President of the United States of a legacy-defining “We choose to go to the moon” speech? It could go something like this: My fellow Americans, by 2025 every American will have his or her DNA collected and catalogued, and by 2025 every movement and every breath of every American man woman and child will be associated with their genomic sample, launching the grandest experiment in the history of mankind. From the ashes of the Great American Experiment, we will bring you more than freedom, more than liberty and more than a futile pursuit of happiness. We will bring you, Health. Download it for free from iTunes today.

In 1802, Thomas Jefferson wrote in a letter to David Hall: “We have no interests nor passions different from those of our fellow citizens. We have the same object: the success of representative government. Nor are we acting for ourselves alone, but for the whole human race. The event of our experiment is to show whether man can be trusted with self-government. The eyes of suffering humanity are fixed on us with anxiety as their only hope, and on such a theatre, for such a cause, we must suppress all smaller passions and local considerations.” Whatever.

Article link: http://hitconsultant.net/2014/12/15/jason-report-the-great-american-experiment/

12/1/2014
By: Health.mil Staff

We just completed a remarkable first year in the Defense Health Agency.

In December, you will all be receiving our first Annual Report on what we have accomplished, and where we are headed in 2015. But let me give you a preview of what I consider the principal takeaways from our first year.

Unity of Effort is critical. Our successes in year 1 are directly attributable to your ability to bring people together on behalf of our broader purpose in military medicine. We put a new system of decision-making for the Military Health System (MHS) in place. And it ensured engagement at every level – the Office of the Secretary of Defense, the service secretaries, the Joint Chiefs, the service Surgeons General and all of their staffs. To some, the MHSER, the SMMAC, the MDAG, the MOG, BOG, and MPOG are an alphabet soup of bureaucracy. But not to me, and hopefully not to you. These committees are the machinery that allows us to tee up, vet and make sound decisions on the future of this vital system of care. Together.

The business of building consensus is not easy – but the payoffs are enormous. And, so for the many initiatives that we introduced this year, we succeeded when the hard work of building trust, ensuring transparency and skillful execution were sustained.

And the inverse is also true, when unity of effort was lacking, when the processes became slow or bogged down – sometimes on substantive policy issues, sometimes on minutiae, and sometimes on simple misunderstanding – we fell short of our goals. But, if we had nothing but successes this year, I think it would be a sign that we were not challenging ourselves enough. Perseverance matters. We will pick it up in 2015.

Success is not only measured in dollars saved. I am as pleased as anyone that we saved $250 million in 2014, which was $250 million more than we projected! This was supposed to be a building year, creating the infrastructure and hiring staff. But through aggressive action by leaders at all levels, we also provided the department and the taxpayer with a return on investment. Yet, equally important to saving dollars is the long-term work of creating common clinical and business processes.

Let me give you one example of an area where no money has yet been saved, but tremendous progress has been made: creating a common cost accounting structure for the MHS. This has been “behind the scenes” work by an often unheralded team of budget and financial management experts. They are positioning the MHS for the long-game.

In the coming years, we will look back at the work of 2014 – across all of our domains – and we will recognize this was the beginning of a process that genuinely allows us to compare performance in a meaningful way across the system of care. Not just counting dollars and cents, but utilization, outcomes, quality, safety and access to care. Not every success has a price tag on it, but they are all valued.

2014 was a down payment on a bigger promise. It has been a transformational year. At the same time that we stood up the DHA, which required a tremendous amount of energy and intellect in its own right, we have also played an indispensable role in the Secretary of Defense’s “Review of the Military Health System” and in implementing the action plan that followed it. We have an important role to play – in creating, maintaining and communicating a Performance Management System as well as a broad mandate for ensuring greater transparency to the public.

Now, add in the deployment of thousands of service members to West Africa in support of the larger federal response to the Ebola outbreak, along with the deployment of service members to Iraq to confront the threats from ISIS, and you have a sense of why having a “Medically Ready Force…Ready Medical Force” is more than a mere slogan; it is a perpetual promise in our combat support agency role.

In such a world, our customers – the services and the combatant commanders – need a system that ensures their medical logistics needs are met. They need medical facilities that are designed, built and sustained for 21st century medicine. They need a pharmacy system that can deliver vaccines, therapeutics and other medicines that prevent disease when possible, and treat disease when needed, which is often immediately. They need a health system in which private sector providers complement our direct care system and reach every corner of the globe where our service members and families live and work. They expect the care that we provide in Afghanistan, Iraq, Liberia, South Korea or the South Pacific to be captured, shared and available worldwide to our medical teams through a functioning Electronic Health Record. They need a global public health system that monitors the environment and disease threats anywhere in the word. They demand a medical research and development system that never stops the search for better ways of addressing the myriad of threats and disease and injuries we face in this unique line of business. They need us to educate and train thousands of new recruits and experienced professionals. They need a procurement system that can respond in a timely manner with high quality products and services. And they need us to properly budget, oversee and account for all of these things. And they need leading, joint institutions for health care delivery – and they are right here in the National Capital Region.

And they need the DHA.

And we have a deep moral and personal obligation to ensure that their needs are met.

I know that many of you were double and triple-tasked to manage the avalanche of requests for policy reviews, data calls, and briefings. But it all had a purpose. In Dr. Woodson’s words, we are building a better, stronger, more relevant MHS. I can see the concepts that were just words a year ago beginning to take root. This has been an extraordinary year of progress. And, yet, our work has just begun. So, let’s keep our sleeves rolled-up and let’s keep our unity of effort focus … we’re burning daylight as we speak!

Article link: http://www.health.mil/News/Articles/2014/12/01/Robb-Leadership-Message

By Frank Konkel

December 15, 2014

IBM’s Watson technology – first made famous in 2011 after besting human competitors on the television game show “Jeopardy” – is now turning its computing power toward improving veterans’ health care.

The Department of Veterans Affairs announced today a two-year pilot program with the company worth $6.8 million, signaling the agency’s intent to assess innovative and emerging technologies that could benefit the 8.3 million veterans requiring care each year.

IBM’s Watson technology “will ingest hundreds of thousands of Veterans Health Administration documents, medical records and research papers” and distill information and knowledge to clinicians in near real-time, according to IBM.

During the pilot, Watson will base clinical decisions on realistic simulations of patient encounters – not on actual patient encounters – providing a test-bed for how computers might handle patient care decisions.

“Physicians can save valuable time finding the right information needed to care for their patients with this sophisticated and advanced technology,” said Carolyn M. Clancy, VA’s interim undersecretary for health, in a statement. “A tool that can help a clinician quickly collect, combine and present information will allow them to spend more time listening and interacting with the veteran.”

IBM will support VA care providers in one of the agency’s data centers located in Austin, Texas.

If the pilot program is successful, it could show how cognitive computing systems can distill complex data sets — such as electronic health records, which are made up of large sets of both structured and unstructured data — into useful information.

The Defense Department recently accepted bids for a revamped version of its electronic health records system contract that could eclipse $11 billion in value. IBM is one of the bidders on that contract, and while the contract language doesn’t require cognitive computing capabilities, a Watson-like capability would be something IBM could integrate into its platform should it win the award.

“IBM designed Watson to help solve some of the world’s greatest challenges, and I’m humbled to be working with VA in helping them, including enhancing treatment efforts for PTSD,” said Anne Altman, general manager for IBM’s federal practice.

By Frank Konkel

December 15, 2014

http://www.nextgov.com/health/health-it/2014/12/va-wants-ibm-watson-come-ways-improve-veteran-care/101316/

Monday, December 8, 2014

Integrating unique device identifiers into electronic health record systems could improve medical device safety and make recall efforts easier, according to a Brookings Institution report released Friday, Politico’s “Morning eHealth” reports (Gold, “Morning eHealth,” Politico, 12/8).

Background

In July 2012, FDA released a proposed rule to create a UDI system to track medical devices. Such a system would allow FDA officials to electronically track medical tools and promptly recall any devices that could jeopardize patient safety.

FDA in September 2012 issued a report that outlined the agency’s approach to improving its post-market surveillance system for medical devices, including the creation of a UDI system (iHealthBeat, 9/3).

Details of Report

The report aims to advise providers on how to adopt and integrate UDIs to improve patient safety, research and analytics, according to EHR Intelligence.

Specifically, the report outlines key steps to integrating UDIs into:
•Provider systems;
•Administrative transactions; and
•Patient-directed tools.

The report focuses on high-risk devices, but the authors note that all medical devices affecting patient care can benefit from tracking UDIs.

The report states, “Recording UDIs at the point of care in EHRs and in claims data could significantly enhance the nation’s ability to conduct medical device safety surveillance and manage recalls.”

In addition, the authors write that using UDIs could help to:
•Determine devices’ long-term quality and performance;
•Efficiently identify and communicate device safety concerns;
•Improve reimbursement transparency;
•Make supply chain processes more efficient and accurate; and
•Streamline premarket device approval.

Recommendations

In the report, the authors recommend:
•Conducting studies to showcase the benefits of UDI use;
•Including UDIs in claims details for high-risk, implantable devices;
•Incorporating UDIs into EHR systems and personal health records;
•Increasing outreach about UDIs through collaborations between advocacy groups, FDA and providers; and
•Using UDIs across supply chain, clinical and revenue cycle processes to obtain the highest return on investment.

The authors also recommend including UDIs in Stage 3 requirements of the meaningful use program. Under the 2009 economic stimulus package, health care providers who demonstrate meaningful use of certified EHRs can qualify for Medicaid and Medicare incentive payments (Bresnick, EHR Intelligence, 12/5).

Article link: http://www.ihealthbeat.org/articles/2014/12/8/report-providers-should-integrate-unique-device-identifiers-into-ehrs

by Bob Kocher, MD and Bryan Roberts

December 8, 2014

A flood of new health care IT companies has been pouring into the U.S. health care market. The cause of this torrent: the recognition that as market and regulatory forces alter incentives in health care, IT companies will play a powerful role in combating the overemployment and declining productivity that has plagued this industry and in helping providers improve the quality of care.

The dam broke in September 2007, when Athenahealth went public, the price of its shares jumping by 97% on the first day. Since then, the company’s value has risen to $5 billion. Athenahealth proved to entrepreneurs, software engineers, and investors that the health care sector is fertile ground for creating large technology-services companies that use a subscription-based business model to offer software as a service (SaaS).

Despite its size and growth rate, the health care sector was long considered an impenetrable, or at least an unattractive, target for IT innovation — the entrepreneurial equivalent of Siberia. Athenahealth broke the ice by proving that it could sell SaaS efficiently to small physician businesses, get doctors to accept off-premises software, and achieve the ratios of customer-acquisition costs to long-term value that other sectors already enjoy.

As Athenahealth accomplished its goals, several larger forces have dramatically widened the scope of opportunity in the sector:
•The Great Recession led to a loss of 8.8 million U.S. jobs and big declines in demand throughout the economy (including health care services) — yet health care employment grew by 7.2%. That reality increased awareness that a decline in labor productivity was driving much of the excessive spending in health care.
•The American Recovery and Reinvestment Act of 2009 included the Health Information Technology for Economic and Clinical Health (HITECH) Act, a $25.9 billion program to give doctors and hospitals incentives to adopt electronic health records. EHR adoption has now grown to nearly 80% of office-based physicians and 60% of hospitals, fueling many successful software start-ups, such as ZocDoc, Health Catalyst, and Practice Fusion.
•The Affordable Care Act (ACA) requires that an enormous amount of data on cost and quality be made freely available. In addition, digital health applications, mobile phones, and wearable sensors, as well as breakthroughs in genomics, are creating truly big data sets in health care. These data contribute to greater market efficiency, more consumer-oriented products and services, and clinical care that is evidence-based and personalized.
•The ACA has led to a proliferation of risk-based (rather than fee-for-service) payment models. For example, providers in accountable care organizations are rewarded for generating annual savings, and providers who use bundled payments get a fixed budget for an end-to-end course of treatment. Effectively responding to these changing economic incentives will increase reliance on software that helps providers manage population risk, understand costs and trends, and engage patients.

These macro-level developments set the stage for other SaaS companies to follow Athenahealth’s lead in enormously improving labor productivity and quality of care.

Within the next decade, software tools will eliminate thousands, perhaps millions, of jobs in hospitals, insurance companies, insurance brokerages, and human resources departments. Not the jobs of people who actually provide care — but those of administrative middlemen, whose dead weight contributes to economic loss. Here are five examples:

1.Digital insurance markets, combined with ACA-enacted regulatory changes such as guaranteed issue and community rating, make it possible to price and sell health plans to anyone immediately. These developments will decimate the armies of brokers who act as intermediaries between customers and insurance services.

2.Price transparency, digital insurance products, and tools such as reference pricing make it possible to generate an exact price and instantly collect payment for a health care service. As a result, revenue cycle managers in hospitals and claims adjudicators in insurance companies will be displaced.

3.The inevitable shift to the cloud will render obsolete the costly, insecure data centers that most doctors and hospitals are now building, staffing, and running.

4.Adopting self-serve mobile applications will eliminate the forms, faxes, and excess staffing at many call centers, thereby improving satisfaction for everyone in the process.

5.Centralized clearinghouses that share information across organizations and state lines will eventually replace the byzantine, paper-based process of credentialing doctors, tracking continuing medical education, and keeping licenses up-to-date. That means smaller staffs in hospitals’ medical affairs divisions, health plans, medical boards, and state and local health departments.

Given that wages account for 56% of all health care spending, improvements in labor productivity could generate enormous value. Simply reducing administrative costs could yield an estimated $250 billion in savings per year.

As compelling as the prospective labor efficiencies are, the benefits of SaaS extend beyond direct labor costs. Easier access to data on physician quality, specialization, and adherence to evidence-based care will better match patients with doctors who provide high-quality, efficient services, thereby averting health complications for their patients. Moreover, software can help bring relevant clinical guidelines and personalized risk scores to patients and clinicians as they improve care plans, engage in shared decision making, and avoid duplicative services. Such efficiencies will, in turn, enhance how patients perceive and experience the care they receive. SaaS companies can trumpet all of these advantages, not just the employment savings they yield.

To seize on the new opportunities in the health care sector, SaaS companies can take these steps:
•Attack economic inefficiencies in order to generate immediate, tangible customer return on investment. Witness how Castlight Health’s transparency tools are generating annual savings for employers and employees. And be clear about the source of the ROI, given that in most cases the revenue comes from another health care stakeholder who may be able to undermine the business.
•Focus on building in network effects so that improvements made by one user enhance the product’s value for current and future users, just as Athenahealth does when it rapidly disseminates changes in payment rules at one provider to all other providers. Most SaaS businesses in health care IT cannot protect their intellectual property; so it is important to continually augment the value of the product to achieve scale.
•Use software-enabled service models, rather than pure SaaS. For example, Grand Rounds’ software not only recommends an expert doctor for a patient but also collects, organizes, digitizes, and summarizes the patient’s records — and then books the appointment for the patient. In effect, the software makes it easier for patients to adhere to high-quality, cost-effective care, thereby enhancing the overall ROI for the product.

It took Athenahealth a decade, from 1997 to 2007, to go public on the strength of its SaaS model. It took Castlight Health only six years, from 2008 to 2014, to do the same. Now an array of highly valued healthcare SaaS companies, each worth more than $100 million, is emerging. They include Zenefits, Grand Rounds, Doctor on Demand, Omada Health, Health Catalyst, Doximity, and Evolent Health. Indeed, Zenefits is one of the fastest-growing SaaS companies ever, regardless of industry, surpassing $500 million in enterprise value in its first year.

The success of SaaS companies in health care is thanks, in part, to an influx of leaders from other sectors. They bring with them teams of technical talent that deliver consumer and enterprise software faster, better, and more cheaply than many legacy health care IT companies can do. Witness ZocDoc, founded by first-time entrepreneurs from McKinsey; Grand Rounds, founded by Owen Tripp, who cofounded Reputation.com; Zenefits, founded by Parker Conrad, who cofounded SigFig; and Doctor on Demand, founded by Adam Jackson, who cofounded Driverside (just to name a few). This type of cross-pollination is an essential ingredient of innovative change.

The barriers between health care IT companies and IT in other industries are clearly coming down, and we expect the number of sector disruptions and billion-dollar companies to swell. As each innovation wave generates more data, disruption-cycle times will shorten, thereby forcing all players in the health care ecosystem to address inefficiency as they compete on quality and value creation. Those who fail to act will be washed away by the tide that lifts all other boats to greater productivity.

Article link: https://hbr.org/2014/12/why-so-many-tech-companies-are-getting-into-health-care?utm_campaign=Socialflow&utm_source=Socialflow&utm_medium=Tweet

November 13, 2014 | By Dan Bowman

Interoperability and Meaningful Use efforts need to be aligned with other healthcare regulatory and industry initiatives, according to the eHealth Initiative, which on Thursday unveiled its 2020 roadmap for transforming health IT.

The roadmap, which eHealth Initiative CEO Jennfier Covich Bordenick calls “a framework for discussion about core technology issues,” includes priorities for three areas: business and clinical motivators, interoperability and data access and use. In particular, she says, the private sector’s role must grow in order for health IT to move forward.

“We are heading into a world where healthcare data needs to be exchanged, shared and analyzed, not simply pushed from place to place,” Bordenick says in the document. “Similarly, we are developing a 2020 roadmap that requires sharing, analysis and above all, collaboration.”

Compared to the Office of the National Coordinator for Health IT’s interoperability roadmap, which will be available for public comment in January, the eHealth Initiative calls its plan “much broader,” but acknowledges that there is overlap between the two efforts to ensure synchronicity.

The roadmap specifically calls for an extension of time between Stages 2 and 3 of the Meaningful Use program, and also says that compliance with ICD-10 by next October is mandatory. The adoption of standards and open architecture also is encouraged for interoperability to evolve, as is the adoption of “approaches reflecting cross-industry IT trends” such as REST and FHIR.

Additionally, the roadmap says that Meaningful Use, despite its importance, is not a “sufficient lever” to ensure interoperability throughout healthcare.

A survey published in September from Premier and the eHealth Initiative concluded that poor interoperability is a significant barrier for accountable care organization success.

“We envision a high-performing healthcare system centered around the patient, where all those engaged in patient care are linked together in a secure and interoperable environment,” the roadmap says.

The roadmap also looks to kick-start conversations about how to solve several privacy and security challenges in healthcare today, including data security, appropriate data sharing, granular data control, data provenance and data matching.

To learn more:
– read the roadmap (.pdf)

Article link: http://www.fiercehealthit.com/story/ehealth-initiative-roadmap-calls-alignment-hit-regulatory-efforts/2014-11-13?utm_medium=nl&utm_source=internal

healthcarereimagined

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ONC unveils Interoperability Roadmap for public comment – Fierce Health IT

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Message from Lt. Gen. (Dr.) Douglas J. Robb – A Year in Military Health – Health.mil

VA Turns to IBM Watson to Improve Veteran Care – Nextgov

Report: Providers Should Integrate Unique Device Identifiers Into EHRs – iHealthBeat

Why So Many New Tech Companies Are Getting into Health Care – HBR

eHealth Initiative roadmap calls for alignment of HIT regulatory efforts – FierceHealthIT

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