Our world is shrinking, and yet it is becoming increasingly more complex. Therefore I generally assume—perhaps inappropriately—that those of us in healthcare leadership positions practice systems thinking and understand the influence of industry and organizational culture on large-scale change.
CHIME Time: Making it all come together
The federal government's Decade of Health Information Technology, now presenting in the form of the American Recovery and Reinvestment Act's HITECH provisions and related state-level regulation, is a perfect example of wholesale change that requires a lot of things to come together to form "the miracle." Now more than ever, meaningful adoption of electronic health records and their derivative data exchange systems will require that we effectively assimilate and interpret the interrelationships between quality and patient-safety reporting; present information in useful or at least tolerable workflows; provide patient-care decision and delivery processes; and enable technology components.
If we are to be successful in achieving meaningful adoption of EHRs, many things must cooperate. Better said, many people must cooperate to ensure that we can make technology interrelate. As a chief information officer, I usually write on behalf of provider organizations in matters related to technology. This time, I am writing as someone who wants to see our industry be successful for the good of our healthcare-related missions. I'm concerned about the ability of the broader constituency to fully cooperate, so that meaningful use of EHRs can become a reality. To that end, I see four areas in which breakthroughs in systems thinking and interorganizational collaboration are essential.
First, quality measures, medical vocabulary content and technology standards must align; if not, then HITECH is more of the same old stuff. Unfortunately, many folks do not understand these relationships, and our best explanations come across as too technical or, worse yet, “dense.” Bringing these elements together is a sort of holy grail for healthcare. Without medical content standards, information reads as “what you see is what you get” to clinicians, presented in all sorts of various formats and with information that is unique to each provider organization's clinical language. “Semantic interoperability translators” (Yes, I said technical or dense) are one solution to this problem, even though this approach represents an additional layer that is resource-intensive to build and maintain.
Exporting, importing and presenting clinical data depends on vendors agreeing to universal standards—especially when data is moving across disparate EHRs without a costly middle-layer infrastructure. Even for the most simple of EHR-to-EHR exchanges (see directproject.org), such as closed-loop movement of a referral request to a subspecialist physician with the timely return of the episode's summary care, teamwork is necessary. These technical standards have been in the making for some time, and several of the big EHR vendors are collaborating on pilot use demonstrations. We need promulgation of standards and commitments to design products to take advantage of the same, always with concern for physician usability.
Second, EHR and health information exchange vendors need time to react to newly published meaningful-use requirements because of the differences in how these systems have been designed. As an analogy, the homes we live in can be made of stone, brick, wood or shingles, and thus they will look different from the outside. Floor plans, framing, electrical wiring and plumbing systems further differentiate homes and living space on the inside. Changes to a floor plan may require an examination of the supporting structures and all associated systems. Local building-code requirements and the age of the property may also need to be taken into account.
Similarly, as EHRs may require changes to support meaningful use, those changes may be invasive. EHR vendors must be given ample time to react to new meaningful-use requirements so they can not only create system changes but make them fully available to providers in productive use. Consider the complication of addressing an ICD-10 architectural change within these solutions while they are already doing systems redesign to support evolving meaningful-use requirements.
Third, we need engaged constituents to support our health IT policymakers. Our policymakers understand the greater good for public health that can come from having systems that support patient care, population health, and clinical utilization and quality. However, they need vendor and provider constituents to engage in regulation-defining bodies to ensure that requirements are based in sound practice and historical knowledge of developing or using those health-record systems, data integration and use, clinical use in daily care delivery. And although this type of engagement requires a sense of selflessness that may be uncommon, lack of leadership here will provide us with regulation absent the translation to capabilities that work in practice.
Finally, healthcare IT leaders—in particular chief information officers and chief medical information officers—must continue to direct the symphony of voices and be the first-chair section leaders. It is our collective responsibility to bring together all of the complex elements to ensure success, including co-opting internal and external people to address a shared mission. This means that we need to understand one another's incentives and find common ground. It also means partnering among providers, vendors, public entities and payers in ways we have not done before, especially when our missions and incentives do not align.
George Hickman Executive vice president and CIO Albany (N.Y.) Medical Center Member, CHIME board of trustees
Executive vice president and CIO
Albany (N.Y.) Medical Center
Member, CHIME board of trustees
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