MH: The 21st Century Cures Act has a whole section on EHRs that states, “promote interoperability; promote usability; promote patient-centric care.” It’s all very general. What does this administration need to do to lower the regulatory burden yet achieve the promise of EHRs?
Halamka: I met with CMS officials this morning. This does not represent any official government policy. But what did the CMS say? Value-based purchasing is here to stay. They’ll be less prescriptive of how you achieve that value and that outcome. Quality measures need radical revision because many of them are not relevant to workflow and are too complex. I think you’ll see the private sector have an opportunity to innovate because the regulations will not say, “Buy a DVD player that’s purple with two green buttons.” The regulations will say, “Play movies.” That’s what the CMS is thinking.
Probst: Having worked with (HHS Secretary Dr. Tom) Price’s office prior to his appointment, the sentiment is we have too much regulation. His staff wasn’t very supportive of meaningful use. Having been on the original committees that worked on meaningful use, it’s become a very negative influence on healthcare.
Chambers: I may be a bit of a cynic. Right now, one of our inpatient EHRs has to have an upgrade of several million dollars for new hardware just to avoid the stick. We’re past the carrot. Now we’re trying to avoid the stick of something like $12 million for meaningful use Stage 3 violations. We’re spending a lot of money to avoid losing a lot of money. It’s not incredibly productive.
MH: Does anyone hold out hope for the more prescriptive regulations in the 21st Century Cures Act?
Halamka: I was talking to two very notable senators and I asked them, “What is interoperability?” They said every data element in the electronic health record can be shared with every person for every purpose in real time, at no cost. If that is your definition of interoperability, we should just go home. Because, forget it—not going to happen.
My definition of interoperability is the minimum information you need for reasonable quality care, available with reasonably low effort, at reasonably low cost. In Boston, we are at best an affiliated group of friends and family with six different EHRs in our health system. Therefore, what do we do? Sometimes we push data to a central repository to measure quality and outcomes. Sometimes we pull data for real-time clinical care coordination. And sometimes we do the quick and dirty, like when I’m in one EHR and I can view another EHR because all I want to see is what meds the patient is taking and that sort of thing.
But there are a couple of other things we need. We do not have a good way to match patient identity. Although we do name, gender, date of birth and other combinations, it doesn’t work, especially in areas like south Boston where the Irish-Americans named Maureen Kelly may have the same birthday on the same street. Having mixed medical records is dangerous. We need a patient identifier, or biometrics, or something.
We don’t have a doctor directory for the country. If I wanted to send data to Utah, I wouldn’t have the first clue how to do it. Let’s make sure our privacy policies are rational. I live in New England. The nearest state is just 20 miles away. Yet I cannot send data across that border because the policies are so heterogeneous.
Probst: We’re not going to be interoperable at any level unless we get standards that are acceptable across the whole industry. There are 157 ways to represent blood pressure. That’s not a standard. That means we’re sending data that you might be able to interpret if you bring it up on the screen and you’re a physician. But if you want the computer to do anything with it to make it more efficient, it doesn’t have enough specificity.
This must be a national priority for our national safety. Hundreds of thousands of people are dying every year needlessly because we don’t interoperate well. Hundreds of billions of dollars every year are being wasted because we don’t interoperate.
I am about as conservative a guy as you’re going to find. Yet I think the federal government has to take a very distinct and forceful role in ensuring that we get the standards over the next 10 years.
We’re not going to be interoperable at any level unless we get standards that are acceptable across the whole industry. There are 157 ways to represent blood pressure. That’s not a standard.
MH: How will a government-enforced common standard on medical data play down in Texas?
Chambers: I agree that it’s going to take a federal mandate. They do have to get engaged. Houston is much like your Boston situation. There are 258 Maria Sanchez’s with the exact same date of birth in their system. There’s a lot of patient misidentification potential there. A national patient identifier is needed.
MH: I’m hearing two different views of regulation. In one case you want prescription— a patient identifier. But in another case, you just want a general overview and say, “Let us figure out how to do it.”
Probst: I’m OK if they tell you to drive on the right side of the road. I don’t want them to tell you how to build every car that’s on the road.