Tuesday, November 4, 2008

Unsolicited Advice for the President-elect

This blog has moved to: http://frissepolicy.blogspot.com/

As I write this, Americans are still voting in one of the most polarizing and critical elections in modern history. Although our preferences for presidents and other elected officials may differ, we Americans face a common reality, and it is this reality, I believe that must be the cornerstone of the inevitable re-evaluation that comes with an election of this significance.

Here are a few principles I would recommend to the new Administration.

Stop the hype

It is perhaps disingenuous to call for a cessation of exaggerated claims after one of the most acrimonious and expensive campaigns in history, but recipients of the many email press releases and announcements of HIT "accomplishments" are no strangers to the very real disconnect between what people say they are doing and what really works. Debate must be moved forward by a realistic assessment of our past accomplishments, not by exaggerated claims made by vendors, agencies, delivery organizations, and even the HIT "Illuminati." Let's build our delivery system on the basis of what we know can work rather than on what we hope will happen.

Never advance health information technology for its own sake.

Translated. Fix the health care system first, then draft health IT legislation. Information technology is a way to enable processes and realize goals. As Carol Diamond and Clay Shirkey recently wrote in Health Affairs: "If you computerize an inefficient system, you will simply make it inefficient, faster."

Acknowledge scarcity
There is little money for HIT at the federal, state, local, organizational, or individual level. We must do more with less. Demand for health outstrips supply. Priorities must be set. Every effort must be directed towards avoiding a catastrophic recession.

View health care as a central component of our economic infrastructure, not as a service.
Health care - like education and public safety - is essential for economic prosperity. We invest in schools and teachers to help create an educated populace; we invest in law enforcement to ensure the safety necessary for public prosperity. We invest in health to ensure that our citizens are not limited unduly through avoidable illnesses or inadequate treatment. Health care is about the individual! If we start with the goal of a healthier individual, we will realize healthier families and communities and, in the process refine our health care system to assure the achievement of these central aims. We would put an end to delivery silos that do not make sense and would move naturally toward a system where knowledge, coordination of care, self-sufficiency, and evidence dominate.

Build on what works

A lot of good ideas have been advanced over the past eight years (and some rather flawed ones). It is critical to build on the ideas that are gaining momentum and where additional effort can align these efforts with near-term outcomes. These would include ongoing efforts to achieve price and quality transparency, a growing consensus on the problems with our current privacy infrastructure, and our emphasis on prescription medications. Each of these efforts need a lot more work than press releases would imply. But they are important and positive legacies.

Give providers a stable mechanism for payment

If providers have a reasonably reliable forecast of what they are to be paid to do, and if these forecasts treat everyone more or less the same (i.e. fewer networks, differences in payment, coverage for everyone), I have every faith that providers will invest their own funds on systems that work to achieve their aims more efficiently. Right now, we ask providers to invest heavily in EHRs that often cannot realize their potential because communication with labs, pharmacies, and other care providers is not optimized, because critical workflow issues have not been resolved, or because they cannot support ongoing expenses to accommodate an ever-changing payment system growing in complexity. is not available or because

Develop the health care workforce
The aging population will create unparalleled demand for a flexible workforce capable of meeting growing needs. At the delivery level, we do not have sufficient home health aids, nurses, nurse aides, and other care workers required to meet the demand. In many cases, these very care providers are not able to pay for health care coverage for themselves or their families. At the administrative level, cut-backs and early retirements in government threaten to eliminate critical organizational memory at the very time where we must work even harder to simplify program administration and advance coordination. A commitment to a workforce must be a top priority.

Kill all unnecessary complexity
Complexity without measurable value is arguably the most immediate target for change. Every unnecessary administrative step saps our health care system of dollars that could be spent on care. Clinicians are told repeatedly they must standardized care based on best available evidence. I agree. But should not intermediaries do the same thing? If so, will we continue to see the hundreds of different formularies, prior authorization rules, network negotiations, and other administrative nuances that make every plan different than another? Progress is being made here, but there is still much work to be done, and the message must be made loud and clear that best practices will drive both the administration and payment of care as well as care delivery itself.

Incorporate health care services training into our educational system

At the community college level, teach the next generation of computer technicians what HIPAA means and what the differences are between servicing a convenience shop computer and servicing a system in a health care setting
At the work force level, create more programs that produce flexible health care workers who pursue lifelong learning and who are adept at both the humanism and technologies required to provide care for our aging society

Focus on functions, not products

There has been a tendency to objectify nascent efforts instead of viewing these efforts as unique and evolving combinations of specific components and discrete services. When we speak RHIOs, PHRs, and even EHRs we are really talking about combinations of services like medication histories, clinician notes, laboratory values, and alerts alerts. These in turn rely on core principles like data integrity, auditing, non-repudiation, authentication, and authorization. Principles should guide the use of specific services and efforts must be made to encourage secure "data liquidity" to ensure the right information is made available at the right time. By focusing on these services rather than on products, we advance the public trust without immobilizing innovation in the bureaucratic morass or product certification or accreditation.

Simplify NHIN
If there is to be an NHIN, there are about 12 core services that I believe should gain top priority. My priorities are to be found on my blog and has been discussed in a trade press article.

Enormous amounts of effort have been expended over the past eight years to create a more effective health care system. But somehow, things have gone awry. I often make the analogy to a soccer game. Health care is like a soccer game with 10 teams and 14 balls. Everyone is running around kicking, but since there appear to be no rules or order, the "game" is mere exercise. It makes no sense beyond that. The efforts of these countless hours and many projects have contributed to the collective wisdom. We now must be honest with ourselves and ask:
  • what is the primary problem we want to solve? (I'd claim it is a healthier society)
  • what preconditions are required to ensure that technologies can make a difference?
  • what have we done that gets us closer to a solution?
  • what have we done that has only worsened the "problem" and distracted us from our goals?
I think it is time to take a deep breath and think very hard about what it is we want to accomplish; then ask ourselves how we can help; then re-visit our principles and revise our policies; and only then, start programs and legislation to ensure we get what we now know we need.

And more than anything else, we should - individually and collectively - promise each other that if we are doing things that do not help, we will cease our efforts in these directions and turn towards more positive things.


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