# The state of health IT according to the American Hospital Association

Last week, the American Hospital Association released a major document. Framed as comments on a major federal initiative, the proposed Stage 2 Meaningful Use criteria by the Centers for Medicare & Medicaid Services (CMS), the letter also conveys a rather sorrowful message about the state of health IT in the United States. One request–to put brakes on the requirement for hospitals to let patients see their own information electronically–has received particularly strong coverage and vigorous responses from e-Patient Dave deBronkart, Regina Holliday, Dr. Adrian Gropper, Fred Trotter, the Center for Democracy and Technology, and others.

I think the AHA has overreached in its bid to slow down patient access to data, which I’ll examine later in this article. But to me, the most poignant aspect of the AHA letter is its careful accumulation of data to show the huge gap between what health care calls for and what hospitals, vendors, standards bodies, and even the government are capable of providing.

Two AHA staff were generous enough to talk to me on very short notice and offer some clarifications that I’ll include with the article.

### A survey of the U.S. health care system

According to the AHA (translated into my own rather harsh words), the state of health IT in American hospitals is as follows:

• Few hospitals and doctors can fulfill basic requirements of health care quality and cost control. For instance, 62% could not record basic patient health indicators such as weight and blood pressure (page 51 of their report) in electronic health records (EHRs).

• Many EHR vendors can’t support the meaningful use criteria in real-life settings, even when their systems were officially certified to do so. I’ll cite some statements from the AHA report later in the article. Meaningful use is a big package of reforms, of course, promulgated over just a few years, but it’s also difficult because vendors and hospitals had also been heading for a long time in the opposite direction: toward closed, limited functionality.

• Doctors still record huge globs of patient data in unstructured text format, where they are unavailable for quality reporting, tracking clinical effectiveness, etc. Data is often unstructured because humans are complex and their symptoms don’t fit into easy categories. Yet doctors have learned to make diagnoses for purposes of payment and other requirements; we need to learn what other forms of information are worth formalizing for the sake of better public health.

• Quality reporting is a mess. The measures currently being reported are unreliable, and standards have not been put in place to allow valid comparisons of measures from different hospitals.

• Government hasn’t stepped up to the plate to perform its role in supporting electronic reporting. For instance, the Centers for Medicare & Medicaid Services (CMS) wants the hospitals to report lots of quality measures, but its own electronic reporting system is still in the testing stages, so hospitals must enter data through a cumbersome and error-prone manual “attestation.” States aren’t ready to accept electronic submissions either. The Direct project is moving along, but its contribution to health data exchange is still very new.

There’s no easy place to assign blame for a system that is killing hundreds of thousands of people a year while sticking the US public with rising costs. The AHA letter constantly assures us that they approve the meaningful use objectives , but say their implementation in a foreseeable time frame is unfeasible. “We can envision a time when all automated quality reporting will occur effortlessly in a reliable and valid fashion. However, we are not there yet.” (pp. 42-43)

So the AHA message petition to the CMS can be summarized overall as, “Slow everything down, but keep the payments coming.”

AHA staff referred to the extensively researched article, A Progress Report On Electronic Health Records In U.S. Hospitals. It corroborates observations that adoption of EHRs has vastly increased between 2010 and 2011. However, the capabilities of the EHRs and hospitals using them have not kept up with meaningful use requirements, particularly among small rural hospitals with few opportunities to hire sophisticated computer technicians, etc. Some small hospitals have trouble even getting an EHR vendor to talk to them.

### Why all this matters

Before looking at some details, let me lay out some of the reasons that meaningful use criteria are so important to patients and the general public:

• After treatment, data must be transferred quickly to patients and the next organizations treating them (such as rehab centers and visiting nurses) so that the patients receive proper care.

• Quality measures are critical so that hospitals can be exposed to sunshine, the best disinfectant, and be shamed into lowering costs and reducing errors.

• Data must be collected by public agencies so that data crunchers can find improvements in outreach and treatment. Hospitals love to keep their data private, but that gives them relatively tiny samples on which to base decisions, and they often lack the skills to analyze the data.

No one can predict what will break logjams and propel health care forward, but the patient engagement seems crucial because most health care problems in developed countries involve lifestyle issues such as smoking and body weight. Next, to provide the kind of instant, pervasive patient engagement that can produce change, we need electronic records that are open to innovative apps, that can accept data from the patient-centered medical home, and that link together all care-givers.

### The state of electronic health records

The EHR industry does not come out well in the AHA list of woes. The letter cites “unworkable, but certified, vendor products” (p.3) and say, “Current experience is marked by limited vendor and workforce capacity.” (p. 7) The latter complaint points to one of the big hurdles facing health care reform: we don’t have enough staff who understand computer systems and who can adapt their behavior to use them effectively.

Functionality falls far short of real hospital needs:

…one hospital system spent more than $1 million on a quality reporting tool from its vendor that was, for the most part, an unwieldy data entry screen. Even medication orders placed using CPOE [computerized physician order entry] needed to be manually re-entered for the CQM [Center For Quality Management] calculation. Even then, the data were not reliable, despite seven months of working with the vendor to attempt to get it right. Thus, after tremendous investment of financial and human resources, the data are not useful. (p. 45) The AHA claims that vendors were lax in testing their systems, and that the government abetted the omission: “the proposals within the certification regulation require vendors to incorporate all of the data elements needed to calculate only one CQM. There is no proposal to require that certified EHRs be capable of generating all of the relevant CQMs proposed/finalized by CMS.” (p. 41) With perhaps a subtle sarcasm, the AHA proposes, “CMS should not require providers to report more e-measures than vendors are required to generate.” (p. 36) Vendors kind of take it on the chin for fundamental failures in electronic capabilities. “AHA survey data indicate that only 10 percent of hospitals had a patient portal of any kind in Fall 2011. Our members report that none had anywhere near the functionality required by this objective. In canvassing vendors, they report no technology companies can currently support this volume of data or the listed functions.” (p. 26) …in Stage 1, some vendors were able to dictate which clinical quality measures providers chose to report–not based on the priorities of the provider, but based on the capabilities of the system. Subsequently, market forces corrected this and vendors have gone on to develop more capabilities. But this anecdote provides an important lesson when segmenting certification criteria–indeed for most technologies in general–flexibility for users necessitates consistent and robust standards for developers. In short, the 2014 Edition must require more of the vendor community if providers are to have space to pursue meaningful use of Meaningful Use. (p. 2) Better standards–which take time to develop–could improve the situation, which is why the Office of the National Coordinator (ONC) has set up a Health IT Standards Committee. For instance, the AHA says, “we have discovered that vendors needed to program many decisions into EHRs that were not included in the e-specifications. Not only has this resulted in rampant inconsistencies between different vendors, it produced inconsistent measure results when the e-measures are compared to their counterparts in the Inpatient Quality Reporting (IQR) Program.” (p. 35) The AHA goes so far as to say, “The market cannot sustain this level of chaos.” (p. 7) They conclude that the government is pushing too hard. One of their claims, though, comes across as eccentric: “Providers and vendors agree that the meaningful use program has stifled innovation in the development of new uses of EHRs.” (p. 9) To me, all the evidence points in the opposite direction. The vendors were happy for decades to push systems that performed minimal record-keeping and modest support such as formularies at huge costs, and the hospitals that adopted EHRs failed to ask for more. It wasn’t a case of market failure because, as I have pointed out (and others have too), health care is not a market. But nothing would have changed had not the government stepped in. ### Patient empowerment Now for the point that has received the most press, AHA’s request to weaken the rules giving patients access to their data. Once again, the AHA claims to favor patient access–and actually, they have helped hospitals over the years to give patients summaries of care, mostly on paper–but are passing on the evidence they have accumulated from their members that the systems will not be in place to support electronic distribution for some time. I won’t repeat all the criticisms of the experts mentioned at the beginning of this article, but provide some perspective about patient engagement. Let’s start with the AHA’s request to let the hospital can choose the format for patient data (pp. 25-26). So long as hospitals can do that, we will be left with formats that are not interoperable. Many hospitals will choose formats that are human-readable but not machine-readable, so that correlations and useful data cannot be extracted programmatically. Perhaps the technology lags in this area–but if the records are not in structured format already, hospitals themselves lose critical opportunities to check for errors, mine data for trends, and perform other useful tasks with their records. The AHA raises alarms at the difficulties of providing data. They claim that for each patient who is treated, the hospital will have to invest resources “determining which records are relevant and appropriate.” (p. 26) “It is also unclear whether a hospital would be expected to spend resources to post information and verify that all of the data listed are available within 36 hours.” (p. 27) From my perspective, the patient download provisions would simply require hospitals to clean up their ways of recording data so that it is in a useable and structured format for all, including their own staff. Just evaluate what the AHA is admitting to in the following passage: “Transferring these clinical observations into a structured, coded problem list in the EHR requires significant changes to work flows and training to ensure accuracy. It also increases time demands for documentation by physicians who already are stretched thin.” (p. 27) People used to getting instant information from commercial web sites find it very hard to justify even the 36-hour delay offered by the Stage 2 meaningful use guidelines. Amazon.com can provide me with information on all my current and recent orders. Google offers each registered user a dashboard that shows me everything they track about me, including all my web searches going back to mid-2006. They probably do this to assure people that they are not the egregious privacy violators they are regularly accused of being. Nevertheless, it shows that sites collecting data can make it available to users without friction, and with adequate security to manage privacy risks. The AHA staff made a good point in talking to me. The CMS “transmit” requirement would let a patient ask the hospital to send his records to any institution or individual of his choice. First of all, this would assume that the recipient has encrypted email or access to an encrypted web site. And it could be hard for a hospital to make sure both the requester and the intended recipient are who they claim to be. “The transmit function also heightens security risks, as the hospital could be asked to send data to an individual with whom it has no existing relationship and no mechanism for authentication of their identity.” (p. 27) Countering this claim, Gropper and the Society for Participatory Medicine offer the open OAuth standard to give patients easy and secure access. But while OAuth is a fairly stable standard, the AHA’s concerns are justified because it hasn’t been applied yet to the health care field. Unfortunately, allowing a patient to send his or her data to a third party is central to Accountable Care Organizations (ACOs), which hold the promise of improving patient care by sharing data among cooperating health care providers. If the “transmit” provision is delayed, I don’t see how ACOs can take off. The AHA drastically reduces the information hospitals would have to give patients, at least for the next stage of the requirements. Among the material they would remove are diagnoses, the reason for hospitalization, providers of care during hospitalization, vital signs at discharge, laboratory test results, the care transition summary and plan for next provider of care, and discharge instructions for patient. (p. 27) All this vastly reduces the value of data for increasing quality care. For instance, removing lab test results will lead to expensive and redundant retesting. (However, the AHA staff told me they support the ability of patients to get results directly from the labs.) Update, May 20: The difficulties cited by the AHA should be evaluated in the context of the innovative companies, described in my posting one week later , that offer patients access to health records. I’ll conclude this section with the interesting observation that the CHIME comments on meaningful use I mentioned earlier say nothing about the patient engagement rules. In other words, the hospital CIOs in CHIME don’t back up the hospitals’ own claims. ### Some reasonable AHA objections Now I’m happy to turn to AHA proposals that leave fewer impediments to the achievement of better health care. Their 49-page letter (plus appendices) details many aspects of Stage 2 that seem unnecessarily burdensome or of questionable value. It seems reasonable to me to ask the ONC, “Remove measures that make the performance of hospitals and EPs contingent on the actions of others.” (p. 2) For instance, to engage in successful exchanges of patient data, hospitals depend on their partners (labs, nursing homes, other hospitals) to have Stage 2 capabilities, and given the slow rate of adoption, such partners could be really hard to find. The same goes for patient downloads. Not only do hospitals have to permit patients to get access to data over the Internet, but they have to get 10% of the patients to actually do it. I don’t think the tools are in place yet for patients to make good use of the data. When data is available, apps for processing the data will flood the market and patients will gradually understand the data’s value, but right now there are few reasons to download it: perhaps to give it to a relative who is caring for the patient or to a health provider who doesn’t have the technical means to request the data directly. Such uses may allow hospitals to reach the 10% required by the Stage 2 rule, but why make them responsible? The AHA documents a growing digital divide among hospitals and other health care providers. “Rural, smaller and nonteaching hospitals have fewer financial and technical resources at their disposal. They also are starting from a lower base of adoption.” (p. 59) The open source community needs to step up here. There are plenty of free software solutions to choose from, but small providers can’t use them unless they become as easy to set up and configure as MySQL or even LibreOffice. The AHA is talking from deep experience when it questions whether patients will actually be able to make use of medical images. “Images are generally very large files, and would require that the individual downloading or receiving the file have specialized, expensive software to access the images. The effort required to make the images available would be tremendous.” (p. 26) We must remember that parts of our country don’t even have high-speed Internet access. The AHA’s detailed comments about CMS penalties for the slow adoption of EHRs (pp. 9-18) also seem to reflect the hard realities out in the field. But their attitude toward HIPAA is unclear. They point out that Congress required meaningful use to “take into account the requirements of HIPAA privacy and security law.” (p. 25) Nevertheless, they ask the ONC to remove its HIPAA-related clauses from meaningful use because HIPAA is already administered by the Office of Civil Rights (OCR). It’s reasonable to remove redundancy by keeping regulations under a single agency, but the AHA admits that the OCR proposal itself is “significantly flawed.” Their staff explained to me that their goal is to wait for the next version of the OCR’s own proposal, which should be released soon, before creating a new requirement that could well be redundant or conflicting. Unless we level the playing field for small providers, an enormous wave of buy-outs and consolidation will occur. Market forces and the push to form ACOs are already causing such consolidation. Maybe it’s even a good thing–who feels nostalgic for the corner grocery? But consolidation will make it even more important to empower patients with their data, in order to counterbalance the power of the health care institutions. ### A closing note about hospital inertia The AHA includes in its letter some valuable data about difficulties and costs of implementing new systems (pp. 47-48). They say, “More than one hospital executive has reported that managing the meaningful use implementation has been more challenging than building a new hospital, even while acknowledging the need to move ahead.” (p. 49) What I find particularly troublesome about their report is that the AHA offers no hint that the hospitals spent all this money to put in place new workflows that could improve care. All the money went to EHRs and the minimal training and installation they require. What will it take for hospitals to make the culture changes that reap the potential benefits of EHRs and data transfers? The public needs to start asking tough questions, and the Stage 2 requirements should be robust enough to give these questions a basis. Related: • e-Patient Dave Andy, this is a massive amount of work, well reported, and you’re to be congratulated. Having said that, I personally am sick to death of the endless list of reasons why healthcare (particularly in America) continues, year after year after year, to say it just caaaaan’t modernize, it’s too haaaard. Who among them (among us) is ever going to take *responsibility* for solving this? It seems to me that after all other avenues were exhausted, this administration’s staff has finally said “Enough! Do it, or you’ll pay!” And NOW finally we hear the screams. Let the hospitals go beat the crap out of the VENDORS whose systems are underpowered, not out of the patients who suffer from lack of access to this vital information. And believe me, this is not just a matter of the vendors’ atittudes – it’s because most hospitals simply haven’t had patient access as a priority. I know that because Planetree hospitals have offered *continuous* access (not after-the-fact) for years. See Brian Ahier’s Google+ post today, reported on e-patients.net … linking to a post of his in 2009. I would honestly welcome good open dialog with the AHA representatives about this. First, though, I’d want to know their definition of “quick,” because in a public statement last week, they asserted that patients already do get their information quickly. Now they seem to be asserting that quick isn’t feasible. It’s especially ironic that hospitals are now subject to penalties for failed discharges within 30 days, yet they want that full 30 days to even gather the information that might prevent the failure. Plus, in their letter to CMS, they asserted they need to full 30 days to decide how to respond to a request. What do these reps think about that? Again, good job of reporting a big and complex subject. And good work on engaging with them. Pardon me for seeming unpleasant; as I say, after 3 years of learning about ineptitude, it just kinda incenses me that when crunch time comes, they put the squeeze (again) on patients – not on the vendors who are apparently responsible for this situation. And again, I’d welcome good open (cordial, candid) dialog on this, point by point. • http://healthurl.com Adrian Gropper It’s 2012 and patients have every right to expect their health information, representing almost 20% of US GDP, to connect to the Internet in useful and generative ways. The micromanagement of technology by well-meaning and highly competent federal bureaucrats has now reached diminishing returns. There’s no more time for 500-page regulations and 49-page comments. With Stage 1, ONC tried to micromanage technology with the promise of$30 B in payouts and the concept of Meaningful Use. The result has been mixed, with increased consolidation and a general lack of innovation. Teaching to the test has not been great for “no child left behind” but, as with Stage 1, may have been the best realistic choice.

With Stage 2, ONC has the opportunity to step back from micromanagement and put healthcare on the path to market-based technology innovation. In A fork in the road to Meaningful Use, I suggest that, first and foremost, ONC needs to give patients and the Internet a fair shot at their own data.

The current approach to EHRs may be failing right before our eyes. Overly bureaucratic health IT systems, like the UK National Spine, have been spectacular failures. The barrier to entry for health IT innovation has Castlight Health raising $181 Million just to provide a bit of price transparency to a subset of patients. Immediate access and Open Authorization are now as important a principle as Meaningful Use itself. • http://www.thehealthcareblog.com Matthew Holt Excellent piece Andy and you wont be surprised to hear me side with Dave and Adrian, but one line really struck me–when you said some hospitals couldn’t find a vendor to talk to them. One company I know, Razor Insights, waited until MU stage 1 requirements were out and built a cloud-based inpatient management system for small hospitals from scratch in less than a year, got it certified, and told its hospital customers that they didnt need to pay anything until they have received their MU$$from CMS. Anyone in the Web 2.0/Health 2.0 world is very familiar with that level of rapid product development. And cloudbased services mean that there’s no long implementation cycles on the client end. This is just one example. But you have to ask. Is it really the vendor’s fault? Or is it that the hospitals have been captured by the incumbents, including the RECs and consultants who have pre-selected from an existing list.? • http://healthtrain.blogspot.com Gary Levin MD Andy, great article. I think however it is a bit premature to come to conclusions either on the side of AHA or patient advocates. Some of their ‘demands’ are totally unrealistic. MU stage I is still in it’s infancy as far as role out. Stage II is still a ‘gleam in it’s father’s eye. • Wade Schuette John Gall’s law #29 seems relevant here: “Great advances are not produced by systems designed to produce great advances.” The Institute of Medicine also captures this insight: “What we need is a billion one-dollar systems, not one billion dollar system.” Both quotes focus attention on the concept that hospitals are “active adaptive systems” that are more suited for evolving solutions that emerge from ten thousand small efforts than trying to program a monolithic (one-size-fits-none) solution from outside and then “train the staff to use it”. Successful long-term solutions need to be grown, not purchased in whole-cloth. This requires a total change in mind-set within hospital IT departments, from an obsession with large-ticket, huge-dollar, huge projects to a focus on dealing with actually responding to the day-to-day “tiny” needs of the floor staff. These have too often been neglected or treated as low-priority, and few patients or staff members feel “empowered at last” by the process called “selection and implementation of the new system.” If anything, they feel put off yet once more by some massive focus of attention that doesn’t fix where it actually hurts. Meanwhile, with their own eyes, they can each see a few things that WOULD help if fixed, such as an easy way to track who has NOT come back as scheduled, or a way to schedule a room, or to schedule a speaker that won’t turn out to be at the same time as some huge other event. In fact it is precisely the social media and crowd-sourced problem realization, mulling, and solving that is attacked by central administrations as “interfering” with work. What administrators fail to realize is that the hospital doesn’t work BECAUSE of the “systems” in place, it works DESPITE those systems, precisely because people are incredibly skilled at finding ways to help each other out and get work done. It is the height of arrogance for either management or an outside vendor to say “We have the solution” when, in fact, they keep rejecting every squawk and comment from the floor on the actual problems THIS ACTUAL HOSPITAL is facing today. To empower patients, we also need to focus on empowering the front-line staff, clerical staff, the people who actually do the work but get none of the credit and little of the financial reward for the pains they take to do so. Over and over, management asks “What is the problem”, staff responds with ten thousand details (if they haven’t given up caring), and management says ‘No, that’s not the right problem I meant for you to point to, THAT thing will have to wait. THAT doesn’t look important to ME. ___I___ can’t deal with ten thousand problems, let’s “prioritize” down to one or two “big ones”. ‘ The eyes-to-see and motive power have to be reconceptualized to be the patients and the staff, not upper-management. For this to occur, IT departments have to become FACILITATORS, not “packaged-solution providers”. Then, the “impossible” will become possible. • http://praxagora.com/andyo Andy Oram Thanks for all the expansions of ideas in my posting. Wade, the process of bottom-up, incremental development you call for seems to mirror what the Veterans Administration doctors did to create VistA. It ended up a unified system, but was created by innumerable small advances written by the people actually using the system. • http://munnecke.com Tom Munnecke Great research, Andy. A couple of comments: The VA VistA system was created by teams of IT professionals working closely with the users – so while docs were very close to the process, they typically weren’t the ones who wrote the software. What was important, I think, was the fact that we saw VistA as an evolutionary approach, starting with a version that was “good enough” and then followed a “release early, release often” model to get intense user feedback. I talked a bit about this at Health Camp Oregon with Ward Cunningham http://munnecke.com/blog/?p=1280 A bit of clarification: AHA is a trade association representing the interests of hospitals. They are not in the business of keeping people out of their facilities or reducing length of stay, any more than Ford Motor company is in the business of encouraging people to ride bicycles to work. We shouldn’t expect them to be altruistic with regard to our health any more than the American Petroleum Association or the American Tobacco Association. They are a disease-based industry, and the sicker we are, the more money they make. My wake up to this issue was about 20 years ago, when I met a guy who had just left Humana as an IT manager. He said something like, “The turning point in IT in Humana was when they realized that they could use computers to efficiently use computers to charge$20 for a box of Kleenex.” Hospitals are very adept at using IT when it suits their financial interests.

The real change will come when we remove the perverse incentives in our health care system – and inverting our perspective to a patient-centric one is one of the first steps.