Halamka, Stack, Dreyer discuss convergence of technology, art of medicine

BOSTON--“My IT agenda has been co-opted by regulatory demands,” said John Halamka, MD, CIO of Beth Israel Deaconess Medical Center, speaking at a March 27 panel on the art of medicine. A panel of physicians heavily involved in IT at their respective organizations and beyond discussed how IT adoption is impacting the delivery of healthcare at the event hosted by Nuance.

“I can’t get to the things that are truly going to improve the art of medicine,” Halamka said. “There needs to be a little relief to the regulatory agenda.” He cited a large vendor whose 5,000 staff members took 326 man years to do Meaningful Use Stage 2 certification. “I have five guys and a lot of coffee.”

The American Medical Association conducted a study with RAND to find out what makes doctors happy and fulfilled and what frustrates them. They found that their “commitment to patients is alive and well,” said Steven Stack, MD, immediate past chair of the American Medical Association and emergency physician in Kentucky. The study also found that physicians intensely hate their EHR, he said. Most don’t want to go back to pen and paper but the current generation of EHRs interferes with their work, slows them down and causes complications and hassles. Improving EHR systems “has been painful birthing process and there are no signs that it’s going to end imminently.”

“We’re completely overwhelmed trying to respond to regulatory demands,” said Adam Landman, MD, emergency physician and CMIO for health information innovation and integration at Brigham and Women’s Hospital in Boston. While policies, including the HITECH Act, are working very well to drive adoption, “I’m looking forward to when the infrastructure is installed and we can start building on top of it to address usability and efficiency.”

Radiology has been at this longer than most, said Keith J. Dreyer, DO, PhD, vice chairman of radiology informatics at Massachusetts General Hospital in Boston, who also has held several positions with the American College of Radiology. Over the years, he said radiology has been able to replace and upgrade systems quickly because there were no regulations. And, now that clinicians can view images from virtually any location, radiologists “have removed ourselves from interactions with patients and other physicians. No one needs to talk to the radiologist.” Now, radiologists are working to be more connected to the care process, he said.

Regarding the current state of health IT, the panel agreed that the design of EHR systems was driven by reimbursement processes. Changing payment models could result in improved usability in those technology systems. “As bad as they are, [current payment models] are the best the community has come up with,” said Stack. “They are the result of a collaborative effort and that led to compromises.”

Managing all the data presented by those EHRs is challenging. Beth Israel has 3 pedabytes of patient-identified data, said Halamka, adding that the problem with health information exchange (HIE) is that “we’re already overwhelmed with data. What we need is information, knowledge and wisdom. Over time, computers will help us distill 3 pedabytes down to information I need now.”

The current state of EHRs is the result of an effort that throws “tens of millions of dollars at one thing,” said Stack. “It’s overbuilt, overdesigned and we’re trying to make this one tool be all things. It has really spurred adoption but also frustration.”

Mass General and Partners HealthCare is in the process of switching from a home-grown EHR and associated IT, to a single solution, said Dreyer. Although self-designed systems allow for more optimized solutions, he said, they aren’t sustainable. “It’s probably going to take another couple of decades to optimize the user experience. We’re in that frustrated user mode.”

Halamka said Beth Israel’s strategy is to pare down. “Best-of-breed is probably not a good idea because it’s never going to be seamless. Our strategy is to have the smallest number of moving parts, and be cloud-hosted, mobile-enabled and interoperability-focused. Call it best-of-suite strategy.”

Brigham and Women’s too is in the process of shifting to a commercial EHR solution with plans to go live in May 2015, Landman said. These systems are so expensive because “our organizations need to spend a ton of resources to configure that system to work well for us.” His organization is focused on engaging the care community to participate in the design and configuration so it will be optimized for them within constraints. That pre-planning will ease the impact down the road, he said.

Dreyer said Mass General has about 4,000 radiologic procedures performed at several locations—and none call each procedure the same thing. The nice thing about a monolithic solution, he said, is that “it drives that conversation that we have to have now to make sure we can come together. There are extra standards you wind up defining through unification. And that took thousands of hours of people behind the scenes finding commonality.”

“I think patients do better when the people who are trained to be healers have a really prominent role in the design of the systems that deliver their care,” said Stack.

Hospitals where physicians are involved in the planning are almost uniformly more successful, said Paul Weygandt, MD, JD, MPH, MBA, vice president of physician services for Nuance, who moderated the panel. “Even if it’s a wonderful program, there is skepticism from the start if there is no physician leadership.”

However fast technology changes, Stack said the human element can’t keep up. Halamka, Landman and Stack are all practicing emergency physicians, he noted, and must rely on their gut instincts in the moment. “We will always be in a relatively information-poor, fast-paced environment. If we don’t stop overly fixating on all these other things and restore some of the connectivity between healers and patients, I think we’ve lost something really important.”

“The use of bad technology will give bad outcomes,” said Dreyer. “The use of good technology will give good or bad outcomes” so change management among clinicians is very important.

Quality reporting raises numerous issues, the panel members said. Dreyer noted that radiology volume has increased by a factor of 10 over the past 20 years. While he wants good methods to measure the quality of radiologists’ work, the challenge is making sure quality is the same across all 200 radiologists at Mass General, as well as optimizing reports so any recommendations are noted and acted upon.

“We don’t want to structure every element, but enough so that if we ever go back to see accuracy or quality we can measure that,” he said.

Just because we can measure things, doesn’t mean we always should, said Stack, but rather focus on those things that have meaning and impact.

For every structured element, there is a cost for grabbing, curating and analyzing that element, said Halamka.  

Policies and procedures need to keep up with advances in technology, Dreyer said. Speech recognition wasn’t always fast or accurate enough but now, it’s so fast and accurate that at the end of dictation, radiologists can see all the content and check to make sure it’s correct. However, “a large number of radiologists insisted on the old process of reading all their reports at the end of the day. We said they were not allowed to go on to the next case until they signed off on each report.”

The Affordable Care Act is “causing us to rethink all IT systems,” said Halamka. Traditionally, systems have been built to support care for episodic sickness as opposed to continuous wellness. His organization created a central repository that allows a care manager to look at gaps in care. “We’re starting to rethink the purpose of our IT systems,” and he sees the need to employ technologies that are bleeding edge today to tease data out of unstructured notes to help enroll cohorts of patients in programs to get to outcomes. In the future, he said he sees EHRs, personal health records and HIEs with a care management record layered on top that will serve as “air traffic control for continuous wellness.”

One way to drive down healthcare costs is looking at social determinants, said Stack. A lot of emergency department patients are uninsured and have societal needs, such as housing and food, he said. “Instead of having people come to the ER for food when it’s cold out because they don’t have shelter, we need to find a way to address shelter. We could easily take out 10 percent or more while improving quality of care and we could stop tormenting every doctor, nurse and hospital by overlaying all this other rubbish on top that isn’t helping anybody but sure is infuriating a lot of people.”

Technological advances have reaped both benefits and obstacles. “Technology has decreased our ability to communicate but increased our ability to talk into a database,” said Dreyer. Many physicians are distanced from colleagues and patients, and are fearful of Stage 2 because “we might have to talk to a patient about their results and make sure we don’t offend a referring physician by going to the patient directly.”

The technology exists to solve communication problems, he said. “We just don’t have the methods and standards of care and practice in place for those communications to occur.”