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Health Affairs Policy Briefing, Washington, March 10

Posted Jun 03 2009 4:52pm
The journal Health Affairs held a briefing introducing their March issue featuring health care information technology.
The speaker agenda included
Pioneering Initiatives
  • Louise Liang, Kaiser Permanente
  • Farzad Mostashari, New York City
  • James Walker, Geisinger Health System
Industry Perspectives
  • Peter Neupert, Microsoft Health Solutions Group
  • Colin Evans, Dossia Consortium
  • Alfred Spector, Google Inc.
  • Neal Patterson, Cerner Corporation
Health IT and Privacy
  • Deven McGRaw, Center for Democracy and Technology
  • Linda Dimitropoulos, RTI International (unable to attend)
  • Deborah Peel, Patient Privacy Rights Foundation
A Public Policy Discussion on Health IT After HITECH
  • Robert Kolodner, Office of the National Coordinator for Health Informaiton Technology
  • Mark Smith, California HealthCare Foundation
  • Carol Diamond, the Markle Foundation
  • Jon White, Agency for Healthcare Research and Quality
The meeting was well-attended. Indeed, there was overflow and for some time, people were sitting in an adjacent room staring at a blank wall waiting for the wall panel to open to the broader room.

There was consensus on decoupling data, consumer-focused medicine, and privacy. Farzad Mostashari described how implementing his system did not make life easier all of the time, often took more effort and time from practitioners, and did not always make them happy. Jim Walker gave a nice overview of how Geisinger is now working across their traditional organizational boundary and fostering medical homes among individuals who do not have strong relationships with Geisinger.

Colin Evans, when speaking of privacy, said of Washington DC that "nobody minds the answer to a question as long as you ask the wrong question." He says the right question - not answered - is how to get information to consumers. Spector from Google and Neupert from Microsoft both gave a similar perspective. Neal Patterson provoked asking why we did not have a national patient identifier and why we tolerated the financial chaos and transaction confusion of our current system. In discussions, Alfred Spector spoke in greater detail about the tension between innovation/risk-taking and the top down plan approach.

Deven McGraw said that "privacy is the enabler, not the obstacle." She cites that 1 in 6 people exhibit privacy-protecting behavior. She said that work needs to be done, including re-examination of "health care operations" and when personally identified data are really needed. She is concerned about protection for information in personal health records - particularly when they are not HIPAA covered entities. Consent is critical but not sufficient; one needs an enforceable floor of protections; she raises uses that may be absolutely prohibited (e.g., genetic non-discrimination); she raises a common concern about "downstream" use. She wants to make sure applications are somehow addressed. she did not raise the "transitive trust" raised by others.

In a talk entitled "Privacy after ARRA," Deborah Peel spoke of her background in Freudian analysis and the critical role privacy paid in the treatment of her patients. She is optimistic about the role technology can provide in assuring privacy. Her primary concern is on the impact breaches have on denying jobs, credit, insurance, education, and other opportunities. What ARRA did (Peel)
  • No definition of privacy
  • Right of consent not restored
ARRA: new Rights
  • Ban on sales of PHI
  • Segmentation (the right to segment sensitive information)
  • Audit trails x 3 years
  • Breach notice
  • Encryption
  • Right to restrict disclosure of PHR if payment and HCO are paid out of pocket
  • Preservation of the therapist-patient relationship
Peel argues for a "single source" for consent and significant granularity. She also plugs health record banking.

Rob Kolodner began on a humorous note by reminding the audience that in contrast to Dr. Peel, Dr. Kolodner's psychiatric training in St. Louis as a "Renardian" his approach was more data driven. (Only psychiatrists can fully appreciate this pun).

Kolodner gave an excellent overview and spoke of the four principles of the current strategic plan. He points out that Congress gives us room by not over-specifying "qualified record," "meaningful use," and other terms. He reassures that the plan will be aligned with health care reform. His goal is to realize $10 impact for every dollar spent. ARRA is about increased quality with decreased cost, in his view. There are four things that are necessary: must have an impact on standards; standards have to be sufficient but need to be able to move the entire record even if standards don't exist; need to be able to eliminate the disincentives associated with health information exchange; need to move forward with quality reporting; need to unleash innovation. Dr. Kolodner claims that resistance is from people who were in the initial wave and who aren't pleased that the wave has passed.

Mark Smith of the California Healthcare Foundation, gave a rousing sermon-like talk emphasizing three major themese
  1. Reimbursement. In Hawaii Kaiser visits dropped 20% but the incentives are such that such a move is OK there but would not be acceptable in fee-for-service organizations. He wants IT to "unleash us from the tyranny of the visit."
  2. Comparative effectiveness. At present, your incentives are to get as big a grant as possible for as long as possible leaving at the end no impact on the delivery system whatsoever. We need to break out of the paradigm of "research-only data streams." A Wal-Mart spokesperson once said "we know more about a box of cereal than you know about a patient you've cared for over 10 years,"
  3. Regulations that entrench encumbents. He said we need to address the regulations that protect the incumbents. He described Amazon and Travelocity - new organizations in the world that could not happen without enabling IT. The goal is not to wire the incumbents to do what they do more quickly. We don't want to limit our approach to wiring the incumbents (through definitions of "interoperability" and "meaningful use") and if we do this, we just "give the book store a computer" rather than bringing forth forms of service that we cannot yet imagine. He cites "OpenTable" as a model for bringing to smaller practices the capacity they need for "kaiserness."
Carol Diamond summarized the scene as follows:
  1. The world of health IT as we know it has changed and we have to get it right; the is an unprecedented push towards accountability
  2. Getting it right means using IT to stimulate health improvements
  3. Rapid innovation is essential; there is a new and pressing need for new services and technologies.
  4. There is a new demand for assessing population health and improving decisions at the care level.
Jon White gave a brief closing statement thanking the participants. He argued strongly and eloquently for sober, thoughtful and critical evaluation at every step of the way who are involved in implementation.

The Health Affairs briefing was remarkable for the common themes and for the relatively rapt attention of a rather large group. Unlike many Washington meetings, most people sat through over three hours of presentations and rarely stepped out to talk or consult their blackberries. These are the same people who have been watching and participating this scene for a long time. One gets the sense that things are changing and that everyone is somewhat in awe of the enormity of the challenges ahead. Perhaps they agree with Dr. Diamond as I do: this is an era of unprecedented opportunity and equally unprecedented accountability.
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