While at Dreamforce 2022, one of most thought-provoking things I heard was that, in order to really meet the needs of the healthcare consumer, we in healthcare need to once-and-for-all let go of the idea that there will be “one tech system to rule them all” and adopt an “and both” approach that integrates both the EHR and a CRM. The EHR is how we’ll “know the patient” and the CRM is how we’ll “know the customer.”

Dr. Geeta Nayyar, Salesforce’s SVP & Chief Medical Officer and Amit Khanna, SVP & GM of Salesforce’s Health & Life Sciences business join me to unpack this “and both” approach to infrastructure technology and talk all-things healthcare consumer. The paradigm shift that comes with this duality – we are at times “patients”, we are at times “customers” – is a big one. Especially in healthcare.

Dr. G speaks to the strategy that Salesforce is operating under to take its tech further into the healthcare and life sciences space, while Amit introduces us to some of the new Healthcare 360 product features launched at Dreamforce that fully show-off Salesforce’s expertise at integrating different technology solutions (Slack, MuleSoft, telehealth) and making perfect sense of massive amounts of real-time data (longitudinal record, health scoring).

As Salesforce advances further into the health market with more care-forward features in its CRM and a strategic focus on healthcare-important issues like improving equity and access to care, will our traditional view of the importance of the EHR change? What if the replacement tech comes with ‘self-service at-scale’ and more ‘seamless experiences?’ Could we head away from “and both” and choose CRM “instead of?” Tune in – the EHR IT infrastructure may have finally met its match!

One in a series of interviews that should have been posted months ago, but Matthew Holt is just getting to now.

Nearly 20 years after it was a glimmer in Todd Park and Jonathan Bush’s eye, athenahealth remains the prototypical cloud services company in health care. Todd Rothenhaus, the Chief Medical Officer, has been at athenahealth for 7+ years and leads athenaClinicals (the EHR service). At HIMSS in February 2016, Matthew Holt chatted (at some length!) with Todd Rothenhaus about athenahealth’s platform and the evolution of their products. Check out the interview here:

https://www.youtube.com/watch?v=MI-TjHOoX4s

Priya Kumar is an Intern at Health 2.0, and a student at George Washington University

The US has spent several billion dollars on medical records, as part of the HITECH program. The goal of that spend was simple: portable medical records for patients. On our current path, we will have medical records, but without that magic word: “portable.” Ironically, the reason for this is identical to the root-cause of the problems with healthcare.gov

The root-cause of the initial failure of healthcare.gov was a lack of accountability and empowerment. There was no one person who was in charge of the operation, and those who were presumed to be in charge did not have the skill-set or political clout needed to make decisions about the project.

The result was the healthcare.gov train wreck. Thankfully, healthcare.gov was turned around.

That turn-around was the result of decisively fixing these exact issues.

Accountability restored, disaster averted.

You would think that the Obama administration and HHS would have learned the “accountability with empowerment” lesson well, if not for IT projects generally, then at least for projects involving Health IT.

Yet we are repeating this mistake with Meaningful Use. For those who are living in a cave with regards to healthcare reform, Meaningful Use is a set of standards designed to ensure that the money that the federal government spends on Electronic Healthcare Records (EHRs) for doctors results in clinically productive outcomes.

If the Federal government did not have some kind of standards for EHR systems, then  doctors might choose to install some Microsoft Word macros and claim that they should be counted as EHR systems, and qualify for funding. (I wish this was a joke. I make such good jokes usually… but this is not one of them.  I have heard doctors claim exactly this.)

You would think that after the Healthcare.gov disaster, there would be one person whose job it was to make sure the deployment of EHRs by doctors in the United States was going to work. A person who had no other job responsibilities but to make sure that records were “portable”. Someone who had all of the authority and skills needed to make EHR adoption, including “portability”, a reality.

Currently, there are two “versions” of Meaningful Use. One of them is managed by the Office of the National Coordinator of Health IT (ONC for short) and the other by the Centers for Medicare and Medicaid Services (CMS). For those unfamiliar with these agencies, ONC is regarded as being “in charge” of Health IT matters in the Federal government and CMS is primarily tasked with paying doctors for work under Medicare and other federal insurance programs.

The ONC version of Meaningful Use applies to EHR software vendors. This component of Meaningful Use dictates what standards must be implemented by EHR vendors in order to have an EHR software product certified. The CMS Meaningful Use components apply to doctors and hospitals, who must prove that they use certified EHRs in a “meaningful” way. Both CMS and ONC are part of Health and Human Services (HHS).

Guess what? The two programs at CMS and ONC don’t actually work that well together. The process works as an uneasy collaboration between two “cousin” agencies within HHS, rather than two arms of a single effort.

Meaningful Use and the funding of EHR systems more generally have been soundly criticized elsewhere, but this interoperability issue is a central problem. Meaningful Use was intended to fund interoperable EHR systems. In fact the supposed difference between Electronic Health Records and Electronic Medical Records (EMR) is that an EHR is interoperable, at least according to ONC. We have spent billions of dollars on digital medical record systems and for the most part they don’t talk. Which is to say, we were sold EHRs, but we got EMRs.

I am one of the architects of the Direct Project (or just Direct for short), which was expected to help resolve the problem of interoperable Health IT systems. The Direct Project created the Direct Protocol, which is a standard that was created by an Open Source community specifically for inclusion in the second version of Meaningful Use. Direct is one possible solution to the interoperability problem.

Recently, I asked “Why isn’t Direct being adopted?” as part of an ONC townhall at a Health 2.0 conference. The answer was basically “That’s a good question, we wonder the same thing…” I took it upon myself to figure out the answer.

Since then I have been digging into the root causes of the failure of the EHR marketplace to adopt Direct (or some other compelling interoperability solution). I have spoken to dozens of people in the Health IT industry about this issue. I think I have discovered most of the major problems, which are all complex technology and policy interaction issues. Who should I give my findings to? No one is a position to rescue the roll out of interoperable EHR systems.

In order to jump-start interoperability, both EHR vendors and healthcare providers are going to have to adjust how they operate. Because ONC works with vendors, and CMS works with doctors, there is no one person capable of addressing all of the issues that have crippled interoperability efforts.

Technically the words “National Coordinator of Health IT” imply that person who holds that title should be in a position to manage precisely this process. But the people who run Meaningful Use incentive payments at CMS do not currently report to the ONC.

As far as I can tell (from this org chart), the first place that the chain of command that the two agencies in charge of billions of dollars of Meaningful Use incentive payments meet is the office of the secretary of HHS, currently Sylvia Mathews Burwell. Unless Secretary Burwell is the right person for people like me to discuss the pros and cons of FHIR vs HL7v2 (which sounds like geek-speak because it is) … then we have an accountability problem that is essentially identical to the one we had with Healthcare.gov. This is so high up the command chain that one might continue one step higher and involve Obama himself to sort out the issue. That is not actually that far fetched, since that apparently did happen with healthcare.gov. Can you imagine? At one point the President of the United States was in the Oval Office pressing “refresh” on his browser to sort out what the problem with healthcare.gov was. We are not yet there with EHR systems, but we are on the way.

Moreover the current ONC is not “just” the ONC. Karen DeSalvo currently acts as “assistant secretary for health” as well as her duties as ONC. Doctor DeSalvo and I share mutual friends and I have it on good authority that she is super-competent, just like all of her ONC predecessors. (Farzad still wears me out with his energy). This is why, I think, that she was tasked with being the “Ebola Czar”. She is exactly the kind of person we needed in that role, having her quickly shift into that role probably saved lives.

But as she took on that new role, Doctor DeSalvo never stopped being the ONC. DeSalvo cannot do two overtaxing jobs effectively and even if she was the ONC for 100% of her time, that role is crippled with regards to Meaningful Use. She still would not be in a position to make the needed changes. Even if she was put in that position, her strong suits are connecting clinical concepts with policy considerations, while she is technically competent, she is not primarily a technical expert.

This country may spend as much as $20 billion dollars on software for doctors. No one in Washington is going to have the political will for another round of funding for this problem. We are only going to get one shot at installing medical records.

The advertisement made for these dollars, is that healthcare consumers in the United States would be able to have portable healthcare records. But it looks like the American taxpayer is going to spend billions on systems that will not live up to the promise. Sound strangely familiar? It sounds just like Healthcare.gov doesnt it?

The Obama administration needs to get someone who does nothing but Meaningful Use and EHR interoperability. They need to put that person in charge of the process at ONC and CMS. They should appoint a new ONC and make that person report to Karen DeSalvo rather than having her try to wear two hats. Someone needs to be the Czar of “Record Portability”. That person should understand, intuitively geek phrases like “FHIR is based on RIM, but can be expressed in either XML or JSON ”, and have the power to make fast and substantial decisions about interoperability and other critical Meaningful Use policy decisions.

Fred Trotter is a healthcare data journalist and author. He is a founder of CareSet Systems and The DocGraph Journal

A Facebook user’s timeline provides both a snapshot of who that user is and a historical record of the user’s activity on Facebook. My Facebook timeline is about me, and fittingly, I control it. It’s also one, single profile. Anyone I allow to view my timeline views my timeline—they don’t each create their own copies of it.

Intuitive, right? So why don’t medical records work that way? There is no unified, single patient record—every doctor I’ve ever visited has his or her own separate copy of my records. And in an age where we can conduct banking transactions on my smartphone, many patients still can’t access or contribute to the medical records their doctors keep for them.

My proposal? Medical records should follow Facebook’s lead.

On Facebook: The “about” section is the one that most closely resembles the concept of a user profile. It includes a picture selected by the user and lists information such as gender; relationship status; age, political and religious views; interests and hobbies; favorite quotes, books and movies; and free-form biographical information added by the user.

“Privacy Settings” and “Permissions” for Controlled Sharing

On Facebook: Privacy settings allow users to control who can see the information they post or that is posted about them. For example, in my general privacy settings I can choose to make my photos visible only to the people I’ve accepted as “friends.” However, if I post a photo I want the entire world to see, I can change the default setting for that photo to be visible publicly instead.

Facebook also allows users to grant “permissions” for outside applications to access their profiles. For example, let’s say I use TripAdvisor to read travel reviews. TripAdvisor lets me sign in to its site using my Facebook account, rather than creating a separate TripAdvisor account. But, to do this I must grant TripAdvisor “permission” to access my Facebook account.

Additionally, a patient could grant “permission” for other doctors to access their records. When I visit a new doctor, rather than signing a form granting my previous doctor permission to fax over copies of my records, I could simply grant permission electronically within the record–and presto! The new doctor would have instant online access.

On Facebook: “Status updates” let Facebook users broadcast what’s going on with them at a given moment. (For example, my status update might say: “I just had a great idea for improving medical records.”) A user’s latest status update appears toward the top of the timeline; older statuses can be viewed by scrolling through the timeline.

“Photos” for the Online Delivery of Test Results

On Facebook: Users can upload pictures they’ve taken. Photos are organized into albums that are visible on the user’s timeline. There’s also a special “photos” section where viewers of the timeline can go to see all of a user’s photo albums.

“Tagging” to Involve Other Parties and Track Common Themes

On Facebook: Users can “tag” other users to indicate their involvement with the content being posted. For example, when I post a picture of myself with a friend, I can “tag” the friend in that photo. This ties the photo to both our timelines instead of just mine. It also triggers a “notification” to the friend that she’s been tagged. She can remove the tag if she doesn’t wish for the photo to be tied to her timeline.

“Notifications” for Test Result Alerts, Medication Alerts, or Preventive Care Reminders

On Facebook: Users are alerted by red “notification” messages when another user writes them a message, posts a picture of them or otherwise interacts with their profile. These notifications are a way to make the user aware of interactions or information involving them.

“Check-Ins” to Denote Office Visits

On Facebook: Users can “check in” to places they’re currently visiting. For example, I could “check in” to the concert I’m at on a Saturday night. This would serve as both a status update and a record of my attendance of the concert. Photos can also be marked with places to record where they were taken.

“Friendships” to Track New Provider Relationships

On Facebook: Users can create “friendships” with other users when one party electronically requests a friendship and the other party electronically accepts. These friendships are marked on the user’s timeline (“Jane Doe is now friends with John Smith”) along with the date the online friendship was created.

“Events” to Track and Remind for Upcoming Appointments

On Facebook: Users can create online “events” to manage attendance and other details for in-person events. For example, I might create an event for the New Year’s party I plan to host, and I might invite my Facebook “friends” to that online event, where they could RSVP and receive reminders as the event date approaches.

It’s Time(line) for a Patient-Centric Medical Record

Dr. Rob Lamberts–a practicing physician, speaker, blogger, and health IT evangelist–tells me his biggest complaint with today’s digital record: “It’s not a patient-centered [medical record]; it’s payment-centered.” This he credits to the way the US health system has historically paid for healthcare, which is based on the volume of treatments rather than the quality of outcomes, requiring doctors to log complex medical codes into their EHRs.

Lamberts voices support for a timeline-like record, but he points out that the right incentives must be in place: “An improved record system like this would have to go hand-in-hand with a business model of medicine that benefited from it.” In other words, a business model which is patient-centric.

Luckily, this looks more like the direction the US health system is starting to take. Healthcare reimbursement models are slowly but surely shifting to reward physicians for better care instead of more care, and as that happens, technology providers will be incentivized to create solutions that align with that goal. Mine is to bring the magic of Facebook to medical records. But I’m open to other ideas that solve the patient-centric needs of tomorrow’s health ecosystem.