MAY

HIT Roundtable with HHS Sec. Mike Leavitt - meeting brief After introductions around the table, the Sec. shared his analysis of the HIT situation and potential paths forward, asking for feedback from the group at several points. As you will see from my notes, he finds parables and metaphors helpful in describing complex situations. The first metaphor for the healthcare industry he drew from the mechanism of a large antique clock in the Utah governor’s mansion. When servicing the clock, the technician demonstrated to the Secy’s young daughter that there was a maze of complex gears, large and small, inside. The small gears could not be turned by hand, since they were meshed with other, larger gears. But certain large gears could be turned by hand, and the small gears would then spin in response. He felt the large gears in HIT were 1) interoperability 2) adoption and incentives for adoption. He described e-prescribing, pay-for-performance and other efforts as “smaller gears”. The roundtable offered no real dispute with this concept. He then compared the interoperability problem to that of regional railroads, all having incompatible track gauges. Although the problem was solved in America long ago, it persists in Australia, and he fears that could be the fate of HIT in America if we did not address the problem definitively, and he offered three ways that standardization could occur: 1) “Prescription” of interoperability standards by the federal government. His opinion: doomed to failure 2) “Last vendor standing” -- endpoint of industry consolidation into a small number of powerful vendors. He felt this would still result in 2 or 3 different incompatible standards. 3) “Collaboration” – he described it as messy, disruptive, expensive, and painstaking, but the only successful model. He then further broke down the interoperability development process into 3 steps: 1) Development of the standard 2) Defining the architecture (i.e. defining the combination of standards and how they are implemented 3) Certification that products meet the standard Then he added that all of this should take place outside of the government. So, at this point, it’s sounding to me like 1=SDO, 2=IHE (or IHE+EHRVA+SDO), 3=CCHIT, although none of those were explicitly mentioned, and I think Steve and I were pleased with what we had heard. Next he outlined what he felt were appropriate roles for the Federal govt in the above process: 1) Convener 2) Early adopter (which can ‘move the market’ because of the large market share that govt represents) 3) Seed capital provider – selective funding of some early stage efforts and experiments There was some talk of where these seed capital investments might be appropriate 1) Standards development itself – govt already being the biggest funder of SDOs 2) Harmonization -- assess the landscape, close the gaps, harmonize conflicting standards 3) Architecture/infrastructure definition 4) Ensuring that HIT applications use the harmonized standards and architecture, improve healthcare, and don’t have damaging flaws such as security gaps The discussion became more fluid after that and the Secy floated some concepts that weren’t fully formed, and which provoked concerns from the group. First was a concept of “crystals” around which solutions could form: adverse drug event reporting, e-prescribing, lab reporting. To that, I countered that any incremental applications must always be part of a strategy to comprehensive electronic health records. The last idea was more of a bombshell – that of a new group to set the course, which he would chair, with “a small group of deciders” whose membership was “heavily biased toward federal agencies”, with additional “major stakeholders from the private sector”, and a more peripheral “group of advisors providing input”. This was not CSI – he positioned CSI’s role as “painting the broad public case for interoperability.” This idea came out just as we adjourned and really didn’t get discussed in the roundtable, but individual conversations were plentiful. Bottom line from my perspective: 1) I think we can expect Mike Leavitt to be very active in the HIT space, focusing on driving interoperability and adoption. 1) 1) In general, he’s following the directions set by Brailer’s office last July, but is already injecting some of his own new ideas 2) His support for the private sector as leading this was reassuring, but the concept floated at the end of the meeting -- a powerful uber-HIT group with a heavy federal agency composition – raised significant concerns. I’m hoping Steve will add his insights from the meeting as well. Mark Leavitt, MD, PhD Medical Director, HIMSS