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HIStalk Interviews John Halamka

April 7, 2010 Interviews 18 Comments

John D. Halamka, MD, MS, is chief information officer of Beth Israel Deaconess Medical Center; chief information officer at Harvard Medical School; chairman of the New England Healthcare Exchange Network (NEHEN); chair of the US Healthcare Information Technology Standards Panel (HITSP)/co-chair of the HIT Standards Committee; and a practicing emergency physician.


How would you describe, if you had just a couple of minutes, how stimulus funding will change healthcare IT as an industry?

If I look at my own region, we have docs who were all waiting on electronic health record implementation because there wasn’t a value proposition. They said, well, gee, you know I can get this Stark safe harbor, I know the hospital can help out, but still, my office manager’s going to quit. I’m going to lose productivity for three months … what a hassle.

Now with the HIT stimulus funding, they say, “Wait a minute. I get 85% funded by the hospital and I get to keep the $44,000 when this is all done? OK, where do I sign up?” It’s truly accelerating physician adoption by motivating them to move forward.

What I really like about Meaningful Use is it is constructed so that the doctors are paid only when they’re done. That is, it isn’t go buy hardware and software and it’s going to be Christmas for vendors. It’s the fact that docs then have to e-prescribe, and docs are going to have to share data with patients, and docs are going to have to use quality measures. Only when you do that do you get paid.

The mindset of the clinician is, “Ah, I’m going to do it, and now I know exactly what I have to do. Help me out.” So I, as a hospital organization and my community, can work together to make all that happen. It’s an alignment of industry, academia, and practices like I’ve never seen before.

Do you think there’s a risk that they’ll get enticed enough to at least start the journey, but then because of usability issues or just lack of time, it will never really go anywhere?

I wrote a blog, which some people have criticized me for, that said I actually trust ONC. David Blumenthal and the gang he has put together are very good people. If what they discover is that, as we are actually rolling this thing out that there are barriers, then I believe they’re going to help everybody work through the barriers.

I really don’t think that this is a disconnected ONC that is going to force us to do things that are too hard and are going to first, people, as you described, to begin the journey and then fall off. What they’ll say is, “We’ll build the toolkit. We’ll help with the accelerators. We’ll break down the barriers. We’ll make sure you have the resources.” I actually feel good about people getting to the finish line.

Do you think it was a mistake to combine what should be a fairly thoughtful introduction of electronic health records with the urgency of stimulus funding?

My experience in healthcare IT is, unless you create a sense of urgency, nothing gets done. I would rather see us all move forward with great haste and get as far as we can, then along the way do a mid-course correction, than to say, “You know, we’re going to wait five years and then we can get it perfect.” There’s a lot to be said for moving the industry forward now.

These are not new products — they’re the same ones doctors didn’t want before. Do you think there will be some buyer’s remorse?

I love seeing the vendors react by creating new functionality. Certainly they’re much more open to healthcare information exchange and patient engagement than ever before, so in some respects, yeah. It may be products that have existed, but there are feature sets that have never existed.

Then with the modular EHR certification approach that’s been proposed, there’s a capacity for combining many EHR and EHR-lite together in a way that’ll get docs started. I think there’ll be new market entrants, but new features. I don’t think it’s going to be business as usual.

Will there be time for new market entrants given that people have to get on the train really quickly?

I’m now driving, actually, through Westborough, Mass. where eClinicalWorks is located. What I’m seeing these guys do is focus on patient portals. Something called provider-to-provider exchange. It’s like a Facebook function. They’re introducing all this new stuff very, very quickly.

I know the timeframes are crazy, but they have been able to innovate to adapt to ARRA requirements pretty rapidly. You’re seeing Athena move out its athenaClinicals product pretty rapidly. Software as a Service is becoming more and more common, and probably it’s because of thinner, Web-based Software as a Service architectures they can move fast enough to meet some of these deadlines.

What do you think is the majority of the work that needs to still be done to really get us down the path to getting potential benefits?

80% of what I do is people, training, workflow redesign, and process re-engineering. Only 20% is the technology stuff. When I write blogs about this stuff, I just focus on the workforce, focus on the people, and focus on the change management. That’s all the really hard work.

Yes, there are things that have to be done in Washington; and as you’ve seen coming out of ONC in the last week, consent models. How, if we’re going to do information exchange, do we ensure the patient controls the flow of their information? How do we do simple things like controlled substance e-prescribing, making sure that the workflow around writing Lipitor and writing OxyContin is pretty similar? How do we ensure that?

No interoperability’s ever going to be totally plug and play, but if it’s not USB drive kind of plug and play, can at least it be a couple hundred dollars, not a couple thousand dollars, to get a lab interface? It’s the work on specificity, on content, and transmission that still need to be done. All of this stuff on process transformation and workforce development, primarily, and then some of these things the Policy Committee and Standards Committee are doing on privacy, doing things like e-prescribing clean up and making the standards easier to use and more prescriptive.

Do you think federal funding makes it too easy to forget there are workflow changes involved?

I just met with these folks at Lawrence General and they had thought they were ready to go into a procurement phase. I said, well, let’s look at what Meaningful Use really requires. You know, what is your strategy for your local public health interface? What is your strategy for bi-directional data exchange for the community? “Oh yeah, this is a whole lot about workflow, isn’t it? It’s not about bits and bytes.”

As people begin to understand Meaningful Use, they really will understand the community and the workflow and not just the products.

You mentioned privacy. Are there currently debates going on about what form that should take or who should be involved?

I think there are two kinds of architectures that will protect privacy. One of my favorites, of course, is the idea that the medical home, the patient, becomes the steward of their own data. We send the data to them and they elect privacy preferences — who and what they’re going to share with.

Alternatively, of course, there is the clinician-to-clinician exchange. That is really going to require a persistent declaration of patient privacy preferences as to OK, if I the patient am not going to directly control it, how can I declare my preferences of those who do exchange data; whether it’s providers, payers, public health, etc. always use my declared privacy preferences when data is being exchanged?

The HIT Standards Committee, over the course of the next few months, is going to be taking testimony on what standards exist that will help support such a thing. That in combination with work on the policy side and such things as the consent white paper, I hope get us to a place where either EHR to EHR or EHR/PHR/EHR exchanges are ultimately controlled by patient preference.

You mentioned that a lot of data will be collected and exchanged. When will we start seeing the benefit of all the EHR-created data that isn’t out there now, and who do you think will use that to advance the practice of medicine?

Of course, 2011 is more about getting the data in electronic form to begin with; and 2013 more about getting data exchanged. But some beacon communities. some early adopters, I think, by 2011 are going to have substantial improvements in data sharing.

In the Boston area, I funded the creation of a quality registry for 1,560 providers that are loosely affiliated with Beth Israel Deaconess so that we begin to do all of our pay-for-performance, all of our PQRI and Meaningful Use reporting, as a community, rather than as a bunch of individual point-to-point connections. We’re doing public health reporting for the city of Boston in a common way as a community. All of this will be live in 2011. So for some, 2011. For many, 2013. For the majority, 2015.

Do you think there should be a relationship between having more technology and being able to deliver care less expensively?

That is a very good point. What we all want to achieve is high-value care where reimbursement is based on quality rather than quantity. I think the answer to your question is a couple-fold, but everything that I do these days is Software as a Service. I’m able to deliver an EHR at a lower cost than normal because the fact that I have so many clinicians sharing resources, sharing a data center, and sharing interfaces.

My hope is that I can at least, from my IT perspective, reduce the cost of implementing Meaningful Use. Then, we will gather data from a quality perspective that can be used in accountable care organizations and new mechanisms of reimbursement so that, as you pointed out, reimbursement will be fair based on the outcomes that are achieved.

Do you think technology is ready to help offset or mitigate in some way the shortage of primary care physicians?

This is an excellent point. What you hope, coming out of healthcare reform, is differential payments for primary caregivers and accountable care organizations. If I look at the Harvard Medical School experience, the number of folks going into specialty or procedural areas far exceeds those going into primary care. If you’re going to have effective reform, if you’re going to have lower costs, we need more primary caregivers.

Sure, as you point out, maybe technology can help us use extenders wisely so that whether that is some tasks can be delegated to nurse practitioners, physician assistants; some decision support can be offered in the Cloud so that we are delivering coordinated and better care more effectively by using technology rather than physician time for every intervention. All of this still presupposes that we have the primary caregivers who can actually be at the center of the medical home. In my view, you need to redo reimbursement so that the primary caregiver is the one making more than the specialist, not vice versa.

What about telemedicine?

We use telemedicine today to connect rural or community hospitals or emergency departments with downtown Boston for the provision of such things as stroke consultation in real-time for the administration of TPA in stroke. You’re able to leverage the academic health vendor in a far greater reach through the use of telemedicine.

I’ve had a lot of experimentation with remote visits, home monitoring, and again, leveraged telemedicine as a mechanism of making a primary care physician more efficient. Actually, the patients like it because they don’t have to travel into the city. Or, doing interventions like measuring blood pressure, measuring daily weight, and then having a team of nurses doing home care remotely and keep people out of the hospital. I certainly agree that telemedicine can have a role in reducing cost and using time more efficiently.

What do you think the Nationwide Health Information Network is going to look like and when will we start seeing it deliver benefits?

You’re probably familiar with the NHIN Direct efforts that have been kicked off over the last two weeks. The idea of a NHIN, obviously, it’s a set of policies and some open source technologies in reference to implementation to exchange data among various participants and provider, payer, government, etc. In NHIN Direct, the idea that there are some interactions that are simpler — pushing between two doctors, pushing to the patient.

Actually, what you hope is if this becomes a fairly thin, Web-based mechanism of sending data from point to point at very low cost. Here’s an idea. What if every person who wanted to participate in a patient/doctor exchange could sign up for a healthcare URL? Many people — Microsoft, Google, Dossia, who knows, various software vendors — could offer this health URL and all you need to use it is you take it to your doctor and say, “Doctor, here’s my health URL. Every time there’s an entry in my record in your office, push the data to this health URL.” There’s no HIE, there’s no transaction fee, there’s not a lot of complex business structure needed. It’s just an HTTPS post.

What I hope is that sure, for governments, for larger organizations, there will still be a NHIN that has quite a lot of security in its infrastructure, But you hope for a lot of connections that can be as simple as the home banking connection you have with an HTTPS post and it just bakes right in to every EHR.

Some of the folks that have gone into federal service work lately are interesting, like Todd Park and Don Berwick. What do you think that means that people who aren’t lifelong civil servants are popping up out of the private sector and going into federal work?

Knowing Aneesh and Todd and Don Berwick pretty well, these are people who have passion. They’re now able to see change is possible and resources are available. I think they believe that, in the current administration and the current time in history, it’s not business as usual and they’re willing to put in their energy and their passion to making change.

That’s why I write in my blog, these truly are the good old days of healthcare IT. I know I’m putting a significant portion of my time into state and federal efforts on a volunteer basis just because I believe I can make a difference.

You mentioned that you have a lot of respect for ONC as an insider to this whole process. Was the outcome what an idealistic person would have expected, or was this such an ugly compromise that nobody leaves happy?

I will tell you, sitting in the HIT Standards Committee and the Policy Committee and on calls with ONC; the amount of positive energy, as opposed to the amount of negative energy and compromise, is totally different than any other process I’ve been involved in in the past. People who have very different opinions come together and they say, “God, here’s what I want to achieve to improve patient care and quality and efficiency.” Everyone says, “Well, there’s two or three ways we could do it.” I’ve seen harmony rather than ugly compromise come out of each of these processes. That’s why I’m very optimistic.

When you look at your own organization, what are your biggest challenges and highest priorities at Beth Israel Deaconess?

I’ve laid out a 25-step plan to implement Meaningful Use across the organization. The hardest part of it is it is not just one actor. It is not just a hospital in an island. It’s ensuring that you have trust in your community so that you can do these data exchanges across the various providers, public health, payers, and government. It’s been relationship-building more than technology implementation, in my 25 projects, that’s my hard work.

Is there anything else you wanted to talk about?

I just have to say that you do a great service for humanity. Somebody has made this comment to me, that you have become not the National Enquirer, but The New York Times of our industry. It’s built on transparency. People, just like all the stuff I’m trying to work on, are no longer afraid of this special interest or that special interest. It’s everybody opening up and just trying to get the job done. I think you’ve been a big part of that.

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Currently there are "18 comments" on this Article:

  1. A great interview with Dr. John! All of us working together positively can bring profound change where it’s needed by everyone from the patient to the healthcare providers and payers!

  2. I honestly believe that you believe your own wordsThank you! Well ill check later because im at work John. I do not .as the future begins to unveil the legal nightmares ahead and the rush to legitimize unsafe medical devices is examined as the wild and reckless 49er Gold Rush of the century the HIMSS-HIT standards group will be judged accordingly. Unfunded mandates and proclamations of minimal standards of safey will never be acceptable. HIT economists on the order of Greenspan , Brailer et al have allowed greed and negligence to prevail over care and prudent testing before introduction. Too many chips John.

  3. Mr. Histalk, this is a great interview! You asked some very interesting questions, and some very blunt questions that main stream media should have asked: “These are not new products — they’re the same ones doctors didn’t want before. Do you think there will be some buyer’s remorse?”

    I would like to know how a person becomes a member of an HHS committee. How is that “volunteer” selected, is it by nomination, recommendation? And does that person have to disclose ALL their affiliations and positions with other organizations and/or businesses, so there is not a conflict of interest?

    I noticed there is a mix of people in each committee, but who gives the final stamp of approval for every person on every HHS Committee–and that includes the Standards Committee, Policy Committee, and the Privacy and Security Committee. Is that David Blumenthal M.D.?

    This interview was a nice surprise. You are really honing your craft. Keep up the good work!

  4. Articulate comments Mr. Halamka. Is it possible there is enough Kool Aid to go around for all the providers in the country? The government has put out the forumula for it. The vendors seeking certification are making huge batches of it. Are the providers going to drink it?
    Does anyone believe that the same set of “meaningful use” specs are as relevant for primary care, in-patient care and ALL specialties? That all should produce the same data…on the same patient…and it should all be in sync? And all be forwarded to the same registries/data aggregators and be easily interpreted as non-overlapping? Or that providers will know what the they have to do to prove “meaningful use”, even if persuaded to use a “certified” product that may not be a good fit for them because the vendor has little or no experience in that specialty?
    My fear is….Never has so much work been done by so many people that has led to so much confusion and ambivalence in the history of projects. Warren Buffets investment strategy has been described as very simple: “If I don’t understand it, I don’t invest in it” Seems the same might be good advice here for providers.

  5. I agree here, very good interview. One thing we can always count on with Dr. Halamka is the fact that he’s a “hand on guy’, in other words as well as his word of wisdom in health IT, he rolls up his sleeves too, and that may well be where some of the wisdom comes from too.

    Today technology is throwing us a new “left curve” every day so keeping up with new developments and technologies is a challenge.

    I can’t think of any other CIO that has been both sequenced and chipped either, and openly shares those experiences on his blog with all from the participant level and all with a great level of passion; it shows:) A few more clones of Dr. Halamka in healthcare would be awesome:) Again, great interview and good content here for all.

  6. Good interview for a well funded hospital and physician group. Now apply this logic to the rest of us. It does not pencil out correctly.

  7. Wonderful interview, Mr. H, but what is stated remains suspect.

    The process is rife with financial conflicts,a paucity of accountability, and insufficient integrity.

    Upon Halamka stating : “What they’ll say is, “We’ll build the toolkit. We’ll help with the accelerators. We’ll break down the barriers. We’ll make sure you have the resources.” I actually feel good about people getting to the finish line.”,

    I wonder if Halamka will disclose how much he has been paid by HIMSS, Leapfrog, and other HIT zealot “educational” nonprofits to proseletyze the religion of HIT.

    On that matter, there are many on the ONCHIT committees who are conflicted, like being on theBoard of HIMSS. Who on these committees is a naysayer? Halamka is a smart hands on professor who is trying hard but remains the king of the yes people.

    Omce the devices he promotes have been approved by the FDA and the conflicts and cover-ups are outed, he might have more credibility


  8. I’ll second the congratulations: this interview is the best I’ve read on HISTalk since I started following it back in January. Dr. Halmaka’s blog always provides a great prospective, and to see his passion combined with the HISTalk method of truth-finding was great. The questions were ones that everyone in the industry is asking, with they admit it or not.

    The speed/urgency issue is especially a concern for many. I understand Dr. Halmaka’s point, since I too have been part of organizations where a little urgency was needed to get the wheels moving. To use a health example, though, I’d like to respectfully say that there’s a difference between eustress and distress in terms of beneficial output. With none of the three rules in their final version yet, no accredited certifying body or certified products, and hospital payouts set to start in October, I think there’s a lot of distress building up for people who simply haven’t devoted the time/energy toward understanding HITECH and meaningful use.

    I’m also a bit unsure/wary of the “do it now, fix later” proposition presented. While I think all the MU requirements are laudable goals, and the ONC is doing everything it can to start this program correctly, there’s still a lot of work to be done, especially in terms of privacy and flexibility. The blessing and the curse of MU is that the user and not (just) the product is responsible. Assuming June sees both ONC-ATCB and certified EHRs available, the idea that a four-month window for hospitals (or seven for EPs) will allow a sufficient time investment for the training and workflow changes required sounds a bit like the classic Star Trek bit: no matter what technical barrier Scotty presented, Kirk or Spock always found a way around it to save the Enterprise. I certainly hope the ONC is as capable at finding solutions to provider barriers, even without a magic TV script to show them how.

  9. RE: 80% of what I do is people, training, workflow redesign, and process re-engineering. Only 20% is the technology stuff.

    I fully agree with this statement. Now explain where we can find enough of these talents, and who /how we will pay for them? I know the feds have set up funds for training more people to do installs but it takes years before you can take a person from the classroom and put him in the field.

    What I fear is an avalanche of blown installs, with repercussions that set us back decades. That is the real risk of a too hasty federal program.

  10. Suzy RN writes: Omce the devices he promotes have been approved by the FDA and the conflicts and cover-ups are outed … I think Dr. John (via his blog) is pretty transparent with his vendor involvements & disclosures — promoting devices??? — I found he sits on the advisory board of one for-profit (Humedica).

    I’m a believer; healthcare reform has been needed for awhile now and – knock-knock; it has begun.

  11. Halamka forgot about one problem when he uttered “It’s an alignment of industry, academia, and practices like I’ve never seen before.”

    *The so called “alignment” is all about money and not about patient safety.

    *The equipment that is being sold to be meaningfully useful may be meaningfully unsafe with adverse consequences to patients with extensive implications.

    *Matters of patient safety have been ignored.

    * Halamka should put his hospital’s help desk complaints and hospital deaths (at MGH too) where his mouth (clicker and keyboard) is. Nothing less than full disclosure.

  12. As a primary care pediatrician, fan of community efforts, believer in patient-centered healthcare, telemedicine touter, and advocate for “let’s all share the sandbox nicely,” I can’t help but appreciate Dr. Halamka’s comments. (Especially, the part about the primary care doc making more than the specialist! – Is that really thinkable?) Plus, I fully agree that HIT biz isn’t going to be business as usual, not for long.

    But, my snarkism was completely assuaged with the comment that Mr. H and Inga have created “The New York Times for HIT.” Couldn’t agree more.

    John, you’re either one smooth talker, a pro at creating sound bites, or a dedicated HIT man who has some superior vision through all the currently muddy waters. Feeling glass-half-full-ish, I’m going with the latter. I’m a fan. Thanks for sharing your thoughts here.

  13. The big and simple revelation here is the notion of a “Patient URL”. I do think it’s easy to implement such a solution which is open. The technology for this already exists.
    A Patient URL can be an OpenID – Google, Facebook … and if a set of simple REST Apis were defined for the interactions which not only include updates from the doctors but also interaction – appointment requests, questions to docs .. You could easily use standard technologies like OAAuth for authentication ..
    Should be much simpler for any “Patient Portal” the patient uses and any EMR that the doc uses to communicate with each other using standard technologies that already exist.

  14. This business is about the binaries, 1 and 0s. It’s all about packet switching technology and not about patient safety or healthcare. The idea of do no harm is missing and was apparently left out of the EHR business model with 2 major components of the traditional medical record ; case history and bedside notes. What the EHR does is not built upon patient centric care, it is built upon physician orders and financial ledger entry. Evidently Brailer felt that’s all that is needed.the patient centric-safety side of this has been removed and replaced with gag clauses running over speedy, very speedy packet switching networks. It don’t make no never mind don’t apply here…

  15. “…you do a great service for humanity.” Yikes! A little superlative overkill? A great service for the industry… absolutely.

    Hey… looks like visitor # 3MM is about to walk in. Got your party hats and noise makers at the ready?

    [From Mr. HIStalk] I admit that my efforts aren’t generally humanitarian in nature, but I figured if John Halamka wants to say it, who am I to argue?!!

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