HIStalk Interviews Doug Fridsma, CEO, AMIA

Douglas Fridsma, MD, PhD is president and CEO of the American Medical Informatics Association.

What are AMIA’s big issues and where will the organization go in the future?

I’ve been AMIA for approximately three months. It’s been my professional home for nearly 20 years. One of the things that attracted me to moving to AMIA is that as there’s been tremendous change that’s happened with electronic health records and a move from a paper-based economy in healthcare to one that’s about electronic data capture, analytics, and things like that, the informatics professionals that have been doing this for many, many years have an opportunity to have a significant impact on the kinds of decisions that are made around the leadership of various organizations, as well providing expertise as we try to figure out how best to use this new technology.

Part of the attraction in coming to AMIA was we have 5,200 members that stand ready to serve in a capacity that will help advance research on the best ways to use information technology, the best ways to look at the data and do the analytics, how to connect the bioinformatics and the precision medicine initiatives through clinical research and into the clinical care space. This is a group that has provided tremendous value to the community and to the researchers and things like that.

Our role now is to not just think about the value that we can provide, but the impact that we can make in the kinds of decisions that are being made and the kinds of technologies that are being deployed. My hope is that as we move into these new payment models and as we think about the way in which healthcare is being transformed, it isn’t going to be the case where you need a good accountant to get paid. But what needs to happen is if you’ve got a risk-based payment system in which clinical care organizations assume a certain amount of risk for the patients that they care for in those settings, it’s going to be your ability to do good analytics, identify those patients that are high risk, and target your interventions in a cost-effective way that is going to make the difference between those in clinical care organizations and medical homes that can be self-sustaining versus those that are going to be struggling. The difference with that is going to be to have the informatics expertise to come forward. That was what drew me to AMIA.

The other thing we have to recognize is that although AMIA has oftentimes been associated primarily with research and with scientific investigation, we are far more than just that. We have probably one of the broadest representations across the health fields in the association. We have physicians, nurses, physical therapists, pharmacists, and public health experts. We represent the whole scope of care and care delivery that occurs. Very few other organizations have that breadth of expertise within their organization.

We have to also realize that when it comes to informatics, it isn’t really defined by what we know. Although we certainly have a number of experts in our organization that know a lot and are experts both nationally and internationally, we have to recognize that informatics is more than just what we know — it’s what we do. We think about engaging those people that may not consider themselves an officially trained informatics representative, but they are doing the kinds of things that an informatician would do in a health system or within a research environment. Those people also have a home here with AMIA. 

Getting basic science researchers that are doing high-quality research in academic environments connected to the practitioners in the field benefits both communities. It both provides areas that are right for investigation to the researchers because they understand the problems better, but it also provides the latest techniques and the latest technology that then the practitioners can apply to the care that they provide. 

To me, particularly as we look at the federal activities around the interoperability road map and the strategies for getting health information technology across the country, AMIA is well positioned to be a strong contributor and a leader in the ways in which this information can be analyzed and delivered.

Is it important that AMIA makes informatics and informatics education more user-friendly more than it has been in the past?

One of the strengths that we have with AMIA is our educational focus and the high quality of education that is being provided. For example, we have our annual meeting, which is driven by scientific submissions from folks and case studies of practical implementations. At our last annual meeting, we had high school students presenting some of the projects that they had worked on. We have increasingly educational focus on creating high-quality accredited master’s and other programs that are recognized and accredited as being significant in their quality and the way in which they teach.

Engaging that practitioner is increasingly important as well. We have a meeting that we hold every year — we’re in our second year — called iHealth. IHealth is geared towards those practitioners who are out there in the field struggling to implement electronic health record systems, trying to figure out how to optimize them in their environments to make sure that they’ve got the right work flow and work flow integration and usability. How to look ahead to the next phase — what is the innovation that is coming around the horizon?

This notion of implement, optimize, and innovate is where we can make a contribution. That’s going to be a focus on practical applications of activities. Fundamentally, if we want to have the impact out there, we have to make the educational programs more accessible and address the current day-to-day issues that many of the people that are the practitioners out there in the field struggle with. Many folks go through our 10×10 program, which provides a basic understanding and basic introduction to informatics. But we need to make sure that we also address some of the targeted areas that many of the leaders — the CMIOs and the folks that are out there supporting the CIOs in informatics — also have the tools that they need.

HHS says it will move quickly toward value-based payment and ONC is retooling from an EHR implementation focus to more on interoperability. Will things continue to change as quickly as they have in the last few weeks?

I would add to not only the CMS changes around how they want to move very, very quickly to value-based purchasing and get people away from fee for service — they call that category 1 — into category 3 and category 4, which is about ACOs and shared risk models. It’s an aggressive timeline, but it’s those kind of things that are going to drive more and more people to think about sharing data and providing a new format that will allow them to do the deep analytics necessary to make those models work.

The interoperability road map was also issued and it signals an increasing responsibility, if you will, for that private sector to be able to step forward and to answer some of these questions. Of the many recommendations that are put forward, the majority of those recommendations are targeted to the private sector, that is, outside of the federal government. It includes some of the state agencies, the vendors, the physicians, and patients, all of whom have responsibilities for getting to this kind of interoperability that we would like to see.

I think there has always been the plan to take a look at Meaningful Use and to begin to think beyond just the electronic health record and see the ecosystem that’s developed. Certainly within AMIA, we don’t think about things just in terms of the electronic health record. We think about it in terms of the learning health system.

One of the diagrams that is in the interoperability road map was one that I contributed while I was there at ONC. It tried to take a look the forward scale with which we need to engage the community. We need to be able to have patients, the electronic records that are in a physician’s practice … we need to think about this from a population and public health perspective. But we also have to think about it from the clinical research that is intended to benefit the population or the public at large.

All of those things are going to be important. The EHR is only one aspect of that larger learning healthcare system. Organizations like AMIA can provide some leadership there to get the ways in which all of those different systems are going to be needing to interact.

In addition to those two announcements, there were two other announcements that are going to be equally important in terms of the kinds of conversations that need to happen. The first was the 21st Century Cures draft collection of legislation. It runs 393 pages, but it includes a whole host of different areas focused at modernizing the healthcare ecosystem all the way from FDA and the approval of devices and drugs all the way through to how we might be able to get more interoperable systems that are able to share data between the various systems.

The fourth was the President’s announcement around precision medicine. This is an ambitious goal, to begin using this all this data that’s available electronically, to combine that with genetic information and other kinds of information to be able to target the therapies we use for patients more precisely. 

When I think about precision medicine, it’s really not just about understanding a patient’s genome and using that as a way of targeting therapies, although that’s an important aspect of this. Precision medicine is about using all the data that’s out there to be able to better target the therapies that we prescribe and that we deliver to our patients. That may mean that if we have information from a patient that is related to their Fitbit and tells us about their activity cycles, we might be able to use that to more effectively monitor and manage their diabetes and the cycles they might have with their insulin. Knowing something about what they eat and their social circumstance, or maybe geographically that they’re living in a food desert that doesn’t have a lot of fresh fruits and vegetables. All of those things can play into how we can target our therapies to help provide new ways of treating diabetes, obesity, cancer, and all the other things that are out there.

So there’s been really four announcements: 21st Century Cures, precision medicine, the interoperability road map, and CMS. The challenge that we’re going to have is to try to integrate all those activities together. That’s the place where informatics can help. How do we make sure that how we collect data for precision medicine and how we collect data within the EHR can be complementary or that they can support each other? How do we make sure that the incentives that are aligned to try to do value-based purchasing also drive us towards a place in which we have more granular data access that allows for different systems to communicate with one another as well? 

Those are the kinds of challenges that are ahead. I’m excited that being at AMIA, we have a whole host of folks with tremendous expertise that can help add to the conversation that’s sure to happen over the course of the next couple of months.

We’re asking health systems to be even more competitive than they’ve been, but we’re also asking them to share data about their customers with each other. That doesn’t happen in any other industry. Do providers have enough incentive to be interested in interoperability barring the technical challenges?

I certainly think that there are going to be important parts of interoperability that transcend a lot of those business cases. What’s different about healthcare is that the person left out of the equation in terms of incentives is often the patient. From a perspective of competitiveness and taking care of our patients and things like that, one of the things that’s really challenging is that if I’m a patient and I’m seeing a doctor who uses System A, and then my insurance changes or I get a new doctor and I decide to change plans and now I’ve got a doctor who uses System B, that information currently can’t flow from System A to System B. My information is locked away. It’s never able to be moved.

It’s as if financial systems said that once you deposit your money into our accounts, you’re going to have to empty your account because we have no way of transferring the money to another bank account if you decide to change. Or if you buy a car, you’re locked in because your garage and everything else only fits that particular car, so you can’t move to a different automobile.

One of the things we have to realize is that the patient is why all of this industry exists, in that we need to make sure that what we do, the decisions that we make, are focused on the things that can help benefit the patient. There’s a good chance that people will have to move up the value chain. It isn’t that the patients are captured and we have their data and we’re not going to share it — it’s how can we best provide services in that we can compete on things other than our ability to interoperate with other systems. 

That’s really where we need to get to, the situation in which patients have free access to their information. They can move it wherever they want. The way you maintain patients in your practice or in your health plan is by providing higher quality services because you have that openness and can integrate all the various systems that are there.

Is trying to use data from wearables to empower patients an informatics project? Do we need to focus on the intelligence to take those never-ending streams of data and take action without requiring the practitioner to visually examine it to figure out what’s going on?

The way you characterize the problem makes it an informatics issue. The whole notion of how do you summarize complex data in ways that can be easily presented to physicians is really important. As we think of precision medicine and other things like that, we’re going to get a lot more different kinds of data. Precision medicine isn’t going to be just about health data. It’s going to be about wearables. It’s going to be about the kinds of foods that you buy and how much exercise you have and where you live and whether it’s walkable, those sorts of things. 

I really believe that as patients have more and more tools, we shouldn’t be afraid that a patient is going to have a Fitbit and they’re going to have all this other information. We should embrace that because that helps engage patients in their own care. That will be transformational.

Do you have any final thoughts?

We talked a lot about kind of how we can get to patient engagement and the power of informatics with all of this. What’s really important from my perspective is that by engaging the patient and creating a means for us to take informatics expertise and getting it out there for providers and for patients to be able to leverage, that’s when we’re going to see the real value. 

At the turn of the century, there was a tremendous amount of activity and discussion in the Journal of the American Medical Association around a new technology that had just come out. It was all about the physician’s automobile. Between 1906 and 1912, there was a whole series of articles geared towards the physician about how they might best use this transportation revolution that was occurring to create better return on investment. They would be able to see patients more quickly. They would be able to increase the number of patients in their practice and see more patients more rapidly.

There was a lot of discussion about the technology, whether you should have hard tires or soft tires, whether the engine should be gas or electric. Statistics about the Philadelphia Stanley Steamer as an early ambulances. All of that was a very, very an active part of the discussion that occurred. But by 1912, most of that conversation had gone away, and in large part, no one was talking about the physician’s automobile any longer because Henry Ford developed the Model T. This was a technology that simplified things and made it accessible to patients.

There were six Duesenbergs that were produced. They were brilliant engineering feats, but six Duesenbergs weren’t going to change the way in which the transportation industry worked. The way we’re going to transform healthcare is not through creating six Duesenbergs or focusing on the physician’s automobile. It’s about engaging the patient and providing them the tools and resources that allow them to be first-order participants in the care that they receive. 

I’m very hopeful that as we get more and more technology that’s out there, people are going to start to expect that just like they can order airline tickets and they can have their boarding passes on their smartphones and they can pay for their food and transactions using their phone, that increasingly they’re going to see the healthcare environment as something that they’re empowered to be able to manage, whether that’s through a website or through an iPad or an iPhone. That’s when we’re going to get real transformation. 

To get there is going to require us to do all the things that we’ve done in the transportation industry and what we’ve done in electronics — to break down the barriers for sharing information and for getting things from one place to another. Once that begins to happen, we’re going to see a tremendous increase in engagement with the patients. That is going to benefit everybody. It’s going to benefit the patients, the providers, the health plans, and — I hope as we think of precision medicine — the public as we figure out new ways to be able to take care of patients and to deliver their care more effectively.