Informatics 2015: How do we get from meaningful use to precision medicine? - Keynote - Doug Fridsma

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Informatics 2015: How do we get
from meaningful use to precision
medicine?
Doug Fridsma, MD PhD
President & CEO, AMIA
Bethesda MD

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Agenda
• Meaningful Use
• 5 lessons learned
• Near term challenges
• What does the future hold?

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HITECH WAS FIRST AND FOREMOST
A STIMULUS BILL

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HITECH was part of the US stimulus
bill

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ADOPTION FIRST,
INTEROPERABILITY SECOND

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EHR adoption among acute care
hospitals

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Standards support was
programmatically part of “operations”
Standards = $60 million
(of $2 billion dollars)

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WHAT WE LEARNED (IN 5 EASY
STEPS)

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FRAMING MATTERS:
HEALTH IT IS ONE ULTRA-LARGE SCALE
SYSTEM

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It’s not architecture, it’s city planning
Ultra-Large-Scale
Systems
The Software Challenge
of the Future

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It’s not architecture. It’s city planning
• Decentralized control
• Federation and data sharing (via standards)
• Patient will be the one common feature
• It’s a socio-technical system
– People don’t just interact with the systems. They are PART of the
system.
• Unknowable and diverse requirements
• Iterative, incremental development, since we will learn as we go
• Continuous evolution and deployment
• Tolerate differences in semantics, syntax, and sophistication
• Path of least regret
• Normal failures
• Security is important, recovery and restoration even more so
• Orchestration rather than command and control
Health IT and Informatics is not about architecture and engineering.
It’s about city planning.

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STANDARDS AND INTEROPERABILITY:
HARD IN THE CONCRETE, IMPOSSIBLE
IN THE ABSTRACT

15. Interoperability (IEEE)
• Ability of two or more systems to exchange information
• Ability of those systems to use the information that has
been exchanged
Interoperability only makes sense in the context of what
you want to DO

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FRAME THE SOLUTION IN TERMS OF
THINGS THAT MATTER TO PEOPLE

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The Triple Aim
Health Healthcare
Costs

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WE NEED TO THINK ACROSS 4
SCALES OF ENGAGEMENT

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Patient Practice Population Public
The learning health system
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Informatics, standards, testing, business drivers, governance
Big Data and population
health
Electronic Health
Record and Quality
Consumer
empowerment
Clinical and
Translational
Research

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FIVE TECHNICAL THINGS TO
STANDARDIZE

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Meaning
Content
Structure
Technical stack
How should well-defined values be coded so that
they are universally understood?
How should the message be formatted so that it
is computable?
How does the message move from A to B?
How do we ensure that messages are secure and
private?
Transport
Security
Services
Purpose-specific APIs and services that leverage
the 4 other building blocks
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AMIA AND THE EHR 2020 REPORT

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Simplify documentation

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Focus Regulation

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Increase transparency

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Encourage innovation

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Keep the patient at the center

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WHAT’S NEXT?

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REINVIGORATING AMIA: IT ISN’T JUST
WHAT WE KNOW. IT’S WHAT WE DO.

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EHRS WILL NOT BE THE MOST
IMPORTANT HEALTH IT

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EHRs will not be the most important
Health IT

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• PCORI
• Precision
Medicine
• Consumer
devices
• Information-
empowered
Patients
Patients will be first order participants in
health, healthcare and research

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Non-health data will become bigger
than health data

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ALTERNATIVE PAYMENT MODELS ARE
COMING. MU3 WON’T GET US THERE

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Payment reform will increase the need
for informatics skills and data analytics

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THE ONLY STANDARD YOU NEVER
CHANGE, IS A STANDARD YOU NEVER
USE

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Standards life cycle
You are here
Widely adopted, but declining value
Current
state-of-the-art
New
and emerging
Mapping?
value
time

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A PATH OF LEAST REGRET: THREE
THINGS WE NEED

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BUILD DOCUMENTS FROM DATA,
NOT THE OTHER WAY AROUND

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What is needed: A common format
for granular data
• Quality Measures
• Clinical Decision Support
• Registries
• Common data formats for
– Text data
– Categorical data
– Numerical data
– More…

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FULL EXPORT OF THE PATIENT
RECORD (AND NARRATIVE)

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Restore the importance of the
narrative and unstructured text
• Move patient between vendor “ecosystems”
• Precision medicine
• Restore the balance of power for access to
data
• Maintain the importance of the narrative in
the medical record

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TEST BOTH SIDES OF EXCHANGE

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Postel’s principle
• When you send, conform to the standard
– Pick a set of options and make sure it conforms to
a valid instance of the standard
• When you receive, accept ANY version that
conforms to the standard
– Any variation that is valid
• Create the conditions of interoperability when
you create the standard, rather than when
you implement it

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What to learn more?

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Knowing is not enough; we must apply.
Willing is not enough; we must do.
-Leonardo da Vinci
Doug Fridsma, MD PhD FACP FACMI
President & CEO, AMIA
www.AMIA.org fridsma@amia.org

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Extra slides below

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WE DON’T LET PHARMACEUTICAL
COMPANIES TEACH US
PHARMACOLOGY. WHY SHOULD
HEALTH IT BE DIFFERENT?

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Structured data, unstructured data
and true interoperability testing
• A fundamental building block for granular data
– A common data element format
– Separate structure from meaning
• A full export of patient data (structured and
unstructured)
– Move between ecosystems
– Share data for multiple purposes
• Test both ends of the transaction (Postel’s
principle)
– Send on the “or”, receive on the “and”

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The good

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The bad

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The ugly

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MU3: THE GOOD, THE BAD, THE
UGLY

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THE GOOD

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• More transparency and oversight of the
certification process
• Some simplification of the current standards
(but no clear driver to make sure they stay
that way)

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THE BAD

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• Still too provider centered and not patient
centered
• Patients still don’t have access to their entire
medical record in an electronic format
• Doubling down on direct with edge protocols
doesn’t advance modern standards for
exchange or APIs

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THE UGLY

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• Completely missed the point about testing
both sides of the interoperability exchange
• No pathway to MIPS and MACRA
– No standards for representing quality measures
– No granular standards
• I
• Reliance

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AMIA IS A HOME FOR APPLIED
INFORMATICS

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Applied informatics
• Updated our strategic plan
• Adding applied/practical tracks to all of our
conferences
• Applied Clinical Informatics (ACI) now an
official journal of AMIA
• iHealth is the official meeting of the clinical
informatics diplomates and fellows