Did anyone predict when Meaningful Use was conceived that in 2015 the federal government, payers and providers would be pushing the reset button? Yet starting in 2014, indications were there that Meaningful Use as it was conceived was not working. Physicians weren’t happy. Contrary to what Congress was promised, costs were not reduced nor was quality improved. Gains, if any, were minor, and projected costs continued into the foreseeable future. A high profile report recommended utilizing new technologies. So in 2015, a new roadmap was published; new Chronic Care Management payments are promised; and, of course, the finger pointing continues.
The AMIA EHR 2020 Task Force published its recommendations in a published position paper.  Within six sections they include ten recommendations for creating a suitable environment for vendors and providers to create useable HIT. The position paper points out the many ways that other interests have distracted vendors and providers from having systems that take too long to use, create longer than necessary notes and distract from taking care of their individual patients. In this blog, I'm highlighted some of their recommendations I think are particularly important.
RECOMMENDATION: Make documentation easier and more efficient. The position paper discusses complaints that EHRs create problems delivering good patient care. These complaints include interference with patient relationships (because of multiple questions and typing required), disruption of workflow, excessive data requirements not related to patient care and inadequate data sharing capabilities. Research has addressed ways to improve usability, and that research should be applied to systems so that data entry burdens can be reduced. Also, multiple care team members can enter data, including patients and family members, which will lessen the time and disruption that having all data entry happen in a short visit. This will require a change in many EHR systems or provider organizations, but it could increase accuracy (if patients enter their own data rather than answer questions) and improve the quality of face to face visits (if the standard question time can be eliminated) because patients and clinicians will have more time to identify and solve problems.
Interoperability and data sharing capabilities have disappointed clinicians and patients, and much debate has occurred about how to make it better. The position paper discusses some of the reasons it hasn’t worked, including technological and financial. Too much data is currently being entered is required primarily for billing and quality reporting and not for patient care. In addition, standards have not been fully developed or implemented so that data can be easily shared. More consideration is being given to the “comprehensive, longitudinal information needed for precision medicine” than in the past,  and that means that data needs to be aggregated from multiple sources, not only physicians and hospitals but also other healthcare services. As a longitudinal view of a patient’s health history become more available, with more care team members accessing and contributing information, communication becomes easier and more helpful.
RECOMMENDATION: Encourage innovation. The position paper supports the JASON Report and the JASON Task Force because they encourage new ways of utilizing health data. This means that “public APIs and data standards should be consensus based, transparent, well documented, and openly available in a fair and non-discriminatory way.”  The report goes further and names HL7’s FHIR as an example of a consensus-based standard that should be used. Patients will need to be more involved with their data – contributing and utilizing their information via APIs, mobile apps and document and other standards. In this way, a new ecosystem of data sources, including EHRs currently used in hospitals and clinics, could be facilitated. Data from and apps for other healthcare clinicians, such as dentists, pharmacists, social workers, school nurses and more, will be added to the mix to provide a more complete and accurate picture of an individual patient.
RECOMMENDATION: Support person-centered care delivery. The position paper describes a radically different healthcare environment compared to what we experience today. A shared record is envisioned where patients and their care team members can all access and contribute to their records, as well as utilize the data for a variety of purposes, including population health and research. This is especially needed with the advent of precision medicine where more data (including social and eventually, genomic) will be important for decision-making.
The Patient-Centered Medical Home model has advanced the idea of team care, and EHRs are being utilized to support that model today. The future will demand more, however, when more functionality will be needed for the new care models to evolve. The position paper goes on to say that “without new payment models or research providing impetus for change, change will not occur…there is now a disconnect between the promise of what we can do and the real-world infrastructure required to make it operational and scalable.” 
A recent study found that the biggest predictors of high cost Medicaid care are behavioral health problems and substance use. In the study, the top 5% super-utilizers in California’s Medi-Cal program account for at least 51% of the costs. After identifying the top utilizers, researchers investigated the root causes and found several factors. One major one was duplicative testing and overprescribing of pain medications, exacerbated by multiple care plans across systems. They began a program with a multi-disciplinary approach, increasing communication among team members and realized a 33.9% decrease in emergency department utilization over two years. Communication was the key to getting the systems to work together. 
At Datuit, we are developing software to support patient-centered health records that are also flexible to enable team members to work together and meet their communication needs. The AMIA Report is a bold call for what’s required to support healthcare in today’s world.
 Payne TH, et al. Report of the AMIA HER 2020 Task Force on the Status and Future Direction of EHRs. J Am Med Inform Assoc Online First (May 29, 2015). Accessed at http://jamia.oxfordjournals.org/content/jaminfo/early/2015/05/22/jamia.ocv066.full.pdf.
 Report at page 5.
 Report at page 5.
 Report at page 7.
 Gorn D. Surprising Results From Pilot Program Aimed at Medi-Cal ‘Super-Utilizers’. California Healthline (June 4, 2015). Accessed at http://www.californiahealthline.org/insight/2015/surprising-results-from-pilot-program-aimed-at-medical-superutilizers.