The next step

Go to the edge of the cliff and jump off. Build your wings on the way down.

--Ray Bradbury

D.A. Freccia: You're a pretty smart fella.

Joe Moore: Ah, not that smart.

D.A. Freccia: [If] you're not that smart, how'd you figure it out?

Joe Moore: I tried to imagine a fella smarter than myself. Then I tried to think, "What would he do?"

--Gene Hackman, Heist (2001)

It’s smarter to be lucky than it’s lucky to be smart.

--Charlemagne “War is a Science” Pippin (1972)

I don’t think I’m jumping off a cliff – and I know I don’t have any wings, at least not yet – but I am taking a leap into something new, different, and exciting, and I want to share the news with all of you today. Beginning December 3, 2014, I will be leaving my current position in the breast cancer program at the Kimmel Cancer Center at Johns Hopkins and beginning a new full-time position as Medical Director of the Institute for Quality of the American Society of Clinical Oncology (ASCO) in Alexandria, VA. I will help lead and support a number of key programs that make up ASCO’s quality portfolio, including the Quality Oncology Practice Initiative (QOPI), the QOPI Certification Program, and the revolutionary and ambitious CancerLinQ project, among other ASCO quality initiatives. The ASCO Board of Directors and CEO Dr. Allen Lichter recently made the decision to bring on board to the ASCO staff a physician to provide medical oversight for this key area. I am deeply honored to be the inaugural person selected for this position.

ASCO’s vision for the future of oncology, well articulated in the 2012 document “Shaping the Future of Oncology: Envisioning Cancer Care in 2030” is one that really resonates with me. ASCO believes that all patients with cancer should have access to high quality care and that the information learned from every patient should accelerate the progress against cancer. ASCO has identified health information technology, particularly the ability to collect and analyze vast amounts of big data, as a key driver to achieve this vision. I couldn’t agree more. For the past 23 years that I have practiced clinical oncology, patients and families have come to me for my expertise in what is often the most overwhelming crisis of their lives. They may be full of fear and anxiety, but they are all hopeful for cure, while expecting compassion and respect. As a clinician, I know that the only thing that really matters is the needs of that patient in the exam room across from me, and my primary responsibility is to help them navigate the shortcomings of our byzantine and often-insensitive healthcare system, to deliver to them the right diagnosis and the right treatment, based on the best possible evidence and shaped by their own preferences and values. To do that, I need access to data, information, and knowledge of a complexity and quantity that was unthinkable when I graduated from medical school in the 1980s. To get this access, oncologists need tools that can’t be discerned in the Google searches and social media streams of today, as critical as the Internet is to medicine – let alone the medical libraries and Index Medicus of the last century! ASCO’s rich portfolio of quality programs, which started with QOPI, an oncologist-led, practice-based quality assessment and improvement program that launched in 2002, through today’s eQOPI and the growing library of practice guidelines, to tomorrow’s CancerLinQ rapid learning system, will continue to be foundational in providing oncologists with some of these needed resources.

I’m joining ASCO now as a full time employee because I’m passionate and optimistic about the future of our field, and I want to devote the rest of my career to enabling this change. I’ve not been blessed with unique or extraordinary vision, but I think I can see what it is going to take. We need to create a world where medical practice consistently reflects unfettered access to meaningful data; where clinical care and discovery co-exist and enrich each other; where oncologists discover new knowledge not only from the 3% of patients who bravely enroll on clinical trials but from the routine care experiences of all; where the documentation of such care experiences is freed from proprietary electronic systems – currently shoehorned into the rough and inflexible mandates of the meaningful use requirements (as necessary a first step as they were) –  and shared freely by all; where delivery is not constantly undermined by the specter of the perverse incentives of quantity-based reimbursement particularly “buy and bill;” where the amazing advances in panomics are allowed to flourish and inform today’s care processes and not exist only as vague promises of “precision medicine;” and where patient-centered care is something we all are proud to deliver, not just to satisfy next month’s Press-Ganey surveys, but because it represents the fundamental passion and dedication of our profession as physicians.

Will I be able to do all of these things as an ASCO Medical Director? Lordy, I’m going to need a lot of help! I’ve experienced oncology in both private practice and academics, so I know all too well the challenges of transformation and how disappointment oft rules. But I think I’m smart enough to associate myself with some very smart people, and I’ve been lucky enough in my career – blessed in fact – that I’ve been able to enjoy a wonderful, fulfilling practice environment and the collegiality and camaraderie of superb colleagues everywhere I have been. So I think this “leap” – from the familiarity of a single institution to a visionary, mission-driven organization like ASCO and this work blending quality, clinical medicine, and information science – is not just the next step for my professional development but something that feels positive, natural, and just right. I’ll build the wings later.

An Epic narrative

My professional life at Johns Hopkins has been largely consumed in recent months by preparations for the implementation of the Epic electronic health record (EHR) system. Our so-called "Ambulatory First" go live for all outpatient Hopkins clinics in the Baltimore-DC area begins 4/4/13 with the scheduling and registration system and then swings into full gear with the clinical roll-out of the EpicCare EHR at Green Spring (where I practice) on 5/16 and in East Baltimore at Johns Hopkins Hospital clinics on 6/27. If you've ever been part of a major EHR go-live at a hospital, clinic, or office, you know what a monumental undertaking this is and why "consumed" doesn't really do the experience justice. For Hopkins, we are transitioning from many years of doing things a certain way using a huge variety of legacy and/or best-of-breed electronic systems for data capture and analysis, including some homegrown ones and in some cases paper records, to a single, enterprise-wide, vendor system. It will impact every aspect of our clinical operation and touch everyone who works here, not just those in patient care. While I'm confident we will emerge in a much better place, I am not looking at the coming months with much joy.

Hopkins is doing this for all of the right reasons, many of which are listed at the link above. The most important reason is, of course, the patients, so that we can improve the safety, quality, and efficiency of the care we deliver. A single EHR will enable us to collaborate better with other physicians and engage patients by giving them greater access to their records and treatment team. In some ways I am most looking forward to the implementation of the patient portal myChart, since I think it will revolutionize access. As a patient of a Hopkins physician myself, I received an email today touting the benefits of the portal and encouraging me to sign up (yep, got that one covered).

Sounds great, right? Well, not always. The reality is that many physicians are not very fond of EHRs, for a lot of complex reasons. To put it bluntly, many truly can't stand using them for patient care and rarely find much good to say about them. And it's not that physicians are inherently technophobic - quite the opposite, as virtually every physician I know owns a smartphone and tablet - but as a profession we are deeply skeptical of anything that slows us down and changes our workflow. A major EHR implementation like this has a huge impact on productivity for weeks if not months. And it's not just about the change process. The reality is that most EHRs, including this one, leave a lot to be desired in terms of usability (how easy it is to navigate and get through your work) and interoperability (how well these systems share data with each other). Physicians have to spend more and more time entering data at the point of care through menus, drop-down lists, and checkboxes, and - as many point out - less and less time interacting with and looking at the patient in the exam room instead of the computer. And in spite of the multimillion dollar investment this requires for a large health care system like Johns Hopkins, these systems still don't talk well with other non-Epic systems (true for other vendors as well). 

Certainly, there is another side of the story. For the first time ever, Hopkins physicians, nurses, pharmacists, and other allied health professionals will be able to access clinical information about a patient from any one of our clinics and hospitals, something that was virtually impossible to do before this. The reduction in duplicate labs and imaging tests should be immediate, as so often in the past, labs were repeated simply because we didn't have access to prior results. Electronic prescribing will be uniformly implemented, and medication reconciliation will finally become part of our everyday clinic workflows. And while it won't happen right away, Epic's data mining capabilities will allow us to track many aspects of care with ease, analyze trends across populations of patients with similar clinical characteristics, and hopefully soon link these routine clinical data with personalized genomic markers being identified in our labs. 

I hope to write some future posts on this blog about different aspects of EHRs, like the Federal meaningful use incentive program and whether it is still "meaningful," why many doctors are disappointed with their existing systems (here's a teaser), why cost-savings and efficiencies EHRs were supposed to bring have, to date, not yet materialized, and why, in my opinion, greater penetration and implementation of EHRs is mandatory for the dysfunctional U.S. health care system to truly make our care patient-centered, something it obviously is not much of the time right now. Here's the take-home message for today: No industry in the U.S. in the 21st century is as dependent on paper-based record-keeping as health care historically has been. Even the most strident critic of EHRs would have to acknowledge that there is no justification for continuing to use antiquated, analog workflows based on the classic paper hospital or office chart, a place where data go to die, locked in a single vessel that cannot be viewed by more than one user at a time and not manipulated, analyzed, or transmitted (sorry, your 1980s fax machine doesn't count). U.S. health care has no choice but to adopt a fully digital infrastructure to achieve the goals of what some call the Triple Aim: higher quality and greater patient satisfaction, better population health, and lower cost. Clinicians must lead from within, by being fully engaged in system selection, design, and implementation, and not defer to the "IT team" or administrative managers. At a higher level, the physician voice must be heard by vendors and policymakers. I disagree with those that claim our input is useless. I acknowledge that it's difficult to move along a monolithic, billion dollar vendor when you're a single voice but it's not hopeless. Frontline clinicians are the only ones who really know what it takes to take care of patients. We should be the ones who are in the front leading change in health IT. Sniping from the sidelines, griping anonymously in comment sections on NY Times articles, or tagging tweets with #EHRbacklash may feel good momentarily but isn't going to help our patients or make our lives easier.

To be clear, I'm not talking about my colleagues at Hopkins who have generally been open to this implementation, even though they have been understandably apprehensive about the impact on clinic throughput and efficiency. I know they will rise to the occasion and do the right thing since that's our culture. But bashing health IT and meaningful use has become fashionable in the blogosphere and popular press these days, and it is becoming relentless. So here's my call to action: Physician colleagues, step up and engage. I understand your reservations, but I think our patients deserve better. They deserve our professionalism and resolve to make an impact on the current state, not skepticism and griping. They need us to take ownership of this transformation, so it happens with us and by us...not to us.

Health IT predictions for 2013

If you don't read the web site of iHealthBeat or follow their Twitter feed at @iHealthBeat you really should. It's a daily news digest from the California HealthCare Foundation covering the impact of technology on healthcare. Their report from yesterday 1/3/13 is a really interesting read - "11 Experts on Health IT Progress, Frustrations and Hopes for 2013." It starts with a brief digest of some of the important health IT stories from 2012, and then goes on to cover the responses from a panel of 11 diverse thought leaders on three questions:

1. What was the most significant health IT development over the past year?
2. What was the biggest disappointment or missed opportunity in the health IT space in 2012?
3. Looking forward to 2013, what are the biggest remaining barriers to widespread adoption and meaningful use of health IT? And, what can be done to help address those challenges?

The panel ranges from e-Patient Dave to John Sharp (research informaticist at the Cleveland Clinic) to Janet Marchibroda (chair of the Bipartisan Policy Center's Health IT Initiative).

A few themes emerge:

• The importance of patient empowerment and engagement, particularly as incorporated into Meaningful Use Stage 2 requirements
• The proliferation of and opportunities presented by mobile health technology
• Controversies over the delayed implementation of ICD-10
• Issues of privacy and security
• The uncertain impact of Accountable Care Organizations
• The ability of EHR's to facilitate potentially fraudulent upcoding for services (comments on both sides of this issue)

There seems little doubt that in 2013 technology will continue to be a key theme of healthcare delivery and policymaking at every level.

Electronic Health Records Infographic

The blogs that I read regularly are full of posts from physicians bemoaning the shortcomings of electronic health records, from poor usability to exorbitant costs to the impact on face-to-face (or at least eye-to-eye) contact with patients. As someone heavily involved in the design and implementation of the Epic system at Johns Hopkins, I know most of these comments represent an accurate depiction of a technology that is a long way from achieving its stated goals of increasing interoperability, enhancing patient safety, and ultimately improving patient outcomes. But this great infographic from the Office of the National Coordinator for Health Information Technology (ONC) reminds us that despite all of their faults, EHR's are able to connect patients and doctors much more effectively than paper records ever could, and there is no turning back if medicine wants to thrive in the 21st century.