Yesterday I talked about where I'd been last year. Today I'm going to cover where I think things are headed in the US (at least for me).
We'll likely see a new S&I Project on Patient Generated Data.
eMeasures will make significant headway in transition to HQMF Release 2
Clinical Decision Support standards will become more important.
EHR adoption through Meaningful Use will slow down
Plans of Care, Care Plans, and Patient Plan of Care will attempt harmonization
S&I Framework Project on Patient Generated Data
The key challenge for this project will be differentiating between information coming from patients directly, and data coming from home health monitoring devices. My advice is to attack these as separate use cases, but from the same project. The data coming from home health monitoring devices is rather different from self-reported information on symptoms, allergies, social and family history, et cetera.
FHIR Protocols that I've been using for ABBI also have a simplified method by which patients (or devices) can post data to a PHR. The key issue is not transport protocols, but rather content. I suspect that we could use the CCD 1.1 in C-CDA to record patient generated content just as readily as it is used for provider generated content, and we could also use the HL7 Patient Authored Documents specification being balloted now. As for medical device data, I suspect we could look at the HL7 Personal Health Monitoring Report
, and work from IHE
Patient Care Devices and Continua for possible content solutions.
eMeasures in HQMF Release 2
I know the folks at MITRE have already been looking at transforms from HQMF Release 1 format to Release 2. There's some interest in specifying HQMF R2 for Quality Measures in MU Stage 3. A long term result of this effort would be to propose HQMF R2 as a required standard for the 2016 Edition EHR
We've done quite a bit of work on HQMF Release 2, and I suspect it's "nearly ready" for prime time. However, the most critical effort at this point will be to deliver eMeasure specifications in HQMF R2 for use by pilots, get implementer feedback, and either tweak it, or develop an IG that makes it ready for use in the 2016 criteria. Without that, I expect ONC will be scrambling to make it happen anyway, and the quality of our quality measurement tools will suffer.
Clinical Decision Support Standards
If you've been paying attention, you are already aware of the Health eDecisions
work going on in S&I Framework. Use Case 1 is finishing up, dealing with content formats for CDS
rules, forms and order sets. This is now being balloted
in HL7. They will soon be moving on to Use Case 2 (of much greater interest to me), which is how to integrate CDS web services with an EHR. You can see that they haven't gotten very far
on this use case. Again, looking at Stage 3 proposals
, it seems obvious that its about time for this work to really heat up.
My goal here will be to make sure that the proposed standards link up well
with HQMF, and C-CDA specifications for content. The link between quality measurement and CDS has already been made
EHR Adoption Slows
Also easy to guess if you've been paying attention. As I show in this post, there are three stages to technology adoption, exponential growth, linear growth, and saturation. I think we are about halfway done.
If you look at the current data on the HealthIT Dashboard
, you can see a logistic curve (shown to the right) embedded in the data. There are some outliers for sure, but I suspect this has more to due with seasonal (i.e., Fiscal year-end) adjustments. I'm not enough of a data analyst to figure out what those should be, but the pattern seems clear enough.
The topic of Care Plans, Plans of Care, and meeting the needs of the patient via patient centered medical homes, patient centered care planning, et cetera is heating up. Something has to shake this loose. We've had a care plan section in CCD (and now in C-CDA), and their predecessors since 2005. HL7 has a workgroup named Patient Care
, and in IHE, I'm planning chair for the Patient Care Coordination domain. We've been working on this for several years in the SDO community, but it has yet to take hold.
The content of a care plan is fractal and interlinked. Certain kinds of care for this condition affects goals and activities for that one. Tracking that sort of linkage in what we have today is certainly feasible, but little is, I think, really known about what is needed to do that.
The real challenge with care plans is not so much what to put in them (as far as I can see), but rather how to organize and manage them. In other words, it's not a content issue, but rather one of governance. And that governance is created by multiple care providers: doctors, nurses, and allied health professionals; covering general practice and specialties; in the home, and in acute and long-term care settings; by payers, ACOs and PCMHs. Everyone has a use case to address, and frequently, an axe to grind.
I expect to see some motion on Care Plans next year, but it may be sideways. I'm not sure if we'll see real progress until 2014 or later. Perhaps ACOs and Medical Homes will help this along, and perhaps not. Current drivers right now in S&I Framework are coming out of the long-term care community, but their use cases don't address everyone else's requirements.
I think we will need to assess and prioritize the need for care plans by the various axes [pun intended]. I think it likely that there is more value in some kinds care plans for a given type of healthcare provider, specialty, care setting or stakeholder. We should be looking at working on the high value (in terms of costs of care) care planning activities.
We should also start using what we have today in C-CDA to report the basics (goals and interventions linked to conditions), and see where that takes us. We can figure out how to move beyond that limited level of detail when we have more implementation experience. After all, the key point of standardization is to standardize what works or what is best practice, and as far as care plans go, I don't think we know the answer to either of those questions.
So there you have it, my predictions for 2013. It seems pretty obvious to me, but that may also be from knowing where to look for the trends.