The Summer Blockchain Came to Healthcare

This summer, there were visionary conversations about the future of health IT. A new technology may be the needed spark.

ONC Challenge Grant

In July, ONC challenged the health IT community for innovative ideas for apply blockchain. Blockchain, first introduced in 2008, is the technology behind bitcoin.

The core capabilities of blockchain - a secure way to share data and track transactions - address the hot healthcare topics of interoperability and cybersecurity.

ONC Blockchain Challenge Logo

ONC selected fifteen white papers as the winners of their challenge grants. The authors are healthcare providers, academic researchers, consulting powerhouses and individuals. The white papers address policy and technology. They span many use cases including medication reconciliation, clinical research, identity management, and claims processing.

Upcoming Workshop

ONC will be co-hosting a workshop with NIST, September 26 and 27, 2016 to explore blockchain in healthcare and where the selected white papers will be presented.

Healthcare Needs Better Connections

There are a wide variety of constituents in the health and healthcare ecosystem. The many ways they connect today is staggering, from dedicated point-to-point solutions to specialized clearinghouses to public Internet.

Each participant has its own surrounding support network of services, supply chain, and numerous intermediaries. There are many opportunities to simplify the existing tangle of connections.

Blockchain Attributes Address Healthcare Needs

Blockchain brings together cryptography, peer-to-peer networks and highly distributed database technologies. This is the latest version of "the network is the computer," where now "the network" can take on many of the functions of a centralized clearinghouse, potentially replacing not just the centralized servers but also the centralized organization with a hyper-distributed model.

Key attributes of blockchain include

• Trusted Identity
• Smart Contracts
• Shared Ledger
• Non-repudiation
• Highly Distributed Redundant Data Store

Blockchain could be a new platform for implementing solutions. Many of the specific aspects of blockchain are already being modified as different infrastructures are put in place (Ethereum, Gem, IBM, Microsoft, MIT).

The Value of Hype: Vision and Alliances

Hype is an indicator of new activity. That activity may or may not provide real value. Blockchain is the latest technological shiny object that has captivated the attention of innovators and early adopters. That attention may bring needed resources to address real problems.

According to its proponents, blockchain has the potential to disrupt current processes and organizations, to create new wealth and shift the centers of power. Bitcoin and other crypto-currencies, despite ups and downs, are getting attention from financial institutions and governments as a means to improve trust, transparency and operational efficiency, especially with respect to clearinghouses, back office processes, audit and regulatory compliance.

Let's not lose sight of the efforts already in place to provide better connections across the health ecosystem: the well established query capability of eHealth Exchange, the patient identity management in Commonwell, the broad adoption of ePrescribing using Surescripts, and the resilience of several of the state and local health information exchanges (HIE's). As we learned from Direct Trust, taking Direct Project from prototype to production, required more than just a core technical capability.

The opportunity for innovation and the fear of disruption are generating a lot of attention. This in turn is leading to visions for a near term future with lower transaction costs and greater data fluidity. It has the potential to produce new value models. New alliances may form to harness the potential and old adversaries may work together. This is the case in financial services and may also apply to healthcare.

Open Questions in Healthcare

Regardless of technology, some areas, already active in health IT, need further work.

• Value - Is there a direct line of sight from the technology to real value?
• Value from information
• Value to the end user
• Value to the individual patient
• Monetize data and information flow
• Use Cases / Process Improvement
• Applied Technology
• Workflow - Does it fit with what the user is doing?
• Data - Is the information useful to the action at hand?
• Analytics - Has the relevant information been brought forward?

Having these capabilities within a technology is not the same as providing a viable solution. Current problems, such as standards for granular data, usability of clinical systems and a longstanding culture of individual providers, all must be addressed.

Perhaps the threat of disruption will motivate entrenched organizations to move forward on areas of cooperation, common standards, improved care coordination and research. These all areas where coming together and working together may be more important than the underlying technology.

Assessing Progress

Here are four key questions as we look for indicators of change.

• Early Success: Does blockchain solve a specific, "micro-"problem in a way that has less friction, less cost, less overhead, is overall easier to implement and use, than current solutions to that problem?
• Scale: Do the early success grow beyond the pilot user community?
• Partnerships: Do new alliances form around blockchain and successfully address a previously intractable problem?
• Scope: Does blockchain become a broad platform that enables a range of solutions or does it remain in a narrow niche? 

Change from the bottom: community nursing in the Netherlands

Usually when we think of innovation, we assume that a small organization, even a single individual, will create something new, demonstrate it works, and then a large established organization will take it to scale. Very rarely will the innovators themselves grow to scale. In either case, the scaled-out innovation is supported by an organization with the usual management hierarchy and overhead.

Here's an example of an innovative care model and an innovative management model. Both aspects focus on what really makes a difference, understanding what is essential for the organization to nurture its people and its customers, and what is something best left undone or done by others.

This model for home health services builds on local teams of nurses who place high value on the relationships with the people they serve, favoring continuity of provider over specialized providers. It came out of nurse frustration with the fragmented care they had previously given.

Buurtzorg is a community nursing organization in the Netherlands. It started small, focused on the needs of the professional care team and the people in their community. It puts the local team in charge of the care and how they run the team to provide that care.

Buurtzorg provides high nurse satisfaction by "letting nurses be nurses", to build relationships with their patients, to be part of a small supportive team that shares the workload, to cover for each other, to build on each other's skills and knowledge, to access specialty resources as needed. A learning health system at the level of a team of ten or twelve.

A trio of remarkable outcomes were achieved.

1. Extremely satisfied patients with excellent outcomes and reduced home care costs (40% below the expected cost). 
2. Extremely satisfied workers. Buurtzorg was the Netherlands Employer of the Year for three years in a row.
3. Explosive growth, from the first team of 4 nurses in 2007 to 9,000 in 2015. Buurtzorg now provides 80% of the community nursing services in the Netherlands. This has occurred with almost no corporate overhead (a central staff of 50 or so including 15 team coaches).

There are essential, but intentionally limited, services from a central support organization. A key central service is the team's coach, who facilitates communication within the team and helps them network with other teams, but who has no decision making authority.

Buurtzorg Organizational Structure

Shared IT focuses on

• An electronic health record
• A social network
• A team dashboard

There are some outsourced services, such as payroll and legal. Buurtzorg has taken to heart the guideline of keeping the services that differentiate the organization and having others do everything else.

How to build on this?

While Buurtzorg has changed the home healthcare experience and cost, the total cost of care, including all other medical services, such as physician and hospital care, on a risk-adjusted basis, were no different from the average in the Netherlands. Are similar innovations possible in other areas of health and healthcare?

There have been studies of Buurztorg by many others from around the globe. What is special about community nursing in the Netherlands? How might this model be recast in other places?

Here are some references on Buurtzorg.

Buurtzorg Nederland (in Dutch. Google translates it remarkably well into English.)

Buurztorg USA

TEDxGeneva (2015) Jos de Blok - Healthcare: humanity above bureaucracy

The Commonwealth Fund (2015): Home Care by Self-Governing Nursing Teams: The Netherlands' Buurtzorg Model

Public World Consulting (2015): Repository of all things Buurtzorg

Frederic Laloux (2014): Reinventing Organizations (I first learned about Buurtzorg in this book on organizational paradigms. The information on Buurtzorg is spread throughout the book.).

AARP The Journal (2013): Buurtzorg Nederland: Nurses Leading the Way!

KPMG Insights (2013): Empowering caregivers

Interlinks (2010): Care in the neighbourhood: Better home care at reduced cost

ONC RFI Assessing Interoperability for MACRA - part 2 - ONC RFI

Here's a summary of the Request For Information from ONC. Much of what follows is loosely quoted from the RFI, a Request for Information regarding assessing interoperability for the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Comments are due by 11:59pm ET on June 3, 2016.

MACRA and the ONC RFI both focus on measures of interoperability to be able to assess whether "widespread interoperability" has been achieved.

As background and on-going framework, the RFI makes frequent reference to the Shared Nationwide Interoperability Roadmap version 1.0.  

MACRA requires that the interoperability measures be established by July 1, 2016. This timeline effectively requires using metrics that are based on data which is currently being collected. Recognizing the limitations this time constraint creates, ONC also asks for comments about other metrics that might require more time to implement and would better measure the ambitious goal of widespread interoperability.

MACRA defines interoperability as the ability of two or more health information systems or components to:

1. Exchange clinical and other information and
2. Use the information that has been exchanged using common standards to provide access to longitudinal information for healthcare providers in order to facilitate coordinated care and improve patient outcomes.

The ONC RFI asks for comments in three areas:

1. Measure population and key components of interoperability that should be measured
2. Current data sources and potential metrics that address section 106(b)(1) of MACRA
3. Other data sources and metrics ONC should consider with respect to section 106(b)(1) of MACRA or interoperability measurement more broadly

[The text of MACRA Section 106(b)(1) is included in my earlier blog post.]

1. Measure population and key components of interoperability 

MACRA requires assessment of interoperability among meaningful EHR users and clinicians and health care providers with whom they exchange clinical and other information - their exchange partners. The exchange partners do not have to be meaningful EHR users themselves.

ONC is looking to measure interoperability across populations and settings beyond that required by MACRA, as they have previously laid out in the Interoperability Roadmap. In the RFI, they ask for comments on this broader measure population.

In keeping with the MACRA requirement, ONC further states that they are looking to measure not just exchange but use of information that has been exchanged.

ONC proposes a framework for use:

• Sending
• Receiving
• Finding (Request or Query)
• Integrating or Incorporating
• Subsequent use of information from other providers

ONC is asking for comments to cover the following: 

• Should the focus be limited to the MACRA requirements, Meaningful EHR users and their trading partners, or more broadly as laid out in the Interoperability Roadmap?
• How should participants in the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) be addressed?
• Do the ONC components of sending, receiving, finding, integrating and using information meet the exchange and use requirements of MACRA?
• Should the measurement be limited to certified EHR technology (C-EHR-T)? Measurement outside of C-EHR-T?

2. Available Data Sources and Potential Measures

ONC is looking at a combination of two perspectives

1. By provider, based on the proportion of Meaningful EHR users exchanging information with other clinicians and subsequently using that information
2. By transactions, based on the proportion of care transitions and encounters where information is electronically exchanged and used.

The data sources being considered include

• National surveys from stakeholder associations and federal entities
• American Hospital Association, Health IT Supplement Survey (hospitals)
• National Center for Health Statistics, National Electronic Health Record Survey (office-based physicians)
• CMS Medicare and Medicaid EHR Incentive Program

[As an aside, ONC maintains a Health IT Dashboard across a variety of data sources.]

2.1 Measures based on national survey data

• Strengths: The surveys measure exchange with outside providers. Multiple years of survey data are available.
• Weaknesses: self-reported data subject to bias and interpretation. Do not cover all providers. Do not provide transaction-level data.

Survey measures under consideration include

• Proportion of health care providers who are electronically sending, receiving, finding and integrating key health information
• Proportion of health care providers who use the information they receive from outside providers for clinical decisions
• Proportion of health care providers who electronically perform reconciliation of clinical information

The survey results may provide insight into enablers and barriers to interoperable exchange.

Questions about these survey measures:

• Do the survey questions adequately address both exchange and use?
• Could office-based physicians serve as adequate proxies for all Eligible Professions included in the EHR Incentive Program?
• Do the surveys provide necessary information to determine why information may not be widely exchanged?

2.2 Measures based on the CMS Medicare and Medicaid EHR Incentive Program

The EHR Incentive Program is administered differently for Medicare and Medicaid. Provider-level data is collected by Medicare, but the states report Medicaid data as an aggregate. Changes in the data reported by the states would be required to get more granular, provider-level data.

The interoperability objective of the EHR Incentive Program has limited scope, simple ensuring that a summary of care is sent, but not what was done by the receiving provider.

ONC recognizes limitations in these data sets and is looking for comment on the strengths and weaknesses of these data sets as well as other data sets that could be sources for measuring interoperability.

EHR Incentive Program measures under consideration include

• Proportion of transitions of care or referrals where a summary of care record was created and exchanged
• Proportion of transitions or referrals and patient encounters in which the health care provider receives, requests or queries for an electronic summary of care document (beginning in 2017)
• Proportion of transitions of care where medication reconciliation is performed
• Proportion of transitions or referrals where the health care provider performs clinical information reconciliation for medications, medication allergies and problem lists (beginning in 2017).

ONC states that electronic reconciliation may include a combination of electronic and non-electronic information, but that it serves as a proxy for assessing electronic exchange.

Questions about the use of EHR Incentive Program include

• Do the potential measures adequately measure exchange?
• Do the reconciliation-based measures adequately measure use?
• What alternative measures (for example, clinical quality measures) should ONC consider to assess use?
• Can state Medicaid agencies share health care provider-level data with CMS similar to how Medicare collects the data? If not, what are the barriers? What are some alternatives?
• These measures assess interoperability across encounters or transitions of care. Would it also be valuable to develop measures of interoperability across health care providers, even if limited to the Medicare EHR Incentive Program?

3. Other Data Sources and Measures

ONC is looking for additional potential data sources and measures. For example

• Medicare Fee for Service claims data
• Performance data from other programs
• Performance data from the Merit-Based Incentive Payment System (MIPS)
• Performance data from Alternative Payment Models (APMs)
• Electronically generated data from C-EHR-T or other systems

Overarching Questions

• Should ONC select measures from a single data source for consistency? Or leverage a variety of data sources? Would a combination of EHR Incentive Program and national survey data be appropriate? 
• What, if any, other data sources and measures should ONC consider?
• What measures might be provided by EHR vendors, Health Information Service Providers (HISPs), Health Information Exchange Organizations (HIEs, HIOs) or other organizations that enable exchange?
• What information might be added by using measures based on Medicare Fee for Service claims?
• Which are the highest priority measures to consider?
• Address comments within the December 31, 2018 deadline for evaluating interoperability.
• What might be useful for measuring interoperability more broadly?
• How should ONC define "widespread"? What can be in quantifiable terms?

ONC presented a summary of the RFI in a presentation to the Health IT Policy and Standards Committees on April 19, 2016.

ONC Interoperability Measure Framework with MACRA Focus