April 21: Today on Townhall, Brett Oliver, Family physician and Chief Medical Information Officer at Baptist Health interviews Coleman Smith, Emerging Practice Lead at Himformatics. Coleman is a regulatory expert educating on trends in healthcare and regulatory compliance programs. What positive aspects have we seen with the implementation of the Cure’s Act? Are there unintended consequences? How will TEFCA shake out? With all these legislative changes, what can the average person expect to see over the next 12-18 months?
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The beauty of the Cures Act is I think it, it pushes us towards a necessary federally mandated future state of interoperability where you have more engagement. And you have the ability to pass those notes and those vital data to different care team members from a care coordination perspective in a stratified manner, which is also important because then it can be more readily ingested into my EHR.
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All right. Welcome back. This is Brett Oliver, CMIO for Baptist Healthcare system and I'm excited today to have Coleman Smith with me. Coleman is the Emerging Practice Lead at Himformatics although I would prefer to call him the Resident Professor at Himformatics. And I think, I think he would too. We're going to talk a lot of regulatory legislative stuff today that may seem dry to some but I think it's really important and loved talking to Coleman about, so Coleman welcome.
Thank you for having me. I'm excited to be here and you're right. I get it. Not everybody loves this stuff. I love it. So thank you.
Yeah, absolutely. So we got to start with the cures act. I know, obviously you and I have had multiple conversations over the years about the cures act but since the requirement, one specifically, I'd like to talk to you about as, since the requirement for the release of results and notes immediately, what positives have you seen amongst other clients or just in the industry, but let's start with that.
Okay. So, I love this question because I am admittedly a glass half full optimist. Unicorns and rainbows. So I like, I think that as difficult as the cures act has been for a lot of healthcare organizations. It is a at its heart, a good thing. And there's two main things that I see for this connectedness and engagement.
Those are the two positives. And I say that when I say internally, when we've helped our clients, you're pulling together him. Cause it's ultimately a release of information. You're pulling together. IT, cause you've got all this new technology happening or these new functionality happening all the time, whether you're releasing different stuff to your portal or when fire API becomes more standardized.
And we see that even when you get to EHR export, you're just seeing a lot of that. You, you connect with your policy, your legal department, as far as updating your policies. And and understanding when I can use exceptions and when I can, and kind of you're connecting with the physicians and the clinicians and the caregivers and explaining like we got a new way.
We're having to do things and you're, and I've seen such great leadership with all those things. And then, you know, you have a great program management, just people bring it all together. And I, I say that to say in time inside an organization, there, there are rare. Major regulations like HIPAA is probably one of the UN examples, but that connect so many people across an organization at one time.
So, so in a time when we can feel very solid and I'm just kind of doing my job, it does that. But the most important thing that I think it does, and I really believe in this. And it's the start of, this is the elephant to me, my bias that as we try to move from fee for service to value based care is patient.
we can do everything we want for our patients. I speak from the heart from, I always use my dad's example and my dad's my best friend, but if he goes into his Chick-fil-A or McDonald's or whatever, five times a week, that's not going to help his, his scores. That's not going to help us help. And you know, he's in his eighties.
And so what I've noticed over the past couple of years is even in our small town, that, that they still live there. He has way more access to data. More efficient. Then he has more readily than he has in a long time. and so I see him and hear him and had these conversations about, well, yeah, I've been monitoring this and he goes, he has a multiple care teams.
He has to see a little more frequently than on people. And so he, even that, that data point of one, he is engaged, but that's the bigger pieces. If we really want to go from fee per service to value based care, to really provide medicine that is reimbursed for how healthy. And I believe in that too, is that patient engagement is the key.
And this is one of the variables in that equation to help solve that. So those are two big things that I see just more engaged patients and more connectedness across a healthcare system.
I think that's great. I think when you think about, as an analogy to that remote patient monitoring, and why is that successful? You're engaging the patient. You have more points of connection outside of the office, outside of the hospital, outside of our four walls. Surprise, you know, it helps people stay, stay more engaged. Well, along those lines though, on the other side of things, what so far, and I know we're relatively early in this journey with this immediate release stuff. What about unintended consequences? Or maybe, maybe they were predicted, but maybe some negative consequences that you've seen so far.
It's the flip side of that coin. when you look at providers and what they're having to do them to take more time, we're already stressed. They're already overworked to write their notes, to make sure that they know that they say things the right way, or they put this particular piece of a note in a right section in the EHR so that then they can withhold it, whatever you, I mean, it's, it, it slows down some of that, and that is hard.
The engagement side of it. you know, like preventative harm is the exception everybody talks about, but it's like very clear around, this is harm, physical harm to the patient or somebody else's. and so in the beginning you saw a lot of people saying, what about my oncology results? Things like that. Listen, Dr. Oliver, if you're going to give me bad news, I want you to tell me that before I read it, my cholesterol was a little high. When I went to see my general practitioner this year, I did not like that. And I saw my results before she called me and I was like, oh, but she's like, you're fine.
You're fine. But it's so funny. Like, and that's a small thing. The flip side is, especially during this time when we have such staffing shortages and stress on an environment. When I talk about everybody's connected, they're also connected in the fact that they have so many things going on and, and we have this big regulation.
So my heart hurts for them in that regard. And then my heart hurts for the patient because the more engaged I am sometimes then there is unnecessary fear that has real damage. To me emotionally, physically, possibly, you know, I think it's fascinating. I think you'd be really great to talk about. This is how some states are helping support their providers when it comes to these types of conversations.
Yeah. Yeah. I actually just, within the last two weeks, Kentucky has passed house bill 529. I could, I could potentially argue with some of the wording, but basically what they're doing is they heard back from a number of providers. We had some anecdotal patients stories that were disturbing in terms of receiving malignancy diagnosis that you know, led to them taking their own lives and things like that. Before they could talk to somebody. So who knows, you know, if you're not be as hopeless as you think it is when you, read that report. And pathology reports, they're not written you know, on a patient eighth grade level or something like that as a family physician, you know, there are times where I'm like, I don't know what that stain is that they're talking about and what pertinent set as I have to go look it up.
So as a result of Kentucky passed a law, that's enacted. I mean, it takes place immediately. we have to delay the results for 72 hours of any genetic markers or radiology and pathology results. And here's, here's the problem with it, or the challenge that have the high likelihood of revealing malignancy? Oh gosh. Well, you know, when I x-ray your elbow, I'm probably not worried about malignancy.
But you can't say all x-rays cause maybe a sculpt male mind may be looking for multiple myeloma. So it's from a technical perspective, from an it perspective, it's challenging trying to figure out how do we, you know, okay genetic markers, that's, that's maybe easy that's one group or of, of testing, but to, break it down. So we're working through that, but that is one example of how at least Kentucky is looking at. Listening to the providers and saying, we think it's okay to have a delay. I know the federal government feels like we're being paternalistic. When we want to have that short delay to be able to talk to the patient, we're not talking about delaying it any longer than we have to. It's just, we want that ability to to talk to the patient themselves.
I love that and you know, we're all navigating as best we can. I mean, like so many. I think it's a step in the right direction, but as my sons are a little bit older now, but they're not far moved from stumbling as they're trying to learn to walk. And so they had to start it. And that's, again, the beauty of the cures act is I think it, it pushes us towards a necessary federally mandated future state of interoperability, where you have more engagement and you have the ability to pass those notes and those vital data to different care team members from a care coordination perspective in a stratified manner, which is also important because then it can be more readily ingested into my EHR. And I think some of the HRS, you know, they're doing the best they can to, I don't think. And you see some of the things that they are responding too quickly to say, oh, preventative harm. Okay. I get it. But if you have something, we'll create a space for you to do that. And I'm not all EHR has had that, but you're saying. People try to be responsive and just try to move this along. So, yeah.
Yeah. I agree. I agree. Well kind of as a tag, along to that, so by October we have to release all the aHI that's probably a podcast in and of itself, but I'm just curious how you, you know, the organizations that you get to interact with, how are most handling.
So anybody that I talked to, because again, we talked about staff shortages and many other things that are going on, people coming out of COVID and trying to deal with like heart, like the old joke that he was like, heart attacks didn't go away during COVID, you know, like, but what happened is that a lot of people stopped going to the hospital and then now their acuity is greater and they're more complex situations.
Like it's a rough time. And my heart goes out to our healthcare. And partners. What, so what we talk about is I say everything risk mitigation to the point that the team members that I work with and even the clients are like, eh, it is, but like it it's all about risk mitigation and what I say. It is a as of today, you are correct that designated record set that EPHI and the concluding the designated record set needs to be available by October 6th, just like the U S CDR was back in April of last year.
Now, what we look at is that's where you start from, it's the patient's data. How do you get it? Right. But you may not have the functionality like EHR. And your EHR yet. You're I mean, they give them their deadline. And so the end of next year, so we say, okay, let's do a couple things to mitigate the risk first and foremost what's the source of truth for your designated record set. Just tell me that across your organization. If you have one main HR, it's a little bit easier, but you're always going to have ancillary systems, but there are plenty of clients we have who have multiple EHR. And so, so it is understanding what I had to play with.
So if I'm looking at that as site, let me go to my EHR. let me go to my HR department and say, what is our designated record set? Give me the data elements that are included in that. Is it images or is it, you know, the narrative of the image? and I'm country. So I said the narrative of the image, I can't remember the fancy term for it, but like that's what we asked them to, lay that out.
And as you're doing that, then you get an idea of how can this electronically access, can it be electronically exchange and in what usable format. Let's try to just answer some of those questions cause then legal and compliance and go, okay, let me look at the functionality we have. And let me look at the capabilities we have and what we're missing and stuff. And so, okay. Now I can, I can work with some exceptions. Him can have a better conversation just to avoid an information by complaint. They can say, listen, we can do this for you right now in a very quick fashion, but we can't do this now.
We're not saying we won't do it, but we just going to be different in how we can and we, work a lot with that. We work a lot with workflow as far as like helping to understand, but at the end of the day, you say, all right, on October 6th, what are the tools that you essentially have to help with this?
And then what can you put in place as you get more functionality available? to help this along, to make it more efficient or things like that. So a lot of it is that you just meet the client where they are and you figure out a way to mitigate the risk as much as possible, because it's a big, it's such a big animal.
there isn't a single answer. Organization's going to be so different, which is totally understandable. Right. It makes total sense. My question is like, how do you enforce that? You know, the complexity of these to, well, they say they can't do this then are you going to go? And, you know, as a regulatory body go and check and make sure that they can, or maybe it's so obvious that I don't know. I think there's significant challenges. It seems early to me to do that from a usefulness standpoint. That's the other piece like you're going to give me an electronic data. And I think patients think it's great. I'm going to get my whole record. It's like, I don't know that it's going to be divided up. Like you are thinking.
Yeah. And you know, we talk about what could happen. I mean, I think this is a lot like HIPAA and as much as when HIPAA first came out, it wasn't an common. Topic or healthcare organisms kind of, but not, I don't think as many patients kind of knew it and now you can, you can't go anywhere and a patient doesn't it doesn't know what HIPAA is.
I mean, it's a thing, right? I think here's what kind of move in the same way. Organic much like talking about our kids is like, it will in the beginning, I think there'll be a little bit more gracefully. You know, we're doing the best we can. My thing about risk mitigation is if I was ever audited or for a claim of information blocking what I can do with that documentation is basically say, listen, I did the best I could.
And did I mess up a little bit maybe, but maybe not. Maybe, maybe this is exactly what it is, but the key again, I think is that the recognition of that initial conversation, what would cause there are, like I said, everybody's got a different, but there are things that are the same. I'm talking to the him department. This is a negotiation to keep that patient happy to get them the information. So you may not have all the tools, but I'm going to tell you the menu that you have. So that's you know, you won't be able to, it let's understand really the capabilities and who's going to help with this. When you have something complex, let's get that in place, right?
Like, and maybe want to put some more data elements on the patient portal. Maybe not all the data elements, but maybe some more so than him says, Hey, you've got more on your patient portal or they never even ask because they just feel more informed. Right? Another provider like. Once a a bunch of information about a patient and you can't provide all it, but you're, you're saying I really need these particular data elements.
And because you've done the work, you can say, well, I can provide most of that to you pretty quickly. So I do think there's that and legal and compliance is continually kept up to date to say, alright, well, we might've made sure we were following the letter of the law as we entered. And also we are in a position to defend a claim if we have to, because we're not caught unawares, we're all connected with that.
So that, and then of course, when it comes to clinicians and for the physicians, it's education, and then really that's across the board, it's like, here's what we want you to make sure you understand where to put it, what you got to, right. Things like that, but also your client, your patient, my primary care doc said to me, which I love.
She said, do you want your, information in the portal before. And I said, yes, that would be great. And then I said to cures that she had no idea what I was talking about. That's fine. It's like, but she, like, you can ask. Right. You can ask that question. And so, like, I think there are standard things, but to answer your question directly, you kind of say here's all the kitten caboodle, what can we do to re kitten caboodle? Grew up in the thirties is here is here's what you can do today to mitigate that risk. And here's what you can do tomorrow to mitigate that risk some more.
Makes sense. Well, let's, briefly switch gears to Tefca and talk a little bit about that. Just exchange framework, common agreement. So we've got the first version out in January. And I'm just curious, just your take on, okay. This is supposed to be created to be the floor for interoperability. Yeah. How do you, how do you see it shaking out? just I'd love your take on it. You know, right now it's voluntary. Just patient only, you know, do you see, I mean, I guess it'll probably be a wait and see aspect that you think they'll start turning some levers, you know, in terms of maybe it's a requirement for participation in Medicare or something kind of like a threat in the back. I'm just, I'm just curious because. I feel like interoperability has really advanced in the last several years, just from a clinician's perspective, CMIO perspective there's challenges to it, duplication of things, all this things that we have to work on, but I'm wondering where TEFCA fits in from your perspective.
I like this question because I honestly was asking the same question a couple of months ago when I was talking to my friend and colleague Jessica Barnett. And so we were sitting having a discussion about it. And she's done a ton of research looked at a lot of things. And, we were asking ourselves that question, cause I was like, honestly, at this point in time with all the requirements that are part of TEFCA and everything else you have going on, like, come on it's right. This is a yes, but it's a necessary thing. Like I can see it exactly. Like I understand the goal of it, but she said, she said the same that you did, which I have to agree. She said, what do you make it. And like it drops into a MACRA or it drops into promoting interoperability for hospitals that, that program, whatever it happens to be, or just something else they create.
And they say part of the, this, like you said, is a requirement to connect. And I think some areas will be a little bit more prepared for that based on their connections today. But it's a lot of, it's a lot of work for them. You know, HIV is today that are, or Q hands or whoever trying to make this happen.
yeah, I think it's going to take required stuff to really make it happen. I do. I think there's some tertiary ones that can make a good kind of care gap argument today that could fall under that to make you save some money or things. But I don't think it will be adapted. And I'd be curious to see what it looks like in a couple of years. Like I also feel like this. First step, and then there'll be like, okay, well let's figure this out from, you know, what comes next?
Yeah. That's fair. That's fair. Well kind of on a practical side of things with all these legislative changes, right. And, and you, and I can get into the weeds on some of this stuff, which is what we're supposed to do, but what can the average patient, I'm not even say clinician because that's, they know even like, what did the average patient is that what can they expect to see in the next year, year and a half? Will it will this impact, will they have something noticeable or do you think it's going to take longer to really see the impact?
I think two things, I don't see it. I got to is that the first thing is I think for the majority of healthcare, all patients much like also might HIPAA. It will, they will come with. You know, where everybody kind of knows about it and they may not call it the cures act like everybody calls it HIPAA, but they'll just say, I know I have access to all my information. I think that will grow organically and it'll be more of like an exponential curve. But I think that what really could happen, which is exciting and maybe a little scary is our phones when we standardize fire API. And I'm so used to picking up my phone for stuff. And I really try not to, I mean, granted, I live on the side of the mountain, so it doesn't always work, but I, you know, whenever I'm out and doing stuff, you know, my phone is on. And Becomes more readily accessible if an app does it really well it's the beauty of innovation. Like there's probably somebody out there right now, or several people creating some app that is going to take this data. and because of that fire API standards, is going to accelerate that path to it being more readily available. And that's what I think was the, and they may not have any idea why that's there.
They may never know about it, but when their buddy or a friend says, Hey, you know, you can just get on your phone and it's got a lot of information on there. You don't have to go type into a patient portal. You don't have to do any of this. It's like just it's on your Sony phone. I think that those are the two things. That one, yes. Long-term, we'll see a lot more care coordinator. We'll see a lot more patient engagement, a lot more data that's easily stratified. EHR will Recode differently to meet this. But I, to me, the second piece is kind of the timer of that, of it. When those things occur, it could be pretty exciting.
I hope you're right. I agree. I know. That's the federal government there take that. We're going to create. Environment for app developers to come in. It, it smells a little bit like Kevin Costner in the field of dreams. And if they build it, they will come. I hope it ends up as positive as that movie did.
I hope it does too to you're right. I mean, this is my, this is why we say when people ask me, especially it's my bias is this, you know, my bias is to be positive because honestly, It's a, again, I do mean this. Like whoever's watching from a healthcare perspective. My heart will always hurt for you. Like whenever I have these conversations, I jokingly say, remember, I didn't write the regs. I'm just trying to tell you what they said, because it's a lot for people to tackle.
as a provider who has kind of walked in that space and now as a CMIO walking in this space and then curious hits, so you really are one, like to me, CMOs, especially are wonderful to ask this question too, is you're on both sides of the coin and in such a unique way that I've never cared for patients. Right. What do you think about it? What do you think about the cures act and its impact?
I think with the right education, anything, that's mandated for me and my colleagues, if you give us the why, and it's a legitimate, why and you can get our attention. 'cause you know, we don't pay attention or myopic in what we do. I think it works out in the end. You know, I had conversations with a couple of surgeons last week, cause talking about our new state law and just asking, do you have any problem with us doing that? I mean, I don't know if we're gonna have a choice, but here's how we're thinking about building it in our EHR.
And both of them were like, you know, This would maybe be a problem, but I've changed the way that I talk to my patients before a biopsy, before a procedure, what to expect, or that was already part of my, you know, my workflow and it just hasn't been an issue. So that was, that was very good. Now that was a bit, you know, an N of two so it was a small, a small number, but it was encouraging to me that, and I think it illustrates what you were getting at is we're adaptable.
We're just burned out overworked and you better give us a good why. If we're going to have to change what we're doing. There was an article that one in five clinicians were planning their exit at the end of this coconut. And, you know, we are already at a shortage. And so that's what gets me up in the morning every day.
I appreciate the question because it's I understand, I understand at a level. That some can't because I've lived it. And so what can we do at least from a technology standpoint to remove some of that burden? And if there's a burden that we have to add, can we take something away? And if we can't let me make sure you understand why we have to do this, and what's the positive what's coming out of this, you know, here's the heart behind why this was passed to begin with.
So I love it. I appreciate you, man. Thank you. I appreciate you too.
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