Halamka's Advice to the Trump Administration

John D. Halamka, MDAs I've listened to the confirmation hearings for cabinet nominees, I’ve realized that no one with healthcare IT expertise has yet been identified by the transition team.   I continue to ask all my colleagues about any contact they’ve had with anyone advising the new administration - so far, no one has been asked anything by anyone related to healthcare IT.

At this early time in the administration, it’s important to offer advice as to the priorities ahead for the next few years.    What would I recommend to the new administration?  

Here’s my five point plan:

1.  Focus on enabling infrastructure - instead of asking for “pledges” to share more data (the pledge idea should never be used again for anything), create the enabling components that will actually make data sharing easier.  21st Century Cures asks the GAO to research the costs and benefits of a national healthcare identifier.  Let’s create a national healthcare identifier and be done with it.   It’s the simplest and most reliable way to coordinate care across multiple providers and heterogenous EHRs.    Let’s create a national directory of provider electronic addresses that any application can query to make data exchange simpler.   Let’s create a unified baseline privacy policy and universal consent for data sharing across all 50 US states.    As I’ve said many times - you cannot tell the clinicians to drive unless you build roads first.    Suggesting that cars cannot drive because of “transportation blocking” when roads don’t exist is just an excuse for a lack of infrastructure.     Also, the Federal Government needs to practice what it preaches – if DoD and VA don’t share with each other or if all Federal agencies don’t abide by industry-adopted standards and business practices, then the private sector cannot be criticized.

2.  Reduce clinician burden and prescriptive regulations while moving to an outcomes focus.  Demanding that my opthalmologist report smoking cessation and vital sign data is not helpful.    Opthalmologists should be graded based on the visual acuity, field of vision and intraocular pressure of their patients.    The outcome we want is healthy people.  How you achieve it with technology should be up to each hospital and professional.  It’s fine to require some reporting of appropriate quality measures and cost data, but don’t try to dictate the workflow of each provider.

3.  Strong leadership of ONC with deep domain expertise is really important to avoid regulatory zeal.   I describe the later stages of Meaningful Use as “lead a physician to water and beat him/her until he/she drinks”.    There are only 3 ways to influence a clinician - pay them more, improve their quality of practice life, or help them avoid public embarrasment (malpractice assertions, poor quality scores, high cost compared to their peers etc).   If the right tools are created that help with those three items while achieving policy goals, they will be adopted.  You cannot regulate a solution to every societal problem, but you can align incentives so that people act appropriately.   CMS and ONC need to continue to coordinate their work closely.

4.  Focus on cybersecurity and risk mitigation while fostering trust for data exchange.  The new threats to information security and integrity are state sponsored cyberterrorism, hackivism and organized crime.  Every CIO I know loses sleep over these threats.  Let’s work together to identify emerging threats, implement best practices for mitigating risks and investigate promising new technologies like blockchain.

5.  Reward innovation instead of co-opting it.   Every major EHR vendor laments the burden caused by regulatory compliance and certification.   Customer needs and market competition should drive product advancement, not legislation or regulation.  50% of clinicians want to leave the practice of medicine because of the administrative burden.  We’ve achieved exactly what we have required by regulation - turning clinicians into expensive data entry clerks.   Now that high levels of technology adoption have been achieved, companies should sell their products based on usability and efficiency, not certification.

I do not see these five recommendations as abandoning the gains of the past.   I see them as refining the path forward based on what we’ve learned.  The last eight years have achieved remarkable gains and I do not believe we need to lament the gaps remaining, we just need to focus on the right work.