Daniel Nigrin, MD, MS, is the SVP and Chief Information Officer at Boston Children’s Hospital, Assistant Professor of Pediatrics at Harvard Medical School, and a practicing member of the Children’s Division of Pediatric Endocrinology. As CIO, he is responsible for all IT systems at one of the world’s preeminent institutions for pediatric clinical care and research. As a practicing physician, medical informatics researcher, and IT executive, he is in a unique position to put into practice cutting edge technologies and ideas, bringing advances to patient care, quality, and research, but while keeping in mind the needs of busy clinicians.
Why is it important for healthcare to rally around this idea of convergence?
First, there’s the widespread realization that costs continue to rise at unsustainable rates and something has to be done. With that comes new approaches to payment methodologies and accountable care organization (ACO)-type ideas. There is no way to achieve good outcomes without using our data more effectively than we have done before. And not just a single organization’s data. It really is that ability to aggregate data across care venues – from both an administrative and clinical perspective– and then use that data toalter the trajectory of patient’s health – keeping patients out of the medical system, achieving a better overall state of wellness, and thus consuming fewer healthcare resources like in the past. That is one thing that could be done.
What’s best for the patient…is the right thing. If the measures we take are really in the patient’s best interest, then we have a fighting chance to convince clinicians. When we start to see results come back –patients staying out of hospital and leading healthier lives – and as a side benefit we are saving money, clinicians will understand.
The other more provider-centric area where we could make headway would be to improve the state of IT systems that clinicians use to make them more efficient and usable. We want to use data more effectively for more informed decision making. We also want to better see where care might have occurred in other venues, and showing that data to providers will enhance care and reduce redundancy.
Do you think that private payers or public payers are moving more rapidly toward value-based contracts?
Our experience as a children’s hospital was that, initially, private payers were leading the way. But we are seeing a change with our entry into a Medicaid ACO in Massachusetts in this coming year. Public payers are starting to get on board with it. It will only be a short period of before we see all of our contracts have at least a component that is value-based, if not a full ACO approach.
Some in the industry have resisted that idea of mandatory payment reform. Do you think that voluntary or mandatory reforms will be more effective?
I might be naïve, but I like to think of this not so much as a way to reduce costs but as a way to improve care. I also wear a clinical hat and understand that the idea could sound corny. But what’s best for the patient isn’t really corny, it is the right thing. If the measures we take are really in the patient’s best interest, then we have a fighting chance to convince clinicians. When we start to see results come back –patients staying out of hospital and leading healthier lives – and as a side benefit we are saving money, clinicians will understand. There will be some degree of kicking and screaming about this but, ultimately, we’ll succeed if we focus on the patient.
From a technology standpoint, what will be some of the different enabling technologies?
Two buckets to thinking about this topic. One is standardizing the data. For example, how do I express a blood pressure in a standard way so that when I send it across town or across the country, so the recipients can understand it? That sounds trivial, but it is incredibly non-trivial. Efforts like FHIR and other standards and nomenclature work are great initiatives. We need to keep working on them though we are not done yet.
The second set of technologies is the transport of data between systems. We have achieved some successes at local levels between local providers. I often find that these are one-off exercises. These is not really a standardized way to transport data on a regional, national, and even international basis. We need the fluidly of the banking network. We don’t have it today. Direct is one potential solution but it has some scaling issues. In Massachusetts providers can send data via the Mass HIway – but I believe a current limitation is that providers can only have one Direct address, but many work at multiple locations. Direct has been helpful in getting us part of the way there.
Do applications work well enough?
Well, it is 100% true that applications are better today than in the past, but they are certainly not where they need to be. Providers don’t relish using them. We have to reduce complexity and variation but need an intuitive and pleasurable user experience. We are starting to see tools on top of EHRs that can help with this – e.g., SMART on FHIR. People hope that a Google or an Apple could disrupt and provide the same kind of great smartphone experience, but the complexity in healthcare makes this hard – it’s not banking, nor are requirements black and white. There is lots of gray in medicine that’s hard to fully capture in an application. It is a constant struggle, and improvement occurs incrementally.
What are the significant barriers to progress?
It’s the number and variety of different initiatives that we are being asked to do. IT forms an important basis for virtually every activity in every part of the hospital. I have more projects and needs than I could possibly execute on. There is too much work to do. I have to be able to prioritize and say “No” to many valid and important requests. For many of these, I wish I could say “Yes”. By way of example, “data blocking”, which I don’t think actively occurs, often boils down to the fact that data sharing simply has a lower priority than other things on some organizations’ plates. We want to get to all of it eventually.
At the end of the day, the major reason is that I just don’t have the bandwidth to do everything that needs to be done. It is more than just a matter of the dollar investment in IT. I can certainly do more with more money, but it can’t be just IT. For IT to work well, domain experts in the business and clinical areas need to invest time and effort as well.