PROVIDENCE – On Tuesday morning, Sept. 1, Sen. Sheldon Whitehouse is scheduled to conduct a health IT roundtable discussion at The Tech Collective, sponsored by MedMates, a nascent industry cluster group focused on the medtech industry sector in Rhode Island.

The headline on the invitation to the event read: “Sen. Whitehouse and MedMates invite Rhode Island HIT and health app stakeholders to participate in a roundtable discussion.”

As a way of explanation, that invitation, sent out as a broadcast email by Medmates, continued: “This year, the Senate HELP [Health Education Labor and Pensions] Committee has held a series of hearings related to health information technology, with the goal of identifying reforms to improve the usability of electronic health records, advance health information exchange, and enable patient access to their personal health information.”

The invite then said: “This Committee work continues through a bipartisan working group which aims to make recommendations to the Administration and draft legislation on these topics by the end of the year as part of a broader medical innovation agenda.”

Further, the invite said: “At this discussion, we would like to hear from stakeholders about their work on health IT and get feedback on the barriers to interoperability and data portability; the appropriate role of the federal government in the standards development process; and improving patients’ access to their personal health information, among other issues.”

The invitation said that registration was required, and that there were only 20 seats available for bio, pharma or medical device professionals, on a first-come, first-served basis.

Closed-door discussion?
But, rather than being a open-door event, the discussion turned out to be an exclusive one – limited to only those industry stakeholders that MedMates ordained as their “approved” version of bio, pharma or medical device professionals.

By the published standards, ConvergenceRI met all the pre-conditions set: an industry stakeholder, a professional, a CEO, someone with a keen knowledge of health IT in Rhode Island and its applications across the spectrum of the biomedical, life science, pharmaceutical, and medical device applications.

ConvergenceRI registered, was sent a ticket through Eventbrite, only to be disinvited a day later by Maeve Donohue, the co-executive director of MedMates.

In canceling ConvergenceRI’s registration, Donohue wrote: “Thanks for registering for the upcoming event. Unfortunately, there are only 20 seats available, and it is required that you are a Health IT professional in order to attend. I’ve had to cancel registration for several marketing folks so far. I’m sorry about that. We will be taking notes and will be happy to share with you after the event.”

ConvergenceRI wrote back, protesting the cancellation, to no avail. When asked directly to clarify if ConvergenceRI could attend as an observer, not as a participant, Donohue did not respond.

The conflict over who gets a seat at the table in the conversation with Whitehouse goes to the heart of the debate over future health IT and the burgeoning market for mHealth: who owns and controls the data; who performs the analyses; are there more nimble health management systems that allow providers to management population health at the community level without having to go through a hospital, state or insurance interface; and how can customers and patients talk, and talk back, to doctors, hospitals and insurers in real time, in a patient-engaged world?

It’s all about who will control the digital conversation and the data; it’s a bad sign when an industry cluster group and a U.S. Senator seek to limit participants in that conversation.

Questions for Whitehouse
Before the cancellation of the registration, ConvergenceRI had emailed Whitehouse’s top press aide, Seth Larson, with a series of questions in advance of the scheduled health IT roundtable discussion.

ConvergenceRI then followed up with a phone call to Larson, who explained that Whitehouse was traveling overseas and that it was unlikely that the Senator would be able to respond by ConvergenceRI’s deadline.

Here are the questions that ConvergenceRI posed to Whitehouse:

•   With the tremendous growth in mHealth and wearable bands, how does that change the equation in terms of electronic health records?

•    In a patient-driven, patient-centric, mobile connected world, how do you believe that changes the way that patients and their caregivers communicate with their doctors and health care team?

•    In terms of population health management analytics, who owns the data? Is it the insurer, the hospital, the provider, or the patient? What if the data is self-collected by the patient?

•    Why do you think that CurrentCare in Rhode Island, the state’s health information exchange, has not been readily adopted by doctors [some 82 percent in 2014 survey conducted by the R.I. Department of Health were not using it] or by consumers [only 35 percent of Medicaid patients are enrolled as of the second quarter of 2015, matching the enrollment rate for commercially insured Rhode Islanders of 35 percent]?

•    How does the investment in major upgrades in health IT platforms get paid for? What's the ROI for the investment? How much of that burden will fall to the consumer?

If and when Whitehouse responds to the questions, ConvergenceRI will be happy to publish the answers.

What’s at stake?
The context of the health IT roundtable discussion with Whitehouse is the preparation of new legislation as part of the ongoing activities of the Senate Health Education Labor and Pensions Committee.

The committee chair, Sen. Lamar Alexander, a Republican from Tennessee, opened the first of a series of hearings earlier this year by saying that the aim of the hearings was to make the adoption of EHRs something that is not dreaded by physicians.

Alexander had argued for a delay in the implementation of Stage 3 of Meaningful Use, saying: “My goal is that before that phase is implemented, we can work with physicians and hospitals and the administration to get the system back on track and make it a tool that hospitals and physicians can look forward to using to help their patients instead of something they dread.”

[Meaningful use refers to a carrot-and-stick approach to the adoption and use of electronic health records by physicians and hospitals. Meet the goals and the flow of incentive payments from the federal government continue; miss the goals and there are financial penalties. Under Stage 3 Meaningful Use, the objectives and measures include: protection of patient health information, electronic prescribing, clinical decision support, patient electronic access to health information, coordination of care through patient engagement, health information exchange, and public health and clinical data registry reporting.]

Much of the first hearing focused on interoperability, according to news reports. “Current health IT systems lack true interoperability, and the lack of true interoperability is failing patients,” said Neal Patterson, CEO of an EHR vendor, Cerner. “Without it, we risk missing the moonshot transformation that has positively changed other industries and lives.”

Missing the moonshot transformation? Indeed, that kind of imagery has been attached to the massive investment by the federal government in health IT with the promise [as yet unfulfilled] that it will improve health outcomes, lower costs, and improve patients’ satisfaction.

Talking about interoperability tends to mask the corporate conflict over which health IT system will control the largest market share, and the fact that “interoperability” has proven difficult because of proprietary concerns of the different systems. It’s a trillion-dollar competition. But that’s a story for another day.

Accounting and accountable care
In case you missed it, one of the big drivers in population health management analytics is the push to move from the fee-for-service model toward bundled payments, managed by what’s known as accountable care entities. To do that, it requires providers to manage the flow of data across a continuum of care – and then integrate that data at the point of care.

Both Medicare and Medicaid are designing their future reimbursements around bundled payments, promoting the development of ACOs.

Here in Rhode Island, there are numerous approaches underway to set up Accountable Care Organizations, some driven by the federal government’s pilot program to set up ACOs for Medicare patients, others driven by hospitals such as Care New England, which has created its own ACO known as Integra.

Under the State Innovation Model grant award, there are apparent plans to transform the state’s health care delivery system using an accountable care entity model, based on the current all-payer model known as the Care Transformation Collaborative.

The vision is that these accountable care entities can better control costs, improve health outcomes, and better manage health across a continuum of care. But exactly how these models will perform is still unproven, a work in progress.

And, to accomplish the goals of an ACO, it requires a nimble, robust and sophisticated health IT system that can integrate population health management at the point of care.

Underneath these efforts is a fierce competition around which models will prove most successful, in Rhode Island and in the nation.

Weighing in
At a second hearing earlier this year of the Senate HELP Committee, Meryl Moss, the COO of Coastal Medical, testified before the committee, at the invitation of Whitehouse. Coastal Medical, one of the state’s largest private group of primary care practices, had been awarded a pilot program under Medicare to create and manage its own ACO to see if it could achieve shared savings, which it did.

Dr. G Alan Kurose, president and CEO of Coastal Medical, told ConvergenceRI in March of 2014 that it took a lot of hard work.

“We had to build a lot of infrastructure to [create] a primary care urgent visit system open 365 days a year. It takes some doing,” Kurose said.



“We [hired] 20 nurse care managers, and trained them, with 17 in practices, two that make rounds in hospitals and one that makes rounds in nursing facilities. We added four full-time pharmacists. We made investments and incurred costs. Happily, we were successful enough to cover those costs,” Kurose said.



It’s hard work, Kurose continued. “It’s hard because we had to deliver all those extra services to start to understand the total cost of care. We had to build an analytics platform to [manage] all of the claims. There was a great deal of work on quality; Coastal now has 72 quality measures.”

In her testimony, Moss addressed the problem of having too many quality measures. “We are coming to the realization that there should be harmonized quality measures that all medical groups can use as a standard,” Moss testified. “The government uses one set of measures for Center for Medicare and Medicaid’s Accountable Care Organizations and a different set for Meaningful Use. Insurers require us to achieve different quality targets and these are ever‐changing. NCQA requires different measures as well. All are good, but many are overlapping. This just creates unnecessary complexity and confusion.”

She continued: “If CMS and commercial payers were to establish an agreed upon “core” group of quality measures, and if electronic health vendors were driven to support that “core” through certification standards, this could greatly improve the efficiency of quality measurement, quality reporting, and quality improvement across our industry. The physician community could be certain that whatever record that they purchased would have the basic functionality to manage the core measures that should be used by insurers, the government and accrediting bodies.”

Sounds promising as an idea. But, who gets to decide what those core standards should be? And, do those core standards work equally across different models of health care delivery – hospitals, private groups, community health centers? And, which health IT system will deliver best on the management and the interoperability of data – eClinicalWorks, which Coastal uses, Epic, which Lifespan, Care New England and CVS Health use, athenahealth, which Prospect Medical, the parent of CharterCARE, uses, or NextGen, which the majority of Rhode Island community health centers have deployed, including WellOne, TriTown, CCAP, East Bay, Wood River and Blackstone Valley Community Health Care? 

And, what role will be played by Healthcentric Advisors, the quality improvement organization for Medicare in New England that is deeply involved in working with physicians’ training around practice reorganization in a patient-engaged world?

All good questions.