Insured and At Risk

Reed Ableson reports in today's New York Times on the risk faced by the medically insured. His findings: "three-quarters of people who are pushed into personal bankruptcy by medical problems actually had insurance when they got sick or were injured. And so, even as Washington tries to cover the tens of millions of Americans without medical insurance, many health policy experts say simply giving everyone an insurance card will not be enough to fix what is wrong with the system. Too many other people already have coverage so meager that a medical crisis means financial calamity."
Ableson takes to task the role played by limited benefit plans. In his case study of now bankrupt Larry Yurdin, "$150,000 hospital coverage in the Aetna policy was mainly for room and board. Coverage was capped at $10,000 for “other hospital services,” which turned out to include nearly all routine hospital care — the expenses incurred in the operating room, for example, and the cost of any medication he received. In other words, Aetna would have paid for Mr. Yurdin to stay in the hospital for more than five months — as long as he did not need an operation or any lab tests or drugs while he was there."

Linking this back to the health care reform debate now underway, is there reason to be concerned that private insurance will jettison at-risk patients? Yes according to a former Cigna executive who cautioned "that lawmakers should be careful about the role they gave private insurers in any new system, saying the companies were too prone to 'confuse their customers and dump the sick.'"

HHS State Reports Make Case for Health Reform

On Friday June 26, HHS Secretary Kathleen Sebelius made the local case for health reform, issuing one page compendiums of statistics on health care cost and quality for each of the fifty states.

The state reports include data on:

• Percent increase in family premiums since 2000 (typically more than 85%).
• Costs of care for the uninsured.
• Percentage of state residents without insurance.
• Quality ratings

The state reports are published at healthreform.gov.

The Second Meeting of the HIT Standards Committee

Guest author and co-chair of the HIT Standards Committee John Halamka reports on the HIT Standards Committee working groups' progress on Clinical Operations, Clinical Quality and Privacy/Security.

The Second Meeting of the HIT Standards Committee
by John Halamka

Today, Jonathan Perlin and I ran the second meeting of the HIT Standards Committee.

Here's a report on presentations and the work ahead.

Jamie Ferguson presented the work of the Clinical Operations Working Group. There are three major threads of effort
- Clearly define the standards work to be completed by the Clinical Operations Workgroup and the Clinical Quality Workgroup, since quality measures depend upon clinical operations data
- Select the specific standards and certification criteria supporting Meaningful Use Objectives and Measures
- Create a taxonomy for standards maturity and industry readiness to deploy standards. The draft taxonomy we discussed is:

Category I- Known/Certain for 2011
Standards are well-accepted and generally seen as deployable

Category II- Known/Certain for 2013
Standards exist, are determined, but are not in the market yet

Category III- Work In Process for 2013 or 2015
Need to converge/refine standards for 2013 or develop for 2015

Category IV- Standards to be determined
“Gleam in the eye,” some concepts exist but no clear path

David Blumenthal noted that the stimulus may motivate stakeholders to adopt data exchange more quickly than the past, making stretch goals possible. As a group we discussed the challenge of the healthcare ecosystem - motivating just one segment of the industry may not be sufficient to achieve data exchange i.e. standardizing EHRs to accept specific lab data standards is not sufficient unless the labs also agree to send data in a single standard format.

Janet Corrigan presented the work of the Clinical Quality Working Group. Her group is building on the work of the National Quality Forum's Health Information Technology Expert Panel to identify the Quality Data Set needed to support measurement and reporting. They are not choosing new standards or vocabularies, instead they are developing a framework of datatypes that enable the measures to be expressed in terms of EHR capabilities. For example

% of Hypertensive Patients with BP under Control [OP] requires EHR datatypes for

Age
Hypertension diagnosis
Ambulatory encounter
Systolic blood pressure result
Systolic blood pressure result

The Clinical Quality Workgroup will spend the next month specifying the precise measures in terms of datatypes that will meet the quality measurement requirements of meaningful use. They will work closely with the Clinical Operations Workgroup to ensure the needed data exchanges supporting collection of these datatypes are included in the standards chosen.

Dixie Baker presented the work of the Privacy and Security Working Group. Her group identified three categories of standards and best practices supporting security:

1) Products that can be purchased (certified by CCHIT outside the real-life setting)
2) IT infrastructure necessary to enable the product to be meaningfully used
3) Operational environment in which the product will be used meaningfully

She also described recommended wording improvements to the meaningful use matrix items that will be forwarded to the HIT Policy Committee.

Their work over the next month will be to name the security standards and best practices for each meaningful use item and the ARRA 8 items.

The entire Committee discussed some of the existing gaps in standards. These included
-Standards for ordering including lab orders
-Standards for supporting electronic reporting of some of the meaningful use measures i.e. what percentage of prescriptions were written electronically - how do you calculate the number of prescriptions written manually?
-Standards supporting some of the patient/family engagement provisions of meaningful use

Our plan is to complete the efforts of our 3 Workgroups by the next meeting of the HIT Standards Committee on July 21. The end result will be a matrix of standards, an estimate of the readiness for deployment of each standard, quality measures, and privacy/security best practices for each meaningful use objective.

This work will give ONC and HHS the lead time they need for legal review, budget impact, and rule writing by the appropriate federal agencies.

The next month will be a whirlwind of activity. My thanks and appreciation to everyone involved!

EHR Impact on Failure-To-Inform Rates

7.1% of patients are not notified of abnormal outpatient test results (or the notification is not documented) affecting 1 in 14 patients, with failure rates ranging as high as 1 in 4 patients in some practices. The health implications of this finding are significant.

The study led by Dr. Lawrence Casalino of Weill Cornell Medical College found that "having an electronic medical record did not reduce failure-to-inform rates — and even increased them — if the practice did not have good processes in place for managing test results... The study suggests that five simple, common-sense processes are useful for dealing with test results: (1) all test results are routed to the responsible physician; (2) the physician signs off on all results; (3) the practice informs patients of all results, normal and abnormal, at least in general terms; (4) the practice documents that the patient has been informed; and (5) patients are told to call after a certain time interval if they have not been notified."

The full study - "Frequency of Failure to Inform Patients of Clinically Significant Outpatient Test Results" - in the Archives of Internal Medicine reports that "use of a 'partial electronic medical record' (paper-based progress notes and electronic test results or vice versa) was associated with higher failure rates compared with not having an electronic medical record or with having an electronic medical record that included both progress notes and test results. "

The authors concluded that "they did not find a significant difference between practices that had a 'complete' EMR and those that used paper records; this may be because there is no difference or because the number of practices included was not large enough to detect a difference."

CCHIT To Provide 3 Certification Options

On June 18, the Certification Commission for Health Information Technology (CCHIT) announced that it is extending its certification options in response to concerns from open source developers and in an effort to better position itself to vie for appointment as the certification agency required under the HITECH provisions of the American Recovery and Reinvestment Act (ARRA).

The three options include:

• "A rigorous certification for comprehensive EHR systems that significantly exceed minimum Federal standards requirements. This certification (EHR-C) would be targeted to the needs of providers who want maximal assurance of EHR capabilities and compliance
• A new, modular certification program for electronic prescribing, personal health records, registries, and other technologies. Focusing on basic compliance with Federal standards and security, the EHR-M program would be offered at lower cost, and could accommodate a wide variety of specialties, settings, and technologies. It would appeal to providers who prefer to combine technologies from multiple certified sources.
• A simplified, low cost site-level certification. This program would enable providers who self-develop or assemble EHRs from noncertified sources to also qualify for the ARRA incentives."

These certification options are targeted to be available for 2011-2012 certifications which kick off in January 2010.

CCHIT has been criticized for too close a relationship to Health IT vendors, led most visibly by David Kibbe and Brian Klepper, who have asked "If the HITECH monies are spent on CCHIT certified EHRs that can't do any of these patient-centered tasks, or EHRs that don't come equipped with the features and functions to extend health IT capability to the patients and consumers, do we really think that the money will have been spent wisely? But that's the pathway we seem headed down, led by the vendors." Mark Leavitt, Chair of CCHIT, has responded forcefully to this criticism.

CCHIT's announcement addresses the concern that certification was previously only available to vendors able to deliver monolithic solutions covering all EHR requirements.

Meaningful Use: "It's not about the HIT"

The HIT Policy Committee Meaningful Use Workgroup presented today its vision and recommendations for meaningful use of electronic health records.

Here's an 'early look' at the draft meaningful use criteria presented by co-chairs Paul Tang and Farzad Mostashari. Paul Tang emphasized the focus on "patient-centeredness" and quality, saying "It's not about the HIT".

The workgroup has also published a more detailed meaningful use matrix with the roadmap through 2015. The progression starts with a focus on information capture and sharing in 2011. By 2013, meaningful use is expanded to include advanced care processes with decision support and by 2015 is expanded to embrace improvements in outcomes.

ONC to Host CONNECT Open Source Seminar

The Office of the National Coordinator for Health Information Technology (ONC) has announced the agenda for the June 29-30 open source CONNECT Seminar '09 in Washington D.C.

CONNECT is an on-ramp to the Nationwide Health Information Network (NHIN), a network of networks for health information exchanges, providers, payers, and other stakeholders enabling standards-based connectivity and information sharing.

CONNECT is an open source connectivity solution built for use by 20 federal agencies to securely link their systems to the NHIN. Earlier this year, CONNECT was released to the public including:

• The NHIN Gateway is used to locate patients at other health organizations within the NHIN, request and receive documents associated with the patient, create audit logs of these transactions, authenticate network participants, formulate and evaluate authorizations for the release of medical information, and honor consumer preferences for sharing their information.

• The Enterprise Service Component includes a Master Patient Index (MPI), Document Registry and Repository, Authorization Policy Engine, Consumer Preferences Manager, HIPAA-compliant Audit Log and a software development kit for developing adapters to plug in existing systems such as electronic health record solutions to support the secure exchange of health information across the NHIN.
  

• The Universal Client Framework is used to develop applications using the Enterprise Service Component.
  

Speakers at the CONNECT Seminar '09 include keynoters ONC head David Blumenthal and CTO Aneesh Chopra, with business and technical tracks delivered by experts on the CONNECT system.