Sunday, June 28, 2009

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

Wednesday, June 24, 2009

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

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."

Monday, June 22, 2009

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.

Tuesday, June 16, 2009

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.

Thursday, June 11, 2009

The First Meeting of the Clinical Quality Workgroup

Guest author John Halamka reports on the first meeting of the clinical quality workgroup with their mission to provide recommendations on quality measures that should be tied to meaningful use. The workgroup expects to receive guidance on meaningful use from the HIT Policy Committee on June 16.

The First Meeting of the Clinical Quality Workgroup
by John Halamka

Today, the HIT Standards Committee Clinical Quality Workgroup met for the first time to discuss our charge, our deliverables, and our workplan.

The broad charge to the workgroup is to make recommendations to the HIT Standards Committee on quality measures that should be included in the Meaningful Use definition and for future EHR requirements. Also to make recommendations to the HIT Standards Committee on requirements for standards, implementation specifications, and certification related to EHRs and clinical quality.

The specific charge is make recommendations to the HIT Standards Committee on specific quality measures that should be included in the definition of Meaningful Use for 2011 within two (2) months of the workgroup’s first meeting. The workgroup will also take into consideration the eight (8) areas listed in Section 3002(b)(2)(B) when developing recommendations for the committee.

As I discussed in yesterday's blog, the HIT Policy Committee will discuss a matrix of meaningful use, standards, certification criteria, and meaningful use measures at their June 16th meeting. The Quality Workgroup will review this matrix and edit/amend it with appropriate accepted/recognized standards over the next 60 days.

For Quality measures, the important work to date includes HITEP I, HITEP II, and HITSP's efforts to create services with the capbilities to exchange raw data and computed measures.

NQF released the draft of HITEP II's work for public comment yesterday. It includes an important framework for describing quality measures based on EHR data types.

HITSP Tiger Teams are hard at work this week finishing a set of services which include 4 capabilities supporting quality:

-Collect and Communicate Quality Measure Data for a Hospital
-Collect and Communicate Quality Measure Data for Clinicians
-Quality Measures for Hospital Quality Information Reporting
-Quality Measures for Clinical Quality Information Reporting

The first two capabilities include the raw data needed to compute quality measures i.e. meds, labs, and process data

The second two capabilities include pre-computed patient level quality measurement numerators and denominators, a summary rather than the raw data. These services use the Quality Reporting Document Architecture (QRDA), a constrained form of CDA

On June 16th, the Quality workgroup will receive meaningful use guidance from the HIT Policy Committee. We'll work hard over the following week and will present our strawman standards, implementation guidance, and certification criteria at the June 23rd public meeting of the HIT Standards Workgroup. We'll continue to refine the matrix in July and complete our work in August.

As I said yesterday, it's going to be a fun summer for everyone in healthcare IT!

Monday, June 1, 2009

ONC Proposes Health Information Technology Regional Extension Centers

The Office of the National Coordinator for Health Information Technology has requested comments on a proposal to establish regional centers to assist providers seeking to adopt and become meaningful users of health information technology.

Comments are due by June 11, 2009.

Highlights from the May 28 Federal Register follow:

"ARRA includes provisions to promote the adoption of interoperable health information technology to promote meaningful use of health information technology to improve the quality and value of American health care. Providers that seek to adopt and effectively use health information technology (health IT) face a complex variety of tasks. Those tasks include assessing needs, selecting and negotiating with a system vendor or reseller, and implementing workflow changes to improve clinical performance and, ultimately, outcomes. Past experiences have shown that without robust technical assistance, many EHRs that are purchased are never installed or are not used by some providers.

A Health Information Technology Extension Program will make assistance available to all providers, but with priority given to assisting specific types of providers. The health information technology extension program consists of a National Health Information Technology Research Center (HITRC) and Regional Extension Centers (or ‘‘regional centers’’). The major focus for the Centers’ work with most of the providers that they serve will be to help to select and successfully implement certified electronic health records (EHRs). While those providers that have already implemented a basic EHR may not require implementation assistance, they may require other technical assistance to achieve ‘‘meaningful user’’ status. All regional centers will assist adopters to effectively meet or exceed the requirements to be determined a ‘‘meaningful user’’ for purposes of earning the incentives.

Whereas research and analysis of best practices regarding health IT utilization rests primarily with the HITRC, dissemination and implementation of those best practices learned from the HITRC will rest with the regional centers.

Each regional center shall ‘‘aim to provide assistance and education to all providers in a region but shall prioritize any direct assistance first to the following:
• Public or not-for-profit hospitals or critical-access hospitals.
• Federally qualified health centers
• Entities that are located in rural and other areas that serve uninsured, underinsured, and medically underserved individuals (regardless of whether such area is urban or rural).
• Individual or small group practices (or a consortium thereof) that are primarily focused on primary care.’’

The minimal level of support must include the provision of unbiased information on mechanisms to exchange health information in compliance with applicable statutory and regulatory requirements, and information to support the effective integration of health information exchange activities into practice workflow.

We anticipate an average award value on the order of $1 million to $2 million per center. The maximum award value we anticipate making available to any one regional center is $10 million."