"How American Health Care Killed My Father"

David Goldhill chronicles in How American Health Care Killed My Father the problems in the healthcare system leading to his father's death by a preventable hospital-borne infection. It's an excellent survey piece, whether or not you agree with the consumer- and market-centered policy conclusions.

Goldhill's comments extend to Healthcare Technology:

"Consider information technology, for instance. Of course the health system could benefit from better use of IT. The Rand Corporation has estimated that the widespread use of electronic medical records would eventually yield annual savings of $81 billion, while also improving care and reducing preventable deaths, and the White House estates that creating and spreading the technology would cost just $50 billion. But in what other industry would an investment with such a massive annual return not be funded by the industry itself? (And while $50 billion may sound like a big investment, it’s only about 2 percent of the health-care industry’s annual revenues.)

Technology is effective only when it’s properly applied. Since most physicians and health-care companies haven’t adopted electronic medical records on their own, what makes us think they will appropriately use all this new IT? Most of the benefits of the technology (record portability, a reduction in costly and dangerous clinical errors) would likely accrue to patients, not providers. In a consumer-facing industry, this alone would drive companies to make the investments to stay competitive. But of course, we patients aren’t the real customers; government funding of electronic records wouldn’t change that."

Minimal Use of $2.5M CMS PHR Program

Medicare's $2.5 million pilot of Personal Health Records (PHR) has drawn so little use that the program may not be renewed according to a recent article in the Arizona Republic. The CMS regional administrator wouldn't give specific figures but did say that the percentage participation was lower than the 3-6% nationally that use some sort of health record.

The pilots in Arizona and Utah provide seniors with access to one of four PHRs from Google Health, HealthTrio, NoMoreClipboard.com and PassportMD. Medical histories can be stored. The PHRs come prepopulated with two years of Medicare claims information documenting recent history (e.g., visits, medications, procedures)

"Officials from Medicare and participating software vendors acknowledge that a small percentage of Arizona seniors have signed up for the $2.5 million health-records program launched in January, raising questions about whether the one-year experiment should continue next year. 'We'd like to see more involvement,' said David Sayen, regional administrator for the Centers for Medicare and Medicaid Services, the federal agency that oversees the government insurance programs for seniors, the poor and disabled."

Dead By Mistake

Preventable medical errors and hospital acquired infections are still the largest causes of accidental death in US. The number of preventable deaths is approaching 200,000. There has been little change in the number of deaths from preventable medical errors since the seminal report on preventable medical errors, "To Err is Human".

Dead by Mistake, by a group of Hearst journalists, reports that "ten years ago, a highly publicized federal report called the death toll shocking and challenged the medical community to cut it in half — within five years. Instead, federal analysts believe the rate of medical error is actually increasing. In its 2008 annual report to Congress, the Agency for Healthcare Research and Quality, a part of the Department of Health and Human Services, reported that preventable medical injuries are growing each year by 1 percent, the first time it had reported such an increase."

As a result of this and other evidence, the Hearst journalists found that, since the original Institute of Medicine (IOM) study, there was no reason to believe that the 98,000 deaths per year attributable to preventable medical errors had declined. And the Center for Disease Control and Prevention found that 99,000 deaths were due to mainly preventable hospital infections.

The report "found that the the medical community, the federal government and most states have overwhelmingly failed to take the effective steps outlined in the report a decade ago." For example, the IOM report

• Recommended national reporting of medical errors. Strong resistance from the AMA and the AHA effectively shelved this recommendation. Of the 20 states that have mandated reporting, "evidence shows that even in those mandatory-reporting states, hospitals report only a tiny percentage of their mistakes."
• "Recommended the creation of a national patient safety center. The center is underfunded and has fallen far short of expectations.
  
• Urged that hospitals improve the level of safety within their walls. Hundreds of hospitals responded, a few of them comprehensively pursuing safer care. Thousands did much less.
• Advocated a voluntary system for hospitals to report and learn from errors. Five years later, Congress approved legislation for 'patient safety organizations' to serve this role, then took four more years to create rules to govern them. But the new organizations are devoid of meaningful oversight and further exclude the public."

HITSP Approves New Interoperability Specifications in Line with ARRA

The Healthcare Information Technology Standards Panel (HITSP) has announced approval of

• IS107 - Electronic Health Record (EHR)-Centric Interoperability Specification
• TN904 – Exchange Architecture & Harmonization Framework Technical Note
• TN903 – Data Architecture Technical Note
• SC108- SC116 – Service Collaborations

In response to the HIT requirements of ARRA, HITSP leveraged its work products – 13 Interoperability Specifications (IS) and 60 related constructs – to consolidate all information exchanges that involve an Electronic Health Record (EHR) system.

HITSP formed temporary “tiger” teams to map EHR-related information exchanges to ARRA requirements. These teams identified “Capabilities” – specific, implementable business services that use existing HITSP constructs to define and specify interoperable information exchanges. For example, the Communicate Hospital Prescriptions Capability addresses the interoperability requirements needed to support electronic prescribing for inpatient prescription orders.

In total, twenty-six Capabilities were defined that support the workflow, information content, infrastructure, and security and privacy requirements laid out in the ARRA legislation. All of the Capabilities are defined in IS107 –EHR-Centric Interoperability Specification.

HITSP Capabilities also address the “meaningful use” requirement of ARRA. ONC’s Health IT Policy Committee recommended a definition of meaningful use that names seven different electronic exchanges to be required by 2011: ePrescribing, lab results, clinical data summaries (problems, medications, allergies, laboratory reports) from provider to provider, Biosurveillance, immunization registries, public health, and quality measurement.

“HITSP Capabilities provide specific transactions supporting all seven of these required exchanges and others that will be needed in 2011, 2013, and beyond,” said HITSP Chair John Halamka.

Definitions of the capabilities and service collaborations include:

HITSP/CAP117 Communicate Ambulatory and Long Term Care Prescription

This capability addresses interoperability requirements that support electronic prescribing in the ambulatory and long term care environment. The capability supports:
1. The transmittal of new or modified prescriptions
2. Transmittal of prescription refills and renewals
3. Communication of dispensing status
4. Access to formulary and benefit information

HITSP/CAP118 Communicate Hospital Prescription

This capability addresses interoperability requirements that support electronic prescribing for inpatient orders that can occur within an organization or between organizations. The capability supports the transmittal of a new or modified prescription from a Hospital to an internal or external pharmacy. It also includes the optionality to access formulary and benefit information.

HITSP/CAP119 Communicate Structured Document

This capability addresses interoperability requirements that support the communication of structured health data related to a patient in a context set by the source of the document who is attesting to its content. Several document content subsets, structured according to the HL7 CDA standard, are supported by this capability. The following are examples of the type of structured data that may be used:
1. Continuity of Care Document (CCD)
2. Emergency Department Encounter Summary
3. Discharge Summary (In-patient encounter and/or episodes of care)
4. Referral Summary Ambulatory (encounter and/or episodes of care)
5. Consultation Notes
6. History and Physical
7. Personal Health Device Monitoring Document
8. Healthcare Associated Infection (HAI) Report Document
Document creators shall support a number of the HITSP specified coded terminologies as defined by specific content subsets specified in this capability.

HITSP/CAP120 Communicate Unstructured Document

This capability addresses interoperability requirements that support the communication of a set of unstructured health data related to a patient in a context set by the source of the document who is attesting to its content.
Two types of specific unstructured content are supported, both with a structured CDA header:
1. PDF-A supporting long-term archival
2. UTF-8 text

HITSP/CAP121 Communicate Clinical Referral Request

This capability addresses interoperability requirements that support provider-to-provider (clinical) referral request interaction. It allows the bundling of the referral request document with other relevant clinical documents of interest by referencing such documents as shared by other capabilities such as:
CAP119 Communicate Structured Document; CAP120 Communicate Unstructured Document; or CAP133 Communicate Immunization Summary.

HITSP/CAP122 Retrieve Medical Knowledge

This capability addresses the requirements to retrieve medical knowledge that is not patient-specific based on context parameters. The actual content delivered is not constrained by this capability; this capability focuses on providing the mechanism to ask for (query) and receive the medical knowledge.

HITSP/CAP123 Retrieve Existing Data

This capability supports queries for clinical data (e.g., common observations, vital signs, problems, medications, allergies, immunizations, diagnostic results, professional services, procedures and visit history).

HITSP/CAP124 Establish Secure Web Access

This capability is focused on providing a secured method to access information available from document repositories (e.g., Laboratory Report) in order to view them locally on a system. The chosen method for viewing the document content is through a web browser.

HITSP/CAP125 Retrieve Genomic Decision Support

This capability addresses interoperability requirements that support the communication of genetic and family history information and an assessment of genetic risk of disease for a patient.

HITSP/CAP126 Communicate Lab Results Message

This capability addresses interoperability requirements that support the sending of a set of laboratory test results. Ordering Providers of Care receive results as a laboratory results message. The communication of the order is out of scope for this capability.
The content of these test results may be either or both: General Laboratory Test Results; Microbiology Test Results
This capability may use content anonymization.

HITSP/CAP127 Communicate Lab Results Document

This capability addresses interoperability requirements that support the communication of a set of structured laboratory results related to a patient in a context set by the source of the document who is attesting to its content. Non-ordering Providers of Care access historical laboratory results as documents and "copy-to" Providers of Care may receive document availability notifications to retrieve such lab report documents.
Lab Report content creators shall support HITSP specified coded terminologies as defined by specific content subsets specified in this Capability for: General Laboratory Test Results; Microbiology Test Results
This capability may use content anonymization.

HITSP/CAP128 Communicate Imaging Information

This capability addresses interoperability requirements that support the communication of a set of imaging results (i.e., reports, image series from imaging studies) related to a patient in a context set. This is done by an Imaging System acting as the information source attesting to its content.
This capability may use content anonymization.

HITSP/CAP129 Communicate Quality Measure Data

This capability addresses interoperability to support hospital and clinician collection and communication of patient encounter data to support the analysis needed to identify a clinician or hospital’s results relative to an EHR-compatible, standards-based quality measure.
Quality measures may include:
1. Patient-level clinical detail from which to compute quality measures. Patient level clinical data is compiled from both the local systems and from longitudinal data available through other sources such as a Health Information Exchange (HIE).
2. Patient-level quality data based upon clinical detail. The “patient-level quality data reports” are exported from EHRs or quality-monitoring applications at the point of care
This capability may use content anonymization. Pseudonymization, if needed, is supported by the Capability 138 Retrieve Pseudonym.
This capability may use Value Set Sharing.

HITSP/CAP130 Communicate Quality Measure Specification

This capability addresses interoperability requirements for an EHR-compatible, standards-based quality measure. In the measure specification, needed patient encounter data elements are identified so they can be extracted from local systems and from longitudinal data available through other sources such as a Health Information Exchange (HIE). The measure specification also includes various sets of exclusion/inclusion criteria to identify which patients to include in calculation of the measure. This capability may use Value Set Sharing.

HITSP/CAP131 Update Immunization Registry

This capability addresses interoperability requirements that enable electronic communication of immunization data among clinicians, with patients, and with immunization registries as unsolicited structured patient immunization data.
This capability may use content anonymization.

HITSP/CAP132 Retrieve Immunization Registry Information

This capability addresses interoperability requirements that support the query and retrieval of structured immunization data related to a patient’s vaccination.
The capability may use one of the following:
1. HL7V2 query with implicit Patient Identity resolution
2. HL7V2 query with explicitly Patient Identity resolution prior to query
3. HL7V3 Query for Existing Data
The query for immunization documents from Capability 133 - Communicate Immunization Summary may also be used.

HITSP/CAP133 Communicate Immunization Summary

This capability addresses interoperability requirements to support the communication of structured health data related to a patient’s vaccination history. This immunization document contains a history of administered vaccines with details such as lot number, who administered it, as well as other information related to the patient's care such as medical history, medications, allergies, vital signs.

HITSP/CAP135 Retrieve and Populate Form

This capability addresses interoperability requirements to support the upload of specific captured data (e.g. public health surveillance reportable conditions, healthcare associated infection reporting) to Public Health Monitoring Systems and Quality Organizations Systems. The forms presented may be pre-populated by information provided by the clinical or laboratory information systems to avoid manual re-entry. A number of supplemental information variables may be captured from within the user’s clinical information system to improve the workflow and timeliness of required reporting. One or more types of form content may be supported:
1. Pre-population for Public Health Case Reports from Structured Documents using CDA
2. Pre-population for Quality Data from Structured Documents using CDA
3. No pre-population content
Systems may optionally support the means to retrieve request for clarifications.

HITSP/CAP136 Communicate Emergency Alert

This capability addresses interoperability requirements to support multicast of non-patient specific notification messages about emergencies events, alerts concerning incidence of communicable diseases, alerts concerning population needs for vaccines and other generic alerts sent to an identified channel. The intended recipients are populations such as “all emergency departments in XXX county”, “within a geographic area”, etc. Note that this capability is not used to communicate patient-specific or identifiable data.

HITSP/CAP137 Communicate Encounter Information Message

This capability addresses interoperability requirements to send specific clinical encounter data among multiple systems.
The content may be either or both:
1. Encounter Data Message
2. Radiology Results Message
It may be used in conjunction with other capabilities such as those related to the communication of laboratory data. This capability includes optional anonymization of content.

HITSP/CAP138 Retrieve Pseudonym

This capability addresses interoperability requirements to support a particular type of anonymization that both removes the association with a data subject, and adds an association between a particular set of characteristics relating to the data subject and one or more pseudonyms. This enables a process of supplying an alternative identifier, which permits a patient to be referred to by a key that suppresses his/her actual identification information. The purpose of this capability is to offer a pseudonymization framework for situations that require the use of specific data without disclosing the specific identity of patients or providers. Pseudo-identifiers are intended to allow accessibility to clinical information, while safeguarding any information that may compromise the privacy of the individual patient or provider. However, unlike anonymization, the alternative identifier key can be used to re-identify the individuals whose data was used.

HITSP/CAP139 Communicate Resource Utilization

This capability specifies the message and content necessary to report utilization and status of health provider resources to systems supporting emergency management officials at local, state or national levels who have a need to know the availability of hospital and other healthcare resources. The resource utilization information may be provided routinely or in response to a request.

HITSP/CAP140 Communicate Benefits and Eligibility

This capability addresses interoperability requirements that support electronic inquiry and response from a patient’s eligibility for health insurance benefits. The information exchanged includes the following:
1. A patient’s identification (i.e., name, date of birth, and the health plan’s member identification number)
2. Communication of a member’s status of coverage and benefit information and financial liability
3. Access to information about types of services, benefits and coverage for various medical care and medications.
It provides clinicians with information about each member’s health insurance coverage and benefits.

HITSP/CAP14 Communicate Referral Authorization

This capability addresses interoperability requirements that support electronic inquiry and response to authorizing a patient (health plan member) to be referred for service by another provider or to receive a type of service or medication under the patient’s health insurance benefits.
The capability supports the transmittal of a patient’s name and insurance identification number with the request for the type of service. It also includes the following optional requirements:
1. Identification of the type of service or medication requested for benefit coverage (does not guarantee payment by insurance provider)
2. Communication of a referral notification number or authorization number from the Payer System to the Provider SystemIt provides clinicians and pharmacists with information about each patient’s medical insurance coverage and benefits. It may include information on referral or authorization permission.

HITSP/CAP142 Retrieve Communications Recipient

This capability addresses interoperability requirements that support access to a directory to identify one or more communication recipients in order to deliver alerts and bi-directional communications (e.g., public health agencies notifying a specific group of service providers about an event). The method and criteria by which individuals are added to a directory is a policy decision, which is out of scope for this construct.

HITSP/CAP143 Manage Consumer Preference and Consents

This capability addresses management of consumer preferences and consents as an acknowledgement of a privacy policy. This capability is used to capture a patient or consumer agreement to one or more privacy policies; where examples of a privacy policy may represent a consent, dissent, authorization for data use, authorization for organizational access, or authorization for a specific clinical trial. This capability also supports the recording of changes to prior privacy policies such as when a patient changes their level of participation or requests that data no-longer be made available because they have left the region.

SERVICE COLLABORATIONS

A Service Collaboration is the composition of HITSP Transaction and or Transaction Package constructs into a reusable workflow, primarily at the infrastructure level. Service Collaborations do not contain content, i.e., Components. Service Collaborations are organized into an external view, i.e., outward facing interfaces, and an internal view that includes inward facing interfaces and HITSP Transactions and Transaction Packages. Security and privacy constructs are incorporated into the infrastructure Service Collaborations.

SC10 Access Control - The HITSP Access Control Service Collaboration provides the mechanism for security authorizations which control the enforcement of security policies including: role-based access control, entity based access control, context based access control, and the execution of consent directives.

SC109 Security Audit - The HITSP Security Audit Service Collaboration describes the mechanism to record security relevant events in support of policy, regulation, or risk analysis. It also provides the mechanism to determine the record format to support analytical reports that are needed.

SC110 Patient Identification Management - The HITSP Patient Identification Management Service Collaboration provides the ability to lookup and/or cross-reference patient identities.

SC111 Knowledge and Vocabulary - The HITSP Knowledge and Vocabulary Service Collaboration provides the ability to retrieve medical knowledge and terminology.

SC112 Healthcare Document Management - The HITSP Healthcare Document Management Service Collaboration provides the ability to share healthcare documents using a set of topologies, such as Media, e-Mail, Point-to-Point, Shared within a Health Information Exchange, and Shared within a larger community (made up of potentially diverse Health Information Exchanges).

SC113 Query for Existing Data - TheHITSP Query for Existing Data Service collaboration provides the capability to query and retrieve data from another clinical system, and the capability to respond to same queries. It applies the necessary Security and Privacy constructs and supports all the queries found in HITSP/TP21.

SC114 Administrative Transport to Health Plan - The HITSP Administrative Transport to Health Plan Service Collaboration provides the transport mechanism for conducting administrative transactions with health plans.

SC115 HL7 Messaging - The HITSP HL7 Messaging Service Collaboration provides the capability to send and receive HL7 messages. This Service Collaboration applies the necessary Security and Privacy constructs.

SC116 Emergency Message Distribution - The HITSP Emergency Message Distribution Service Collaboration performs a multicast notification to specifically identified populations, such as emergency departments.

Obama's Priorities for Reform

The intensifying debate over healthcare reform is forcing Barack Obama to reshape his arguments for reform. Why We Need Health Care Reform reflects Obama's latest talking points with an eye to capturing the support of mainstream voters, focusing on four key messages including 1) access to insurance, 2) cost savings, 3) efficiency and sustainability for Medicare and 4) consumer protections for health insurance:

• "First, if you don’t have health insurance, you will have a choice of high-quality, affordable coverage for yourself and your family — coverage that will stay with you whether you move, change your job or lose your job.
• Second, reform will finally bring skyrocketing health care costs under control, which will mean real savings for families, businesses and our government. We’ll cut hundreds of billions of dollars in waste and inefficiency in federal health programs like Medicare and Medicaid and in unwarranted subsidies to insurance companies that do nothing to improve care and everything to improve their profits.
• Third, by making Medicare more efficient, we’ll be able to ensure that more tax dollars go directly to caring for seniors instead of enriching insurance companies. This will not only help provide today’s seniors with the benefits they’ve been promised; it will also ensure the long-term health of Medicare for tomorrow’s seniors. And our reforms will also reduce the amount our seniors pay for their prescription drugs.
• Lastly, reform will provide every American with some basic consumer protections that will finally hold insurance companies accountable. A 2007 national survey actually shows that insurance companies discriminated against more than 12 million Americans in the previous three years because they had a pre-existing illness or condition. The companies either refused to cover the person, refused to cover a specific illness or condition or charged a higher premium."

Gone from the pitch? The public option and investment in health care information technology.

The public option is no longer included in the bill being negotiated by the Senate Finance committee. In his Friday Town Hall meeting in Montana, Obama mentioned Committee Chair Max Baucus by name some 8 times, - saying Baucus is "working tirelessly to make sure the American people get a fair deal" and is "committed to getting this done." The bi-partisan negotiators are getting heat from progressives, so "Obama’s embrace seemed designed to provide him some political cover to keep those bipartisan negotiations going in September."

And Health Information Technology? It's already funded through ARRA and incidental to the current debate.

The Senate's Gang of Six Stays Inside for Recess

While the rest of the Senate left town for their August recess, six Senators stayed behind. The bi-partisan Senate Finance Committee negotiators are reported to be making progress on their healthcare reform plan.

Max Baucus, the Finance Committee Chair has given the negotiators a September 15 deadline for completing their work. And Chuck Schumer has weighed in that “If they can’t do it by Sept. 15th, I think the overwhelming view on the Democratic side is going to be, then, they’re never going to get it done... And there’s always a worry that, you know, delay, delay, delay, you lose any momentum whatsoever.”

Douglas Elmendorf, CBO Director, has testified that other healthcare legislation in Congress would raise costs. Before the House Ways & Means Committee, he said that "we do not see the sort of fundamental changes that would be necessary to reduce the trajectory of federal health spending by a significiant amount. And on the contrary, the legislation significantly expands the federal responsibility for health care costs." All of which raises the bar for the Senate negotiators to come up with a plan which bends the cost curve in the right direction.

Shailagh Murray and Lori Montgomery recently reported on the Senate negotiators' progress towards eventual coverage of 94 percent of Americans that "would expand Medicaid, crack down on insurers, abandon the government insurance option that President Obama is seeking and, for the first time, tax health-care benefits under the most generous plans." Excerpts of the negotiators' policy positions follow.

• "Seeking compromise on some of the most complex issues .. including how to compel employers to continue providing insurance to their workers; how to more fairly distribute government subsidies for coverage; and who and how many should be allowed to remain uninsured."
• "Limit (congressional) authority over Medicare by empowering an independent commission to extract savings from the program..."
  
• "Rejected a government-run health insurance plan in favor of a network of member-owned cooperatives..."
• "Outstanding issues include how to structure a Medicaid expansion to make it fair to individual states; how to establish subsidy levels to maximize assistance to the uninsured; and how to squeeze savings from Medicare without imposing an undue burden on seniors or compromising the quality of care. Another flashpoint is whether government insurance subsidies could be used to pay for abortions."
  
• "Agreed to about $500 billion in changes to existing federal health programs, including Medicare and Medicaid. For example, negotiators would require wealthier seniors to pay more for prescription drug coverage under Medicare, and they would charge co-payments for clinical lab procedures. The lab co-pays are potentially lucrative, raising about $20 billion over 10 years."
• "Other new sources of revenue include penalties on individuals who do not obtain health insurance, and a "free-rider" provision that would require employers that currently offer health insurance to continue to do so, or to reimburse the federal government for workers who switch to subsidized coverage through an insurance exchange. Both provisions could yield about $43 billion over 10 years."
• "The rest of the additional revenue -- about $250 billion -- would come from new taxes, primarily from an excise tax of up to 35 percent on insurance companies that sell extremely generous policies worth at least $21,000 a year for family coverage or $8,000 a year for individuals, according to aides involved in the discussions. About 7 percent of taxpayers hold such policies... Insurance companies are likely to pass the cost of such a tax to policyholders, raising the price of those plans. That would create a strong incentive for employers to stop offering them, thus driving down overall health-care costs. With employers paying less for insurance, tax analysts predict, they would pay workers more in wages, increasing income tax collections by as much as $180 billion over the next decade."
• "Smaller tax provisions (include) a $2,000 cap on flexible savings accounts -- which are currently unlimited -- and a plan to improve tax compliance by requiring businesses to tell the Internal Revenue Service when they pay corporations for services."
• "Studying a plan to fine insurance companies that do not pay providers electronically, a plan to reduce payments to providers to force them to increase efficiency and a plan to study the comparative effectiveness of various medical treatments."
• "Set a target for savings through those reforms. If the target is not met, they would create a panel, called the Medicare Preservation Commission, that would recommend ways to obtain additional savings."

It's doubtful that liberal democrats and conservative republicans will be able to endorse the resulting plan. However due to the Senate's key role in enabling any healthcare legislation, and the Senate Finance Committee's key role in funding healthcare reform, their recommendations are sure to be influential in this fall's debate.

Let's see whether Senate negotiators reconcile with key elements being touted by Obama in his "What's in it for me?" stage of the debate: "(1) ending the practice of denying insurance coverage to people with a pre-existing illness; (2) keeping people from losing their coverage if they get sick; and (3) protecting Americans who face high out-of-pocket medical costs." The Democratic National Committee released a new television ad today with the same message:

ICD-10 Implementation Should Begin By January 18, 2010

NCHICA and WEDI released their timeline for ICD-10 implementation. The timeline illustrates the need for all segments of the healthcare industry to start planning work now in order to meet the October 1, 2013 compliance deadline. Implementation is estimated to take a total of 966 days and should begin by January 18, 2010.

The timeline was developed by the NCHICA-WEDI Timeline Initiative, a collaboration of provider, health plan and vendor representatives serving on several workgroups. It details the steps and time required for each industry segment (providers, plans and vendors) to effectively implement this major change in how the healthcare industry identifies diagnoses and inpatient hospital procedures.


CMS has set expectations that the industry meet the deadline, and no contingency period will be allowed.

Holt Anderson, the Executive Director of NCHICA, emphasized that “The NCHICA-WEDI timeline shows graphically that the full time from now to October 2013 will be required to successfully meet the compliance deadline. We cannot continue to delay this effort.”

Red Flags Rule Enforcement Delayed Again

The Federal Trade Commission will delay enforcement of the Red Flags rule until November 1st. The Red Flags rule requires the adoption of identity theft prevention programs and is applicable to most healthcare organizations.

Healthcare Resources for Red Flags

• The AMA's Practice Management Center has published a sample policy for Red Flags compliance and a good overview document on what physician practices should do to prepare for Red Flags compliance.
• The Federal Trade Commission has published a more in-depth description: "The 'Red Flags' Rule: What Health Care Providers Need to Know About Complying with New Requirements for Fighting Identity Theft".

Meaningful Use Approved by ONC

On July 16, updated definitions of Meaningful Use were presented and approved by the HIT Policy Committee of the Office of the National Coordinator for Health IT (ONC).


While this does not constitute the final definition which ultimately will be decided through rules issued by CMS, endorsement by ONC is a major step forward. Expect the CMS draft rules this fall and final rules this winter.

The three adoption year progression of meaningful use includes:

• 2011 Data capture and sharing
• 2013 Advanced care processes with decision support
• 2015 Improved outcomes.
  

Sure to confuse is the recommendation that the 2011 recommendations apply to the "adoption year" by the healthcare organization (HCO). In other words, if the HCO first adopts the EHR in 2012, that would be the year in which the 2011 definitions would apply. 2013 definitions would apply to the third adoption year.The workgroup responded to comments on their earlier proposals:
- establishing a lower 10% threshhold for hospital CPOE adoption
- accelerating the intial use of clinical decision support (“Implement one clinical decision rule relevant to high clinical priority”)
- accelerating (to 2011) patients' access to their health information
- improving outcomes measures for care coordination by including a (2012 to 2013) measure of a 10% reduction on 30-day hospital readmissions
- withholding Medicare incentive payments until any HIPAA violations are resolved (and for state privacy and security violations, withholding incentives under Medicaid)

Of particular interest is the Meaningful Use Workgroup's concern over Health Information Exchange. They questioned how health information exchange was to be accomplished in 2011 when HIE organizations do not currently exist or do not connect all clinical trading partners. The workgroup deferred to the HIE workgroup for specific requirements and recommended that the 2015 targets include required participation in nationwide health information exchange.

The Meaningful Use Workgroup presented a 10 page Meaningful Use Matrix which summarizes the health outcomes policy priorities, care goals, objectives and measures by adoption year.

The Workgroup established 5 Health Outcomes Policy Priorities and documented the related Care Goals including:

1. Improve quality, safety, efficiency and reduce health disparities

• provide access to comprehensive patient health data for patient's health care team
• use evidence-based order sets and CPOE
• apply clinical decision support at the point of care
• generate lists of patients who need care and use them to reach out to patients (e.g., reminders, care instructions, etc.)
• report to patient registries for quality improvement, public reporting etc.

2. Engage patients and families

• provide patients and families with timely access to data, knowledge, and tools to make informed decisions and to manage their health

3. Improve care coordination

• exchange meaningful clinical information among professional health care team

4. Improve population and public health

• communicate with public health agencies

5. Ensure adequate privacy and security protections for personal health information

• ensure privacy and security protections for confidential information through operating policies, procedures, and technologies and compliance with applicable law
• provide transparency of dta sharing to patient

Objectives and Measures

For each of the Health Outcomes Policy Priorities, the Workgroup established related objectives and measures. The objectives were set separately for providers and hospitals

Providers' objectives for 2011 include:

Improve quality, safety, efficiency and reduce health disparities

• use CPOE for all orders
• implement drug-drug, drug-allergy, drug-formulary checks
• maintain an up-to-date problem list of current and active diagnoses based on ICD-9 or SNOMED
• generate and transmit permissible prescriptions electronically (eRx)
• maintain active medication list
• maintain active medication allergy list
• record demographics including preferred language, insurance type, gender, race and ethnicity
• record advance directives
• record vital signs including height, weight, blood pressure
• calculate and display BMI
• record smoking status
• incorporate lab-test results into EHR as structure data
• generate lists of patients by specific conditions to use for quality improvement, reduction of disparities and outreach
• report ambulatory quality measures to CMS
• send reminders to patients per patient preference for preventive/follow up care
• implement one clinical decision rule relevant to specialty or high clinical priority
• document a progress note for each encounter
• check insurance eligibility electronically from public and private payers, where possible
• submit claims electronically to public and private payers

Engage patients and families

• provide patients with an electronic copy of their health information including lab results, problem list, medication lists, allergies) upon request
• provide patients with timely electronic access to their health information including lab results, problem list, medication lists, allergies
• provide access to patient-specific education resources
• provide clinical summaries for patients for each encounter

Improve care coordination

• capability to exchange key clinical information (e.g., problem list, medication list, allergies, test results), among providers of care and patient authorized entities electronically
• perform medication reconciliation at relevant encounters and each transition of care

Improve population and public health

• capability to submit electronic data to immunization registries and actual submission where required and accepted
• capability to provide electronic syndromic surveillance dtaa to public health agencies and actual transmission according to applicable law and practices

Ensure adequate privacy and security protections for personal health information

• compliance with HIPAA Privacy and Security rules
• compliance with fair data sharing practices set forth in the Nationwide Privacy and Security Framework

The workgroup framework focuses on health outcomes with reported measures that indicate the effective use by the HCO. The HIT Standards Committee has mapped the related 2011 Meaningful Use measures to existing NQF endorsed measures including:

2011 Measures		NQF Endorsed Measures
% diabetics with A1c under control [OP]		Title: Comprehensive Diabetes Care: HbA1c control (<8.0%)>
% of hypertensive patients with BP under control [OP]		Title Controlling High Blood Pressure*
% of patients with LDL under control [OP]		Title: IVD: Complete Lipid Profile and LDL Control <100
% of smokers offered smoking cessation counseling [OP, IP]		Title: Measure pair -a. Tobacco use prevention for infants, children and adolescents, b. Tobacco use cessation for infants, children and adolescents*
% of patients with recorded BMI		Title: Body Mass Index (BMI) 2 through 18 years of age*
[OP]		Title: Adult weight screening and follow up
% eligible surgical patients who received VTE prophylaxis [IP]		Title: Surgery Patients Who Received Appropriate Venous Thromboembolism (VTE) Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery End Time*
% of orders entered directly by physicians through CPOE		No current measures
% of permissible RX's		Title Adoption of Medication e-Prescribing
transmitted electronically		Title Medical Home System Survey
% of med/all orders entered into		Title Adoption of Medication e-Prescribing
CPOE		Title Medical Home System Survey
Use of high-risk medications in the elderly [OP, IP]		Title: Drugs to be avoided in the elderly: a. Patients who receive at least one drug to be avoided, b. Patients who receive at least two different drugs to be avoided.*
% of patients over 50 with annual colorectal cancer screenings [OP]		PQRI 113: Preventive Care and Screening: Colorectal Cancer Screening
% of females over 50 receiving annual mammogram [OP]		PQRI 112: Preventive Care and Screening: Screening Mammography [PQRI age range 40-69]
% patients at high-risk for cardiac events on aspirin prophylaxis [OP]		Title: Ischemic Vascular Disease (IVD): Use of Aspirin or another Antithrombotic.*
% of patients with current pneumovax [OP]		PQRI 111: Preventive Care and Screening: Pneumonia Vaccination for Patients 65 Years and Older
		Title: Pneumococcal Vaccination of Nursing Home/ Skilled Nursing Facility Residents Description: Percent of nursing home/skilled nursing facility residents whose pneumococcal polysaccharide vaccine (PPV) status is up to date during the 12-month reporting period.
% eligible patients who received flu vaccine [OP]		PQRI -110: Preventive Care and Screening: Influenza Immunization for Patients . 50 Years
		Title: Influenza Vaccination of Nursing Home/ Skilled Nursing Facility Residents.
% lab results incorporated into EHR in coded format [OP,IP]		Title: The Ability for Providers with HIT to Receive Laboratory Data Electronically
		Title Medical Home System Survey
Stratify reports by gender, insurance type, primary language, race, ethnicity [OP, IP]		NQF has identified quality measurement criteria for which there are known disparities. CMS can use these criteria for stratification.
% of all patients with access to personal health information electronically [OP, IP]		Title Medical Home System SurveyDescription
% of all patients with access to patient specific educational resources [OP, IP]		No current measures
% of encounters for which clinical summaries were provided [OP, IP]		No current measures
Report 30-day readmission rate [IP]		Title: All-Cause Readmission Index (risk adjusted)*Title: All-Cause Readmission Index (risk adjusted)*
% of encounters where med reconciliation was performed [OP, IP]		Title: Medication Reconciliation *
Implemented ability to exchange health information with external clinical entity (specifically labs, care summary and medication lists) [OP, IP]		Title Medical Home System Survey
Report up-to-date status for childhood immunizations [OP]		Title: Childhood Immunization Status *
% reportable lab results submitted electronically [IP]		No current measures
Provide electronic syndrome surveillance data to public health agencies according to applicable law and practice [IP]		No current measures
Full compliance with HIPAA Privacy and Security Rules		No current measures
An entity under investigation for a HIPAA privacy or security violation cannot achieve meaningful use until the entity is cleared by the investigating authority		No current measures
Conduct or update a security risk assessment and implement security updates as necessary		No current measures
Other Measures Under Consideration (In addition to initial Policy Measure 2001 Grid)		PQRI 7: Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction (MI)*
Other Measures Under Consideration(In addition to initial Policy Measure 2001 Grid)		PQRI 5: Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)*
Other Measures Under Consideration (In addition to initial Policy Measure 2001 Grid)		Title: Use of appropriate medications for people with asthma
Other Measures Under Consideration(In addition to initial Policy Measure 2001 Grid)		Title: Patients with Atrial Fibrillation Receiving Anticoagulation Therapy Description