Thursday, March 31, 2011

Proposed Statement of Antitrust Enforcement Policy Regarding Accountable Care

Proposed Statement of Antitrust Enforcement Policy Regarding Accountable Care

Accountable Care Organization Proposed Rule

Medicare Program - Medicare Shared Savings Program - Accountable Care

Direct Project - HIT Standards Committee Update

Tuesday, March 29, 2011

Care Coordination Measures Atlas

From the AHRQ announcement:  The Agency for Healthcare Research and Quality (AHRQ) has published a new resource for researchers interested in measuring care coordination, an emerging field of quality measurement. The Care Coordination Measures Atlas identifies more than 60 measures for assessing care coordination that include the perspectives of patients and caregivers, health care professionals and health system managers. To help users easily identify measures that are relevant to their work, the measures are mapped to a conceptual framework for understanding care coordination measurement. In addition to researchers, measure developers, Accountable Care Organizations and others responsible for measuring care coordination will find the Atlas useful in identifying currently available measures to assess care coordination activities, as well as gaps in existing measures that can be addressed in future work.

Care Coordination Measures Atlas - March 2011a

Friday, March 25, 2011

PCAST Use Cases

by John Halamka, Life as a Healthcare CIO

As I posted yesterday, the PCAST Workgroup has discussed use cases which correspond to three levels of healthcare information exchange supported by a Universal Exchange Language (UEL) and Data Element Access Service (DEAS) - "push by patient of data between two points", "simple search for data", and "complex search for data".  They are intended to support PHR and EHR health information exchanges for a multitude of uses, include clinical care, population health and clinical research.  A 4th Use Case incorporates de-identified data.

Use Case 1 - Push by patient between two points.

The patient logs into a tethered PHR via username/password or other authentication mechanism provided by the clinical organization hosting the data.   The patient chooses to push the data to the non-tethered PHR of their choice.   Many possible architectures and approaches can support this including download from the tethered PHR with upload to the un-tethered PHR, a push directly from the tethered PHR to the un-tethered PHR (as Google Health and Microsoft Health support today), or the use of secure email from the tethered PHR to the un-tethered PHR using the Direct standards via a secure health email address.  In each case, the data sent wrapped in a UEL envelope containing patient identity, provenance, and privacy metadata information.     UEL Metadata might also include non-disclosing information about the categories health data available in the content package i.e. medication list, problem list, allergy list, labs, radiology images etc.

When the UEL arrives at the non-tethered EHR, data is shown to the patient, who can elect to incorporate structured and unstructured data into their existing un-tethered PHR dataset.   Then, the patient can then choose to share PHR data with clinicians, clinical researchers, or public health by pushing selective PHR data wrapped in an UEL envelope via secure transmission (such as Direct) to recipients of their choice.    Organizational certificates are needed for the senders (un-tethered PHR hosting organization) and the recipients (clinician offices, clinical research organizations, public health organizations).    Audit trails are held by senders, recipients and any Health Information Service Providers used as part of Direct transport.   Patient authentication is username/password as required by the PHRs.  Provider authentication is username/password or other modality as required by the EHR.

Summarizing the infrastructure for this approach, we will need
*A UEL that includes patient identity, provenance, privacy metadata, and categories of health data available in the content package.   There will need to be semantic standards for this metadata including the content/vocabulary of identity, providence, privacy metadata, and categories of health data
*Applications which are capable of wrapping content packages of clinical data in the UEL
*Applications which are capable of receiving the UEL and unwrapping content packages

*Certificate management to secure the endpoints and support privacy controls

*Policies that support push of data between two points.   

Use Case 2 - Simple Search

A patient presents to an Emergency Department and notes their records are stored at a specific clinician office and a specific hospital.    An Emergency Physician obtains patient consent to retrieve their records.    A query is created that includes patient identity, consent information, and provider authentication data.    A Data Element Access Service which serves as an entity level provider directory is securely queried to determine the Uniform Resource Identifiers (URIs) of the clinician office and hospital.   The query is sent to the URIs, which return a UEL wrapper containing identity information, provenance, patient privacy metadata based on any consents on file at the organizations hosting patient records, and non-disclosing information about the categories health data available in the content package.    The content package inside the UEL includes numerous appropriate vocabularies.   The receiving clinician can choose to incorporate structured and unstructured data into the Emergency Department record.    All exchanges are query/response.  Organizational certificates are needed for the Emergency Department,  the clinician office and the hospital.   Audit trails are held by all these organizations.   Provider authentication is username/password or other modality as required by the ED information system or national policy.

Summarizing the infrastructure for this approach, in addition to the infrastructure of Use Case 1, we will need:

*Policy for issuing queries to organizations hosting patient records

*A DEAS that includes entity level provider directory information to provide the URIs of provider data sources

*The syntax and semantics of a query for clinical data including identity information that is sent to provider organizations hosting patient information

*Applications which are capable of issuing a query to known URIs

*An approach to disambiguate identity conflicts if the query results in multiple patient matches

Use Case 3 - Complex Search
A patient presents to an Emergency Department and is non-responsive.  However, her wallet contains an ID with name and date of birth.   An Emergency Physician, based on policy which grants implied consent for unconscious patients, clicks the external search icon in their EHR.  The EHR creates a query containing patient identity, implied consent information, and provider authentication and role, then sends it to a Data Element Access Service.   The DEAS returns a list of Uniform Resource Identifiers of the organizations which hold the patient's records.   The Emergency Physician’s EHR sends a query containing patient identity, consent information, provider authentication and role to each of the URIs, with a request for problems, medications or allergies.  Each organization returns as many UEL wrapped data packages as match the query and pass the conditions of patient privacy metadata based on any consents they have on file.  Each UEL wrapped package includes identity, provenance and privacy metadata and non-disclosing information about the categories health data available in the content package.   The content package inside the UELs includes numerous appropriate vocabularies.   The receiving EHR filters and organizes the information for the clinician who can choose to incorporate structured and unstructured data into the local Emergency Department record.    All exchanges are query/response.  Organizational certificates are needed for the Emergency Department, the DEAS provider, and the organizations which contain patient records.  Audit trails are held by all these organizations.   Provider authentication is username/password or other modality as required by the ED information system or national policy.

Summarizing the infrastructure for this approach, in addition to the infrastructure of Use Case 2, we will need:

*Policy for issuing a query to the DEAS
*A DEAS which contains patient identity information, provider URIs and potentially more granular information about the types of data available at those URIs

*The syntax and semantics of a query including identity information that is sent to the DEAS.   
*Applications which are capable of querying a DEAS and then querying URIs of provider data sources specified by the DEAS, assembling the data returned into a meaningful display
*Support for privacy metadata that are returned by the DEAS and provider data sources

Interoperation among Use Cases 1-3
The Use Cases and the Levels of Exchange are not mutually exclusive.  If all three are supported, the patient in Use Case 1 can use the simple search of Use Case 2 to query for the URI of a provider they would like to push their information to; and the complex search of Use Case 3 to expose a UEL wrapped subset of their PHR to the DEAS tagged with a privacy tag indicating their desire that it be made available to someone giving them care and a provenance tag indicating that she had edited it.

Use Case 4 - De-identified aggregate data mining

A researcher wants to retrieve de-identified mammograms to investigate a new technology that provides computer assisted interpretation.    The researcher issues a query to the DEAS requesting de-identified mammograms that are reusable for research based on patient consent.    A list of URIs is returned including pointers to mammograms.   The researcher queries the URIs and receives de-identified mammograms.

Summarizing the infrastructure for this approach
*Policy for issuing a research queries to the DEAS
*A DEAS which supports de-identified queries for a specific type of data
*The syntax and semantics of a query including data type information that is sent to the DEAS.   
*Provider data sources that are capable of returning de-identified data
*An application that can query a DEAS and query provider data sources
*Support for privacy metadata that include consent to release data for research and ensure de-identification

The combination of these use cases and the security model described in yesterday's post provides a clear path forward that enables pilots and research to be done in parallel with the meaningful use activities already in progress.

As I think about the exciting years ahead - a PCAST inspired expansion of health information exchange, meaningful use stage 2 & 3, and healthcare reform, I am concerned that doing ICD-10 in the middle of all these other activities will overwhelm healthcare systems and IT organizations.   My thoughts on rebalancing and aligning all of the projects in front of us will be a blog post for next week.

Monday, March 21, 2011

Direct Project Specifications Achieving Widespread Adoption: Could Positively Impact Care Coordination Soon for Millions of Americans

By Doug Fridsma, ONC

As an internal medicine physician, I know how hard it was to coordinate patient care across diverse healthcare systems. Primary care providers struggle to keep up with the flow of information coming in and going out of their offices on faxes, couriered documents and hand carried patient notes. The Direct Project was created to address this problem head-on by creating a simple, secure way to send this information electronically, so that providers can concentrate on what counts: excellent patient care.

Today, The Direct Project announced that over 60 healthcare and health IT organizations, including many state based and private sector health information exchanges, leading IT vendors, and several leading integrated delivery systems, have planned support for the Direct Project. The broad reach of so many significant national players is helping the project reach its goal of providing healthcare stakeholders with universal addressing and universal access to secure direct messaging of health information across the U.S. This is quite an accomplishment, given that the Direct Project just started twelve months ago.

This broad swath of support for the Direct Project represents approximately 90% of market share covered by the participating health IT vendors. With over 20 states participating in the project, including many of the largest states in the country, nearly half of the total U.S. population can now benefit from the Direct Project’s growing integration into the national health IT ecosystem. Growing participation with the Direct Project will alleviate a healthcare system awash in a sea of paper and faxes.

The Office of the National Coordinator for Health Information Technology (ONC) convened the Direct Project to expand the existing specifications incorporated in the Nationwide Health Information Network to be as inclusive as possible for any caregiver regardless of their technology used or the size of the organization. The Direct Project is facilitating “direct” communication patterns, meeting the providers where they are today, with an eye toward approaching more advanced levels of interoperability as they invest in health IT systems.
The result of this groundbreaking public/private collaborative is a set of specifications for simple and directed messages among caregivers and to patients

Widespread Adoption – Up to 160 Million Americans May Soon be Positively Impacted

Many of the country’s largest health IT vendors, most populous states, and robust integrated delivery systems are incorporating Direct Project specifications into their health IT systems. What’s exciting about this growing list of organizations is that over half the country’s population could benefit from the availability of secure, directed health information messaging. The numbers are sure to continue growing in the coming months as more organizations support Direct Project specifications for health information exchange. A complete list of participating organizations, including states, health information exchanges and health IT vendors, is available on the Direct Project website.

Transport of Coordination of Care Messages

The Direct Project also announced finalization of the Direct Project specifications, including the core Direct Project requirements and a specification which describes how EHRs and other health IT systems can leverage the Direct Project to securely exchange direct messages. Such communication is critical, especially when a primary care doctor in the U.S. on average has to coordinate care with 229 doctors across 117 different practices. The Direct Project helps address the technology interoperability challenge created by needing to coordinate with such a large group of diverse organizations. It does so by fulfilling the promise of a real-time secure electronic transport mechanism for referrals and clinical documentation, integrated into the health care workflows and systems across different settings of care. This has enormous impact on the provider’s ability to keep the patient at the center of care. The Direct Project meets providers where they are today and grows with them as they invest in electronic health records, enabling EHR to EHR direct message transport.

Specifications and Compliance

Finally, the Direct Project announced the release two specifications and a draft compatibility statement that will help stakeholders create software that can speak with other Direct-enabled products and will help organizations deploy that software. The Direct Project specifications documents help define and shape the wider adoption of Direct Project technology by healthcare stakeholders. The Applicability Statement for Simple Health Transport outlines the core requirements for a system to declare itself a fully qualified and compliant Health Information Service Provider, or HISP. The Direct Project Compatibility Statement (in draft) addresses the universality of Direct Project messaging. It defines the conditions to participate in universal addressing and transport. The XDR and XDM for Direct Messaging Specification defines a specific gateway solution between the core Direct Project specification and senders and receivers who use IHE specifications.

We are finalizing the Direct Project specifications, engaging with the states, organizations and vendors, and coordinating with the IHE profiles to expand the applicability and value of the Direct Project specifications into a wide variety of use cases.

These developments will be discussed in more depth by Arien Malec, Direct Project coordinator, during a Webinar about the Direct Project on March 21 hosted by the National eHealth Collaborative. For more information, and to register for this webinar, please visit

This has been an exciting year for the Direct Project, and I am encouraged by the quality and speed with which the Direct Project developed its work products and humbled by the community’s incredible work on the project. The Direct Project was started by ONC, but it has been made successful because of the active engagement and support of the Direct community. It is an excellent example of an open government initiative focusing on a specific challenge and working to resolve that challenge in an open and transparent process. If your organization would like more information on the Direct Project or would like to join the growing list of private, public, and government entities that are integrating Direct into their health IT systems, please visit

Wednesday, March 9, 2011

Important New Evidence on the Journey to HIT-Assisted Health Care

 On February 2, ONC had a major announcement related to the Direct Project.  Media were in the audience and on the phone.  One questioner in particular was picking on the value of EHR's, citing a recent Stanford review that suggested EHR's had questionable benefits.

Sitting in the front row of the audience, it was easy to gauge Dr. Blumenthal's heartfelt feelings, that this interviewer, and the referenced study, had it wrong. Now in a systematic and thorough literature review, Dr. Blumenthal, Melinda Buntin, Matthew Burke and Michael C. Hoaglin address these criticisms head-on and find consistently overall favorable affects of Health IT.

Check out this interview: Reaping the Benefits of Health IT: Q&A With ONC's Dr. David Blumenthal

And here's Dr. Blumenthal's response, from the ONC Blog:

Tuesday, March 8th, 2011 | Posted by: Dr. David Blumenthal

When Christopher Columbus set sail from Palos in the Gulf of Cadiz, he knew he had theory and experience on his side. The theoretical conception of the Earth as an orb was as solid as it could be. And Columbus had experience of the trade winds that could speed him both westward and eastward. Yet the final evidence was his to provide.

In deploying health information technology (HIT), including ubiquitous use of interoperable electronic health records (EHRs), we also are at the cusp that is faced by every pioneering enterprise: When all is said and done, the proof is in the pudding.

In 2009, building on a bipartisan foundation of many years’ making, Congress and the President authorized a very substantial national investment in transitioning from paper-based to HIT-assisted health care. We knew the benefits that should ensue, and we had important data from several large HIT “leader” providers, such as the Veterans Administration, Kaiser Health Plan, and others.

Yet, in truth, it is only as we approach the shore of adoption and meaningful use of EHRs that we will truly know the dimensions and consequences of our investment.

Today in the policy journal Health Affairs, an article by several ONC authors shows tantalizing hints at what may await us: Strong evidence regarding the benefits of HIT.

Using assessment methods that were employed by two previous independent reviews, the new study finds that 92 percent of recent peer-reviewed articles on HIT reached conclusions that showed overall positive effects. The study also finds increasing evidence of benefits for all health care providers, not just the larger HIT “leader” organizations that have provided much of the data regarding experience with HIT in the past.

This article brings us much more up-to-date, both in our confidence regarding evidence of the benefits of adoption and use of HIT, and also in our understanding of problem areas that still need to be addressed. This review is important because it helps us correct for the lag in evidence that occurs naturally in the literature, where research has trailed the now-accelerating implementation of HIT.

The review looks at articles published from July 2007 up to February 2010, following up on earlier reviews that had looked at articles from 1995 to 2004 and from 2004 to 2007. This update screened more than 4,000 articles, of which 154 were found qualified for the parameters of the study, a number similar to the previous efforts. It found positive results in 96 of the articles (62 percent), and mixed but predominantly positive results in 46 other articles (30 percent).

Negative findings in the study were most often found in studies of provider or staff satisfaction. According to the article, these findings “highlight the need for studies that document the challenging aspects of implementing HIT more specifically, and how these challenges might be addressed,” such as through strong leadership or staff participation when adopting and implementing HIT. There is also a pressing need to make EHRs more user friendly.

So even as our confidence grows that the nation has made a wise investment, we need to carefully monitor for course correction and continual improvement.

Today’s article adds significantly to strong, evidence-based confirmation that we are headed in the right direction. It likewise confirms what we know intuitively: There will be challenges, surprises, and bonuses throughout this journey to universal adoption and meaningful use of HIT.

Tuesday, March 8, 2011

Healthcare Technology News Listed in Top Health Care Blogs for Professionals

 MCOL, one of the fine names in Health Care Business publications, has recently launched HealthSprocket, a compendium of health care lists.

Healthcare Technology New was recognized in their list of 46 Top Health Care Blogs for Professionals.

Friday, March 4, 2011

Health Wonk Review is up

 The Lucidicus Project hosts Health Wonk Review, the very best of the Health Policy blogosphere.

Wednesday, March 2, 2011

Meet the Bloggers: Provider Edition

 At HIMSS11, I chaired a panel of well known experts in the use of Social Media for provider organizations, including David Kibbe - Senior Advisor for AAFP, John Sharp - Manager of Research Informatics for Cleveland Clinic and John Marzano - VP Communications for Orlando Health.  Great panel with terrific experience and insights.  Thanks to Gregg Masters for the video. 

Meet the Bloggers: Provider Edition - Part I

Meet the Bloggers: Provider Edition - Part II


Moderator:  Rich Elmore is Allscripts Vice President, Strategic Initiatives. He ran the Provider Analytics business for Allscripts and is now working in business development on partnerships and M&A. Rich had a long career at IDX where he was Vice President of Development for IDX Flowcast and Flowcast Hospital P&L leader, growing that business substantially. Rich is the Communications Workgroup leader for the ONC’s Direct Project. He is editor of Healthcare Technology News. He was a charter member of the Interoperability Workgroup for the Certification Commission for Healthcare Information Technology. Rich has degrees from Dartmouth College (BA) and New School University (Masters in Economics). He is on the board for a chronic disease technology company and serves as Vice Chair on the Board of Directors for the King Street Center serving impoverished youth and their families in Burlington Vermont.

Panelist:  Dr. David Kibbe is well known as an innovator and independent mind in the field of health information technology in the United States. A respected technologist, entrepreneur, and co-developer of the ASTM Continuity of Care Record, CCR, standard -- which utilizes XML for interoperable health information exchange -- he is also an experienced clinician who practiced medicine in private and academic settings for more than 15 years, while also teaching informatics at the School of Public Health, University of North Carolina at Chapel Hill. He has started two medical software companies, and in 2005 was voted one of the 50 Most Powerful Physician Executives in Healthcare by readers of the magazine Modern Physician. Dr. Kibbe is a frequently sought after as a speaker on topics that range from the economics of small practice adoption of EMRs, to privacy and security of health data exchange, to Web 2.0 applications applied to consumer health care delivery.

Panelist:  John A. Marzano, Vice President/Chief Communications Officer, Orlando Health. Mr. Marzano began his career with Orlando Health in June 2007. He is responsible for all internal and external communications for Orlando Health including strategic marketing, brand and reputation management, advertising, public relations, media relations, issues management, community and government relations and creative services. Prior to joining the corporation, Mr. Marzano served as a Vice President of MedStar Health, a non-profit, community-based healthcare system of nine hospitals in the Baltimore/Washington metro area. In that role, he directed the communications, marketing and public affairs programs for one of the top 25 largest health systems in the United States. He is skilled in crisis communications and issues management, and is a seasoned leader in integrated healthcare, B2B and consumer advertising and promotion, sports marketing and hospitality. Marzano holds a Bachelor of Arts degree from Bloomsburg University, Pennsylvania (1974) and earned a certificate in Executive Leadership from the Center for Professional Development at Georgetown University in 2004. His professional memberships include the Public Relations Society of America (PRSA), the Society for Healthcare Strategy and Market Development (SHSMD), and Leadership Orlando (Class 77). He currently is a member of the Board of Directors of Visit Orlando! (Orlando Convention and Visitors Bureau) and the West Orange Chamber of Commerce.

Panelist:  John Sharp is Manager of Research Informatics in the Department of Quantitative Health Sciences at the Cleveland Clinic. He manages a team of 20 programmers and systems support to support data collection for clinical research. In addition to being a HIMSS fellow, he is also a Project Management Professional. He has been blogging since 2006 and is active on Twitter and linked in. He has presented nationally and internationally on social media including Medicine 2.0 in Toronto and in the Netherlands. He is also active in AMIA, particularly in Clinical Research Informatics. Previously, John was chair of the HIMSS eHealth SIG. He received his bachelor and master’s degrees from Case Western Reserve University where he is currently a clinical instructor in Nursing Informatics.