On Monday October 26, Senate Majority Leader Harry Reid called for the Senate health reform bill to include a public option. The bill will include a provision allowing states to opt out prior to 2014.
The Senate bill will be sent to the Congressional Budget Office for scoring within the next couple of days. Reid skirted the question as to whether he had the 60 votes needed to bring a vote to the Senate floor.
The much discussed trigger that would have delayed implementation of the public option will not be included nor scored. The bill will include the co-op provisions of the Senate Finance Committee bill.
C-Span reports that progressive Democratic senators refused to accept anything less than the public option, driving the final decision by the majority leader. Why the Opt Out? According to Reid, "we have 60 people in the caucus. It's comfort level - - we all hug together and see where we come out."
Monday, October 26, 2009
Guerilla Music at the AHIP Conference
On Friday October 23, America's Health Insurance Plans (AHIP) met in the aftermath of a tumultuous month in which the health insurance companies' lobbying operation released a study it commissioned which according to the White House is "an attempt to confuse the debate around health reform." The consequences of this ill-timed report could include building momentum for an end to the anti-trust exemptions that the insurance industry has enjoyed since 1945.
Just when the insurance industry must feel that it couldn't get any worse, attendees at the AHIP conference were subjected to this guerilla music by "Public Option Annie":
Just when the insurance industry must feel that it couldn't get any worse, attendees at the AHIP conference were subjected to this guerilla music by "Public Option Annie":
Thursday, October 15, 2009
October 14 HIT Standards Committee update
Guest author and Vice Chair of the HIT Standards Committee John Halamka reports on the October 14th meeting of the HIT Standards Committee, including important updates on patient access through portals, vocabulary standards, quality measures, security/privacy and the formation of a new implementation workgroup.
The October HIT Standards Committee meeting
by John Halamka
The day started with comments from David Blumenthal. He briefly described the Nationwide Healthcare Information Network (NHIN) as an evolving vital element of our national health information strategy. He emphasized that we need to expand the scope of our NHIN thinking to include consumer health information platforms in addition to the provider and government organizations that have been the focus to date. He also noted that we need to move from pilots/prototypes to scalable real world implementations, establishing the right governance mechanism for the NHIN.
The October HIT Standards Committee meeting
by John Halamka
The day started with comments from David Blumenthal. He briefly described the Nationwide Healthcare Information Network (NHIN) as an evolving vital element of our national health information strategy. He emphasized that we need to expand the scope of our NHIN thinking to include consumer health information platforms in addition to the provider and government organizations that have been the focus to date. He also noted that we need to move from pilots/prototypes to scalable real world implementations, establishing the right governance mechanism for the NHIN.
The Clinical Operations update followed and included a discussion of gaps in the current work. We started with a discussion of patient access to an EHR. Should we include clinical summaries, the entire record, or the standard data elements that can be exported to commercial PHRs such as Google Health and Microsoft Healthvault? We heard about experiences at Kaiser, Geisinger, BIDMC and others. It's clear that PHR data sharing is very heterogeneous at the moment and that convenience transactions such as appointment making, medication renewal, and referral management may be more important to patients than full access to every aspect of their record. The HIT Policy committee will be asked to define minimum requirements for patient access to EHR data.
We discussed needed enhancements to vocabularies including a national SNOMED-CT to ICD9/ICD10 mapping, RxNorm mapping to National Drug File Reference Terminology (NDF-RT) and Standard Product Labeling (SPL), a standard lab compendium for ordering, UCUM guidance and testing, and a national infrastructure to distribute and maintain codesets. I discussed this need for enhanced vocabulary tools in yesterday's blog. Our action item today was to create a Vocabulary sub-Workgroup that will address these issues and propose priorities and solutions to the entire Committee and ONC.
We heard an update from the Clinical Quality Workgroup about the re-tooling of quality measures to be more EHR-centric. Good progress is being made.
Next, we focused on privacy & security. Dixie Baker and Steve Findlay summarized a few updates to the standards matrix - SOAP 1.2 is the current recommended version and per evolving federal guidelines (NIST SP 800-63-1), Kerberos will be allowed but not required for 2011 because Federal systems will begin disallowing Kerberos in 2013. NIST SP 800-63-1 is cited as implementation guidance for "Level 2" certification criteria for authentication, but we've been careful not to impose Federal FISMA criteria on the private sector.
We discussed enhancements to privacy and security standards efforts, especially for 2013, including:
* A healthcare specific XML schema and vocabulary for representing subject, resource, action, and environmental attributes in security assertions i.e. SAML for healthcare
* A standard XML schema and vocabulary for representing consumer consents i.e. my CAML proposal
* Baseline security and privacy policies for the exchange of EHR information
* Standards for exchanges between the healthcare enterprise and the consumer
* Specification of Health Information Exchange assumptions and associated privacy and security policy. This relates to my blog yesterday in which I noted that policy guidance is really essential to pick the simplest set of security constructs needed to protect confidentiality.
Our action items today were
1. To spend the entire November HIT Standards Committee meeting hearing testimony from stakeholders on Security issues.
2. To work with ONC to ensure seamless communication and coordination between the HIT Policy Committee and HIT Standards Committee regarding privacy and security issues
3. To specify our assumptions for HIE information exchanges and share those assumptions with the Policy Committee so that they could specify a policy framework that then could serve as the basis for constraining security and privacy standards. One of our committee members noted that policy constrains architectural possibilities, enabling selection of the simplest set of standards needed to meet requirements.
Given the emphasis of the meeting on adoption and implementation, we discussed next steps regarding our new Implementation Workgroup. Specifically we will arrange for a day of testimony on October 29 from many stakeholder groups to better understand adoption and implementation issues, needs for enhanced implementation guidance, and identification of enablers that would accelerate interoperability such as new tools or filing standards gaps. We'll also conduct an online forum and accept written testimony. This feedback process is very important to ensure rapid cycle improvement in the standards making and standards selection processes. Per my blog yesterday, this will help with resolving the outstanding common data transport issues.
We ended the meeting with a discussion of the results from the privacy hearings conducted by the HIT Policy Committee on September 18.
Thus, we have action steps to resolve all the issues I raised on my blog yesterday - alignment of policy and standards activities to create the parsimonious set of security standards to protect confidentiality, a working group to resolve outstanding vocabulary issues, and a feedback process to resolve common data transport and other standards adoption/implementation issues.
A great meeting and I look forward to our day of implementation testimony on October 29 and our day of security testimony on November 19.
Tuesday, October 13, 2009
Blumenthal on Meaningful Use
Dr. David Blumenthal, National Coordinator for Health IT (ONC) has published an open letter on the Meaningful Use of Electronic Health Records. Blumenthal reported that CMS will issue it's proposed rule by year end.
___________________________________
"Meaningful" Progress Toward Electronic Health Information Exchange
A Message from Dr. David Blumenthal, National Coordinator for Health Information Technology
I recently reported on our announcement of State Health Information Technology Grants and grants to establish Health Information Technology Regional Extension Centers, as authorized under the Health Information Technology for Economic and Clinical Health (HITECH) Act provisions of the American Recovery and Reinvestment Act of 2009 (the Recovery Act).
Today I want to discuss the important term “meaningful use” of electronic health records (EHRs) – both as a concept that underlies the movement toward an electronic health care environment and as a practical set of standards that will be issued as a proposed regulation by the end of 2009.
The HITECH Act provisions of the Recovery Act create a truly historic opportunity to transform our health system through unprecedented investments in the development of a nationwide electronic health information system. This system will ultimately help facilitate, inform, measure, and sustain improvements in the quality, efficiency, and safety of health care available to every American. Simply put, health professionals will be able to give better care, and their patients’ experience of care will improve, leading to better health outcomes overall.
As many of you are aware, the HITECH Act provides incentive payments to doctors and hospitals that adopt and meaningfully use health information technology. Eligible physicians, including those in solo or small practices, can receive up to $44,000 over five years under Medicare or $63,750 over six years under Medicaid for being meaningful users of certified electronic health records. Hospitals that become meaningful EHR users could receive up to four years of financial incentive payments under Medicare beginning in 2011, and up to six years of incentive payments under Medicaid beginning in October 2010.
The HITECH Act’s financial incentives demonstrate Congress’ and the Administration’s commitment to help those who want to improve their care delivery, and will serve as a catalyst to accelerate and smooth the path to HIT adoption by more individual providers and organizations. The dollars are tangible evidence of a national determination to bring health care into the 21st century.
The Office of the National Coordinator for Health Information Technology (ONC) is charged with coordinating nationwide efforts to implement and use the most advanced health information technology and the electronic exchange of health information. ONC is working with the Centers for Medicare & Medicaid Services (CMS), through an open and transparent process, on efforts to officially designate what constitutes “meaningful use.”
ONC has already engaged in a broad range of efforts to support the development of a formal definition of meaningful use. The HITECH Act designated a federal advisory committee, the HIT Policy Committee, with broad representation from major health care constituencies, to provide recommendations to ONC on meaningful use. The HIT Policy Committee has provided two sets of recommendations, informed by input from a variety of stakeholders. ONC and CMS have also conducted a series of listening sessions to solicit feedback from more than 200 representatives of various constituent groups and an open comment period where over 800 public comments were submitted and reviewed. The second set of recommendations on meaningful use was issued at a July 16 HIT Policy Committee meeting and details can be found at healthit.hhs.gov/policycommittee.
CMS is expected to publish a formal definition of meaningful use, for the purposes of receiving the Medicare and Medicaid incentive payments, by December 31, 2009. At that time, the public will be able to comment on the definition, and such comments will be considered in reaching any final definition of the term.
By focusing on “meaningful use,” we recognize that better health care does not come solely from the adoption of technology itself, but through the exchange and use of health information to best inform clinical decisions at the point of care. Meaningful use of EHRs, we anticipate, will also enable providers to reduce the amount of time spent on duplicative paperwork and gain more time to spend with their patients throughout the day. It will lead us toward improvements and sustainability of our health care system that can only be attained with the help of a reliable and secure nationwide electronic health information system.
The concept of meaningful use is simple and inspiring, but we recognize that it becomes significantly more complex at a policy and regulatory level. As a result, we expect that any formal definition of “meaningful use” must include specific activities health care providers need to undertake to qualify for incentives from the federal government.
Ultimately, we believe “meaningful use” should embody the goals of a transformed health system. Meaningful use, in the long-term, is when EHRs are used by health care providers to improve patient care, safety, and quality.
What’s next?
As stated above, the next step in our process is a notice of proposed rulemaking in late 2009 with a public comment period in early 2010. As this process unfolds, we will continue to talk and share experiences about transitioning to EHRs, and to help deepen understanding among physicians and hospitals about the use of EHRs. We will also present programs designed to help smooth the transition process, and identify activities physicians and hospitals can engage in now to promote adoption of EHRs. As efforts advance, we will turn our attention to other necessary supporting programs, some of which you will hear more about in the coming weeks, including defining what constitutes a “certified” EHR, which is one of the requirements to qualify for Medicare and Medicaid incentives.
In the meantime, what can providers do to move toward becoming “meaningful users” – even in the absence of a formal definition? Naturally, while understanding that the final definition will be adopted through a formal rulemaking process, it will be helpful to be as familiar as possible with the discussion of meaningful use criteria to date. (You will find that information posted at healthit.hhs.gov/meaningfuluse.)
Armed with an understanding of the discussion of meaningful use as it unfolds, providers can begin to consider how their own practices or organizations might be reshaped to enhance the efficiency and quality of care through the use of an electronic health record system. Be assured you will not be alone as you seek to adopt an EHR system. Through our recently announced collaborative HITECH grants programs and others to be initiated later this year, we will continue to support providers in moving forward. Additional details about the grants are also available in my previous update and at healthit.hhs.gov/HITECHgrants.
To some providers, particularly small or already stretched physician practices or small, rural hospitals, the path toward meaningful use may still seem arduous. To others, who would just prefer to stick with the “status quo,” it may seem like an unwanted intrusion. We believe that the time has come for coordinated action. The price of inaction – in adverse events, lost patient lives, delayed or improper treatments, unnecessary procedures, excessive costs, and so on – is just too high, and will only get worse.
There is much at stake and much to do. We must relieve the crushing burden of health care costs in this country by improving efficiency, and assuring the highest level of patient care and safety regardless of geography or demographics. By using current technologies in a meaningful way, as well as technology to be developed in the future, we will take great strides toward solving some of the most vexing problems facing our health care system and creating a new platform for innovative solutions to health care.
I look forward to providing periodic updates, and to continued interactions with all the communities that have so much to gain from this profound transformation.
Sincerely,
David Blumenthal, M.D., M.P.P.
National Coordinator for Health Information Technology
U.S. Department of Health & Human Services
___________________________________
"Meaningful" Progress Toward Electronic Health Information ExchangeA Message from Dr. David Blumenthal, National Coordinator for Health Information Technology
I recently reported on our announcement of State Health Information Technology Grants and grants to establish Health Information Technology Regional Extension Centers, as authorized under the Health Information Technology for Economic and Clinical Health (HITECH) Act provisions of the American Recovery and Reinvestment Act of 2009 (the Recovery Act).
Today I want to discuss the important term “meaningful use” of electronic health records (EHRs) – both as a concept that underlies the movement toward an electronic health care environment and as a practical set of standards that will be issued as a proposed regulation by the end of 2009.
The HITECH Act provisions of the Recovery Act create a truly historic opportunity to transform our health system through unprecedented investments in the development of a nationwide electronic health information system. This system will ultimately help facilitate, inform, measure, and sustain improvements in the quality, efficiency, and safety of health care available to every American. Simply put, health professionals will be able to give better care, and their patients’ experience of care will improve, leading to better health outcomes overall.
As many of you are aware, the HITECH Act provides incentive payments to doctors and hospitals that adopt and meaningfully use health information technology. Eligible physicians, including those in solo or small practices, can receive up to $44,000 over five years under Medicare or $63,750 over six years under Medicaid for being meaningful users of certified electronic health records. Hospitals that become meaningful EHR users could receive up to four years of financial incentive payments under Medicare beginning in 2011, and up to six years of incentive payments under Medicaid beginning in October 2010.
The HITECH Act’s financial incentives demonstrate Congress’ and the Administration’s commitment to help those who want to improve their care delivery, and will serve as a catalyst to accelerate and smooth the path to HIT adoption by more individual providers and organizations. The dollars are tangible evidence of a national determination to bring health care into the 21st century.
The Office of the National Coordinator for Health Information Technology (ONC) is charged with coordinating nationwide efforts to implement and use the most advanced health information technology and the electronic exchange of health information. ONC is working with the Centers for Medicare & Medicaid Services (CMS), through an open and transparent process, on efforts to officially designate what constitutes “meaningful use.”
ONC has already engaged in a broad range of efforts to support the development of a formal definition of meaningful use. The HITECH Act designated a federal advisory committee, the HIT Policy Committee, with broad representation from major health care constituencies, to provide recommendations to ONC on meaningful use. The HIT Policy Committee has provided two sets of recommendations, informed by input from a variety of stakeholders. ONC and CMS have also conducted a series of listening sessions to solicit feedback from more than 200 representatives of various constituent groups and an open comment period where over 800 public comments were submitted and reviewed. The second set of recommendations on meaningful use was issued at a July 16 HIT Policy Committee meeting and details can be found at healthit.hhs.gov/policycommittee.
CMS is expected to publish a formal definition of meaningful use, for the purposes of receiving the Medicare and Medicaid incentive payments, by December 31, 2009. At that time, the public will be able to comment on the definition, and such comments will be considered in reaching any final definition of the term.
By focusing on “meaningful use,” we recognize that better health care does not come solely from the adoption of technology itself, but through the exchange and use of health information to best inform clinical decisions at the point of care. Meaningful use of EHRs, we anticipate, will also enable providers to reduce the amount of time spent on duplicative paperwork and gain more time to spend with their patients throughout the day. It will lead us toward improvements and sustainability of our health care system that can only be attained with the help of a reliable and secure nationwide electronic health information system.
The concept of meaningful use is simple and inspiring, but we recognize that it becomes significantly more complex at a policy and regulatory level. As a result, we expect that any formal definition of “meaningful use” must include specific activities health care providers need to undertake to qualify for incentives from the federal government.
Ultimately, we believe “meaningful use” should embody the goals of a transformed health system. Meaningful use, in the long-term, is when EHRs are used by health care providers to improve patient care, safety, and quality.
What’s next?
As stated above, the next step in our process is a notice of proposed rulemaking in late 2009 with a public comment period in early 2010. As this process unfolds, we will continue to talk and share experiences about transitioning to EHRs, and to help deepen understanding among physicians and hospitals about the use of EHRs. We will also present programs designed to help smooth the transition process, and identify activities physicians and hospitals can engage in now to promote adoption of EHRs. As efforts advance, we will turn our attention to other necessary supporting programs, some of which you will hear more about in the coming weeks, including defining what constitutes a “certified” EHR, which is one of the requirements to qualify for Medicare and Medicaid incentives.
In the meantime, what can providers do to move toward becoming “meaningful users” – even in the absence of a formal definition? Naturally, while understanding that the final definition will be adopted through a formal rulemaking process, it will be helpful to be as familiar as possible with the discussion of meaningful use criteria to date. (You will find that information posted at healthit.hhs.gov/meaningfuluse.)
Armed with an understanding of the discussion of meaningful use as it unfolds, providers can begin to consider how their own practices or organizations might be reshaped to enhance the efficiency and quality of care through the use of an electronic health record system. Be assured you will not be alone as you seek to adopt an EHR system. Through our recently announced collaborative HITECH grants programs and others to be initiated later this year, we will continue to support providers in moving forward. Additional details about the grants are also available in my previous update and at healthit.hhs.gov/HITECHgrants.
To some providers, particularly small or already stretched physician practices or small, rural hospitals, the path toward meaningful use may still seem arduous. To others, who would just prefer to stick with the “status quo,” it may seem like an unwanted intrusion. We believe that the time has come for coordinated action. The price of inaction – in adverse events, lost patient lives, delayed or improper treatments, unnecessary procedures, excessive costs, and so on – is just too high, and will only get worse.
There is much at stake and much to do. We must relieve the crushing burden of health care costs in this country by improving efficiency, and assuring the highest level of patient care and safety regardless of geography or demographics. By using current technologies in a meaningful way, as well as technology to be developed in the future, we will take great strides toward solving some of the most vexing problems facing our health care system and creating a new platform for innovative solutions to health care.
I look forward to providing periodic updates, and to continued interactions with all the communities that have so much to gain from this profound transformation.
Sincerely,
David Blumenthal, M.D., M.P.P.
National Coordinator for Health Information Technology
U.S. Department of Health & Human Services
Thursday, October 8, 2009
CBO Scores - Does Health Reform Win?
The Congressional Budget Office has released their analysis of the costs and revenues attached to the Senate Finance Committee's Health Reform bill.
By the numbers:
29 million Additional insured (by 2019)
25 million Uninsured (by 2019)
94% Total non-elderly legal residents with health insurance
(up from 83%)
91% Total non-elderly residents with health insurance
13% Maximum % of income to be spent on health insurance
$345 billion Expansion of Medicaid and Children's Health Insurance
$461 billion Subsidies for Insurance
$ 23 billion Small Employer Tax credits
========
$829 billion Gross 10 year cost of coverage provisions
($ 4) billion Penalty payments for uninsured individuals
($ 23) billion Penalty payments for employers
($201) billion Excise tax on high premium insurance plans
($ 83) billion Other effects on tax revenues and outlays
=========
$518 billion Net 10 year cost of coverage provisions
$599 billion Offsetting Medicare savings and increased tax revenues
($ 81) billion 10 year reduction in federal deficit
Senate Finance Committee will vote on the bill after Senator Olympia Snowe has had time to review the CBO analysis, likely by next week.
By the numbers:29 million Additional insured (by 2019)
25 million Uninsured (by 2019)
94% Total non-elderly legal residents with health insurance
(up from 83%)
91% Total non-elderly residents with health insurance
13% Maximum % of income to be spent on health insurance
$345 billion Expansion of Medicaid and Children's Health Insurance
$461 billion Subsidies for Insurance
$ 23 billion Small Employer Tax credits
========
$829 billion Gross 10 year cost of coverage provisions
($ 4) billion Penalty payments for uninsured individuals
($ 23) billion Penalty payments for employers
($201) billion Excise tax on high premium insurance plans
($ 83) billion Other effects on tax revenues and outlays
=========
$518 billion Net 10 year cost of coverage provisions
$599 billion Offsetting Medicare savings and increased tax revenues
($ 81) billion 10 year reduction in federal deficit
Senate Finance Committee will vote on the bill after Senator Olympia Snowe has had time to review the CBO analysis, likely by next week.
Preliminary Analysis of the Senate Finance Committee Chairman’s Mark As Amended
CBO and the staff of the Joint Committee on Taxation (JCT) have just issued a preliminary analysis of the Senate Finance Committee Chairman’s mark for the America’s Healthy Future Act of 2009, incorporating the amendments that have been adopted to date by the committee. That analysis reflects the specifications posted on the committee’s Web site on October 2, 2009, corrections posted on October 5, and additional clarifications provided by the staff of the committee through October 6. CBO and JCT’s analysis is preliminary in large part because the Chairman’s mark, as amended, has not yet been embodied in legislative language.
Among other things, the Chairman’s mark, as amended, would establish a mandate for most legal residents of the United States to obtain health insurance; set up insurance “exchanges” through which certain individuals and families could receive federal subsidies to substantially reduce the cost of purchasing that coverage; significantly expand eligibility for Medicaid; substantially reduce the growth of Medicare’s payment rates for most services (relative to the growth rates projected under current law); impose an excise tax on insurance plans with relatively high premiums; and make various other changes to the Medicaid and Medicare programs and the federal tax code.
According to CBO and JCT’s assessment, enacting the Chairman’s mark, as amended, would result in a net reduction in federal budget deficits of $81 billion over the 2010–2019 period. The estimate includes a projected net cost of $518 billion over 10 years for the proposed expansions in insurance coverage. That net cost itself reflects a gross total of $829 billion in credits and subsidies provided through the exchanges, increased net outlays for Medicaid and the Children’s Health Insurance Program (CHIP), and tax credits for small employers; those costs are partly offset by $201 billion in revenues from the excise tax on high-premium insurance plans and $110 billion in net savings from other sources. The net cost of the coverage expansions would be more than offset by the combination of other spending changes that CBO estimates would save $404 billion over the 10 years and other provisions that JCT and CBO estimate would increase federal revenues by $196 billion over the same period. In subsequent years, the collective effect of those provisions would probably be continued reductions in federal budget deficits. Those estimates are all subject to substantial uncertainty.
By 2019, CBO and JCT estimate, the number of nonelderly people who are uninsured would be reduced by about 29 million, leaving about 25 million nonelderly residents uninsured (about one-third of whom would be unauthorized immigrants). Under the proposal, the share of legal nonelderly residents with insurance coverage would rise from about 83 percent currently to about 94 percent. Roughly 23 million people would purchase their own coverage through the new insurance exchanges, and there would be roughly 14 million more enrollees in Medicaid and CHIP than is projected under current law. Relative to currently projected levels, the number of people either purchasing individual coverage outside the exchanges or obtaining coverage through employers would decline by several million.
Although CBO does not generally provide cost estimates beyond the 10 year budget projection period (2010 through 2019 currently), Senate rules require some information about the budgetary impact of legislation in subsequent decades, and many Members have requested CBO analyses of the long-term budgetary impact of broad changes in the nation’s health care and health insurance systems. However, a detailed year-by-year projection, like those that CBO prepares for the 10-year budget window, would not be meaningful because the uncertainties involved are simply too great. CBO has therefore developed a rough outlook for the decade following the 10-year budget window by grouping the elements of the proposal into broad categories and assessing the rate at which the budgetary impact of each of those broad categories is likely to increase over time.
All told, the proposal would reduce the federal deficit by $12 billion in 2019, CBO and JCT estimate. After that, the added revenues and cost savings are projected to grow more rapidly than the cost of the coverage expansion. Consequently, CBO expects that the proposal, if enacted, would reduce federal budget deficits over the ensuing decade relative to those projected under current law—with a total effect during that decade that is in a broad range between one-quarter percent and one-half percent of GDP. The imprecision of that calculation reflects the even greater degree of uncertainty that attends to it, compared with CBO’s 10-year budget estimates.
These projections assume that the proposals are enacted and remain unchanged throughout the next two decades, which is often not the case for major legislation. For example, the sustainable growth rate (SGR) mechanism governing Medicare’s payments to physicians has frequently been modified (either through legislation or administrative action) to avoid reductions in those payments. The projected savings for the proposal reflect the cumulative impact of a number of specifications that would constrain payment rates for providers of Medicare services. The long-term budgetary impact could be quite different if those provisions were ultimately changed or not fully implemented. (If those changes arose from future legislation, CBO would estimate their costs w
Tuesday, October 6, 2009
Patient-Centered Medical Home Demo Improves Quality and Patient Sat
A demonstration project by Group Health found that the Patient-Centered Medical Home (PCMH) "redesign can be associated with improvements in patient experience, clinician burnout, and quality without increasing overall cost."
With PCMH, Group Health found that the patients' experience was rated higher on 6 out of 7 indicators without an increase in costs. "For staff burnout, 10% of PCMH staff reported high emotional exhaustion at 12 months compared with 30% of controls, despite similar rates at baseline. PCMH patients also had gains in composite quality between 1.2% and 1.6% greater than those of other patients. PCMH patients used more e-mail, phone, and specialist visits, but fewer emergency services. At 12 months, there were no significant differences in overall costs."
Prior to the PCMH demonstration project, Group Health had implemented access and efficiency improvements which increased patient satisfaction but also increase physician fatigue. The improvements had included "same-day appointment scheduling, direct access to some specialists, primary care redesign to enhance care efficiency, variable physician compensation (salaries with relative value unit [RVU] incentives), and an electronic medical record with a patient Web portal to enable patient e-mail, online medication refills, and record review. The reforms succeeded in improving patient access and satisfaction, but also increased physician workload, as evidenced by larger panel sizes, greater resource intensity per face-to-face visit, and increasing adoption of patient e-mail. These workload changes, combined with the implementation of the electronic medical record, resulted in fatigue and decreased work satisfaction. Relative reductions also were seen in nationally reported quality-of-care indicators as well as downstream utilization increases in specialty care, emergency care, and inpatient days."
The implementation of the Patient-Centered Medical Home was organized around the relationship between the primary care physician and the patient. The primary care physician leads the clinical team and coordinates the planning of care with the patient. "Maximum use of technology" facilitates patient access.
Group Health implemented changes related to the structure of the care teams, point-of-care, patient outreach and management. Changes included "the use of team huddles, previsit outreach and chart review, and use of patient-centered quality deficiency reports. The PCMH clinic emphasized both e-mail and telephone encounters (as an alternative or complement to in-person visits), depending on patient abilities and preferences."
As a result of its success, Group Health is expanding its Patient-Centered Medical Home program to all of its centers.
With PCMH, Group Health found that the patients' experience was rated higher on 6 out of 7 indicators without an increase in costs. "For staff burnout, 10% of PCMH staff reported high emotional exhaustion at 12 months compared with 30% of controls, despite similar rates at baseline. PCMH patients also had gains in composite quality between 1.2% and 1.6% greater than those of other patients. PCMH patients used more e-mail, phone, and specialist visits, but fewer emergency services. At 12 months, there were no significant differences in overall costs."
Prior to the PCMH demonstration project, Group Health had implemented access and efficiency improvements which increased patient satisfaction but also increase physician fatigue. The improvements had included "same-day appointment scheduling, direct access to some specialists, primary care redesign to enhance care efficiency, variable physician compensation (salaries with relative value unit [RVU] incentives), and an electronic medical record with a patient Web portal to enable patient e-mail, online medication refills, and record review. The reforms succeeded in improving patient access and satisfaction, but also increased physician workload, as evidenced by larger panel sizes, greater resource intensity per face-to-face visit, and increasing adoption of patient e-mail. These workload changes, combined with the implementation of the electronic medical record, resulted in fatigue and decreased work satisfaction. Relative reductions also were seen in nationally reported quality-of-care indicators as well as downstream utilization increases in specialty care, emergency care, and inpatient days."The implementation of the Patient-Centered Medical Home was organized around the relationship between the primary care physician and the patient. The primary care physician leads the clinical team and coordinates the planning of care with the patient. "Maximum use of technology" facilitates patient access.
Group Health implemented changes related to the structure of the care teams, point-of-care, patient outreach and management. Changes included "the use of team huddles, previsit outreach and chart review, and use of patient-centered quality deficiency reports. The PCMH clinic emphasized both e-mail and telephone encounters (as an alternative or complement to in-person visits), depending on patient abilities and preferences."
As a result of its success, Group Health is expanding its Patient-Centered Medical Home program to all of its centers.
Monday, September 28, 2009
Discharge Summaries Grossly Inadequate at Documenting Pending Test Results
A study in the September edition of the Journal of General Internal Medicine found that "discharge summaries are grossly inadequate at documenting both tests with pending results and the appropriate follow-up providers."
The study found that only 13% of discharge summaries document all pending tests. And only 25% of discharge summaries mention some pending tests. Follow-up providers information was included in 67% of discharge summaries. "The documentation rate for pending tests was not associated with level of experience of the provider preparing the summary, patient’s age or race, length of hospitalization, or duration it took for results to return." The study evaluated discharge summaries at two academic medical centers for patients that had pending test results.
This adds to the communication challenges referring physicians face coordinating care in follow-up to a hospital visit. Yet communications issues are accountable for over half of all preventable errors. And communications issues are twice as likely to be related to deaths as compared to "clinical inadequacy".
The study reported that approximately 41% of patient are discharged with pending test results and 9% of these test results affect patient care management.
The study found that only 13% of discharge summaries document all pending tests. And only 25% of discharge summaries mention some pending tests. Follow-up providers information was included in 67% of discharge summaries. "The documentation rate for pending tests was not associated with level of experience of the provider preparing the summary, patient’s age or race, length of hospitalization, or duration it took for results to return." The study evaluated discharge summaries at two academic medical centers for patients that had pending test results.
This adds to the communication challenges referring physicians face coordinating care in follow-up to a hospital visit. Yet communications issues are accountable for over half of all preventable errors. And communications issues are twice as likely to be related to deaths as compared to "clinical inadequacy".The study reported that approximately 41% of patient are discharged with pending test results and 9% of these test results affect patient care management.
Tuesday, September 22, 2009
Why Did Joe Wilson Yell "You Lie"?
Saturday Night Live takes you behind the scenes as Republicans plan for the president's speech to the joint session of Congress.
Thursday, September 17, 2009
Health Wonk Review
Welcome to Health Wonk Review. A special thanks to the stellar group of writers that contributed. And a remembrance to a leader for reform:
"What we face is above all a moral issue; that at stake are not just the details of policy, but fundamental principles of social justice and the character of our country."Health Care Reform -
"The Great Unfinished Business of Our Society"
Austin Frakt at the Incidental Economist presents Economics Arguments for a Public Option. "Good economics arguments for the public option have finally been made. Will they influence the debate? It may be too late."
Tom Emswiler at New Health Dialogue advocates paying "for expanded coverage, in part, with savings from within the health care system, i.e., by doing a better job than we do now in delivering high quality affordable care."
Doctors Jonathan Skinner, Elliott Fisher, and Jonathan Sutherland from the Dartmouth Atlas Project found that "there is still plenty of potential savings in the U.S. health care system to help pay for health care reform, spending that has nothing to do with health, poverty or urban/rural status... There is a behavioral bias at work, a belief shared across all hospitals that their patients are sicker than average, and this explains why their own spending so high. (This is a “Lake Woebegon Effect” in reverse – the belief that the health of all of their patients are below average.) But this behavioral bias, leading to the denial of the potential for real cost-savings in the U.S. health care system, can potentially derail health care reform – to the long-term detriment of the medical and financial health of the American people."
Bob Vineyard at InsureBlog believes that "nothing proposed will lower the cost of health care, or health insurance. In fact, you could very well see the total cost of health care balloon out of sight and health insurance premiums double overnight."
Elizabeth Carpenter at New Health Dialogue explains why healthcare reform costs close to $1 trillion over ten years. "Subsidies -- financial assistance to help people afford insurance -- are why health reform costs so much. Reform proposals would help many hard-working Americans -- people who make too much money to qualify for programs like Medicaid but make too little to purchase coverage on their own -- buy quality health insurance. People eligible for subsidies would receive a tax credit to help them pay the premium for their choice of plans offered in the new marketplace or exchange."
Mike Allen at Politico's Playbook reports on "what the West Wing is reading: cool new independent web site" Truth About Health Care Reform.
Mad Kane "limericks" Senator Judd Gregg's flip-flop on the use of the Senate's reconciliation rules, supporting it for Republican votes on ANWR drilling, but not for the Dems healthcare reform:
“Majority rule is just great,”
Said Gregg in the drilling debate.
“You’ve got 51 votes,
Then you win.” Check his quotes.
Yet 51 Dem votes don’t rate.
“You’ve got 51 votes,
Then you win.” Check his quotes.
Yet 51 Dem votes don’t rate.
Anthony Wright, Executive Director at Health Access California, raises concerns over the Baucus Senate Finance Committee bill arguing that "the details matter on key issues on affordability, securing employer-based coverage, and the public health insurance option. And some of those details are very concerning." He provides links and context to the current flashpoints in the debate.
Dr. Jaan Sidorov at Disease Management Care Blog reports on the "Senate Finance Committee's Bipartisan (Gang) of Six Framework for Reform: Complicated is Only the Beginning."
Dr. Roy Poses at Brown University School of Medicine writes in Health Care Renewal that "we will not truly reform health care without making the marketing of health care goods and services honest, getting health care professionals to give up their financial relationships with health care corporations to reclaim their professionalism, and getting academic medical institutions, professional and medical societies, and patient advocacy groups to give up their financial relationships with health care corporations to reclaim their missions."
Harvard Medical School Professor Mike Chernew on the Robert Wood Johnson blog notes that as the health reform debate enters its final phases, it’s not surprising that cost containment is among the last, most intractable issues of contention. There are "serious questions about resource allocation that each side must address as we strive to design a sustainable health care system. For example, can we afford to fund access to all care for everyone? Are we willing to change the tax system or to impose other reforms that may lower prices or restrict choices in order to achieve that goal? What role should the government play in creating and managing this system relative to the market?"
Chris questions mandates in his post: Senate Proposes “Health Tax” on Fittest Americans.
Louise at Colorado Health Insurance Insider asks "how do you tell a person who is desperately ill that they can’t receive treatment because they aren’t in the right country (or because they don’t have health insurance, for that matter)? I have to imagine that it would be tough for a dedicated health professional to turn away truly sick patients because they aren’t supposed to be here in the first place. What if turning them away amounts to a death sentence?"
Kostub Deshmukh at Hoot Hoot Hoot! proposes a plan that "shifts the cost of the treatment from the insurance provider to the patient, while the safety net of catastrophic insurance protects people from bankruptcies due to illness."
Princeton Economist Uwe Reinhardt expresses doubts about the impact of the proposed "public option," but he also expresses doubts about the co-op approach said to be included in the Finance Committee package. Reinhardt also worries that $900 billion or less will not provide sufficient subsidies to make coverage affordable for all middle-class Americans.
Harold Miller, CEO of the Network for Regional Healthcare Improvement, focuses on the urgent need for payment reform and calls on Medicare to facilitate and learn from the reform efforts already launched by Regional Improvement Collaboratives.
UNC Associate Professor Jonathan Oberlander believes that Obama's speech was well received. Oberlander reminds us that Bill Clinton's health care speech was well received, too, but he concludes that the reform fight, while no sure thing, is winnable for the administration.
Ken Terry at the BNET Healthcare notes the lack of details on cost containment in the speech and the probability that, even if a reform bill passes, the legislation will have to be revisited in the near future.
Harold Luft, Executive director of the Palo Alto Medical Foundation Research Institute, focuses on three aspects of Obama's speech: Delaying the implementation of the insurance exchange, malpractice reform, and the proposal for back-up spending cuts in case initial expected savings don't materialize.
Henry Aaron, Senior Fellow at the Brookings Institution, says that by reaching out in his speech to undecided moderates and clarifying his goals, Obama revived a reform effort that had been badly wounded during the August recess, Aaron says.
Brad Wright at Wright on Health documents the history of "Presidential Health Reform Speeches: Then and Now". He comments briefly on the relative importance / unimportance of presidential speeches on legislative outcomes, before comparing and contrasting Bill Clinton's 1993 speech to a joint session of Congress with Obama's recent one, including video and word clouds.
Census of the Uninsured
Anthony Wright at New Republic's The Treatment reports on the political attacks on the 2008 Census' 46.5 million uninsured that "doesn’t just seek to undermine the facts; it seeks to both minimize the problem, and place the blame for being without coverage on the uninsured themselves."
Tinker Ready at Boston Health News reports on the 5.5 - 6% uninsured in Massachussetts in the latest census.
Health Care for Older Adults
Amer Kaissi discusses End-of-life Care: The Big Bad Wolf of Healthcare Reform posted at Healthcare Hacks. "End-of-life care as part of the new healthcare reform bills seems to me like a potential good thing for older Americans. The Big Bad Wolf, after all, is just a little lamb!"
Chris Langston at The John A. Hartford Foundation blog finds that older adults are best served by medical teams--but right now, doctors, nurses, and other medical professionals have little incentive to work together, and efforts to foster team care environments are undermined by each health profession's desire to be in charge.
RN Debbie Leyva at Healthcare & Technology: Innovation at the Intersection describes the value of the internet for improving health care in older adults.
Blogs and Tweets
Suzane Smith presents 100 Twitter Feeds for Women’s Health.
Carolyn Friedman lists 50 Oncology blogs.
Susan White documents 50 Lectures About Your Brain.
Healthcare Technology
Vince Kuraitis at Better Health Technologies' e-CareManagement Blog writes that the HIT "Standards Committee recommendations are like mandating that everyone in the U.S. be required to speak Latin by 2013."
Dr. Glenn Laffel at EHR Bloggers discusses Social Media: Disruptive Force in Medicine. He makes the case for implementing a widespread, systematic approach to HIT education in medical schools and CME programs for physicians.
Michelle Snyder at The Health Care Blog discusses a survey exploring the opinions of medical students on issues ranging from the state of the healthcare system and use of technology in medicine to social networking.
Policy Challenges of Diabetes and Obesity
Julie Ferguson of Workers Comp Insider reports on an Indiana court's ruling that an employer must cover the costs of an employee's weight loss surgery under workers comp, which continues to generate controversy and attention.
Next Health Wonk Review
Brady Augustine at medicaidfirstaid hosts the next edition of Health Wonk Review.
Wednesday, September 9, 2009
EHR Certification and Transition Steps Defined
On September 3, the Certification Commission for Healthcare Information Technology (CCHIT) unveiled their plans for certification under ARRA. CCHIT plans two program concepts: 1) comprehensive certification which meets or exceeds federal standards and and 2) modular certification related to security, privacy and interoperability meeting federal standards.
Federal standards for HHS Certification will mean that a system meets the "minimum government requirements for security, privacy, and interoperability, and that the system is able to produce the Meaningful Use results that the government expects." HHS Certification will not be a 'seal of approval' nor an indication of the relative value of systems.
CCHIT's action were in response to ONC's Certification and Adoption Workgroup recommendations presented at the August 14 HIT Policy Committee meeting.
The Certification and Adoption Workgroup's recommendations include:
Unlike CCHIT today, certification criteria should be established independently of the organizations performing the certification. Multiple certification organizations will be allowed to perform testing after they become accredited. Vendors need certification from any one testing organization.
Wes Rishel (Gartner) has argued that "when the choice of certifiers is made only by the vendor, not the organization that relies on the certificate, this creates an inevitable pressure to be the certifying organization that is the least thorough in its process"... "Arguably, if physicians could chose the certifying organization they would not pick the one with weakest accreditation. After all, they have to live with and use the product. But under the “any certifying organization will do” approach, this is not the option that will be presented to physicians. They will be asked to choose among products each of which is rated by several organizations, some of which are focused on the baseline requirements for certification and others of which use any number of criteria for judging products."
As such, accreditation is a lynch pin in the Workgroup's recommendations to "insure that multiple certification entities use identical criteria and provide a 'level playing field' so that all certification organizations offer the same level of scrutiny."
HHS Certification would also serve as qualification for the Stark exception.
Providers would be allowed to achieve meaningful use through use of certified components.
In one sure-to-be-controversial recommendation, the Workgroup recommended that the “lock down” requirements of EHR software should be removed to address concerns of the Open Source community.
Self-developed software may also be certified, on a site by site basis.
The certification transition "includes a concept of 'Preliminary HHS Certification' so that vendors, who take a risk on the content of the final regulations, can be ready as quickly as possible when final regulatory approval is obtained" which should be valid through 2011."
"This certification is called “preliminary” because the meaningful use criteria and the certification criteria will not yet have completed their paths through the regulatory process.
When the regulatory process is completed for Meaningful Use, presumably in early 2010, then, if necessary, establish a short “regulatory gap certification” for any necessary changes from preliminary certifications. After completing this “regulatory gap certification”, the National Coordinator should certify those products as qualifying under the statute, with a goal of having HHS Certified products in the marketplace in early 2010."
"For vendors who already completed CCHIT 2008 certification, we recommend providing an optional shorter, expedited process. Request that CCHIT submit, as soon as possible, a proposal for “2008 Gap Certification,” which will apply only to vendors who already completed 2008 Certification. The 2008 Gap Certification must cover any missing privacy capabilities (e.g., audit trails, consent) required by statute It must also cover capabilities for Meaningful Use, and expanded interoperability capabilities. Once approved by ONC, the completion of 2008 Gap Certification should also qualify products for “Preliminary HHS Certification.” Those products will be required to complete the “Regulatory Gap Certification Process” before the National Coordinator similarly certifies those products. Working with CCHIT and the Policy Committee, the ONC should investigate whether similar gap certifications are appropriate for products that achieved 2007 certification."
Federal standards for HHS Certification will mean that a system meets the "minimum government requirements for security, privacy, and interoperability, and that the system is able to produce the Meaningful Use results that the government expects." HHS Certification will not be a 'seal of approval' nor an indication of the relative value of systems.CCHIT's action were in response to ONC's Certification and Adoption Workgroup recommendations presented at the August 14 HIT Policy Committee meeting.
The Certification and Adoption Workgroup's recommendations include:
- Focus Certification on Meaningful Use
- Leverage Certification process to improve progress on Security, Privacy, and Interoperability
- Improve objectivity and transparency of the certification process
- Expand Certification to include a range of software sources: Open source, self-developed, etc.
- Develop a Short-Term Certification Transition plan
Unlike CCHIT today, certification criteria should be established independently of the organizations performing the certification. Multiple certification organizations will be allowed to perform testing after they become accredited. Vendors need certification from any one testing organization.
Wes Rishel (Gartner) has argued that "when the choice of certifiers is made only by the vendor, not the organization that relies on the certificate, this creates an inevitable pressure to be the certifying organization that is the least thorough in its process"... "Arguably, if physicians could chose the certifying organization they would not pick the one with weakest accreditation. After all, they have to live with and use the product. But under the “any certifying organization will do” approach, this is not the option that will be presented to physicians. They will be asked to choose among products each of which is rated by several organizations, some of which are focused on the baseline requirements for certification and others of which use any number of criteria for judging products."
As such, accreditation is a lynch pin in the Workgroup's recommendations to "insure that multiple certification entities use identical criteria and provide a 'level playing field' so that all certification organizations offer the same level of scrutiny."
HHS Certification would also serve as qualification for the Stark exception.
Providers would be allowed to achieve meaningful use through use of certified components.
In one sure-to-be-controversial recommendation, the Workgroup recommended that the “lock down” requirements of EHR software should be removed to address concerns of the Open Source community.
Self-developed software may also be certified, on a site by site basis.
The transition
The certification transition "includes a concept of 'Preliminary HHS Certification' so that vendors, who take a risk on the content of the final regulations, can be ready as quickly as possible when final regulatory approval is obtained" which should be valid through 2011."
"This certification is called “preliminary” because the meaningful use criteria and the certification criteria will not yet have completed their paths through the regulatory process.
When the regulatory process is completed for Meaningful Use, presumably in early 2010, then, if necessary, establish a short “regulatory gap certification” for any necessary changes from preliminary certifications. After completing this “regulatory gap certification”, the National Coordinator should certify those products as qualifying under the statute, with a goal of having HHS Certified products in the marketplace in early 2010."
"For vendors who already completed CCHIT 2008 certification, we recommend providing an optional shorter, expedited process. Request that CCHIT submit, as soon as possible, a proposal for “2008 Gap Certification,” which will apply only to vendors who already completed 2008 Certification. The 2008 Gap Certification must cover any missing privacy capabilities (e.g., audit trails, consent) required by statute It must also cover capabilities for Meaningful Use, and expanded interoperability capabilities. Once approved by ONC, the completion of 2008 Gap Certification should also qualify products for “Preliminary HHS Certification.” Those products will be required to complete the “Regulatory Gap Certification Process” before the National Coordinator similarly certifies those products. Working with CCHIT and the Policy Committee, the ONC should investigate whether similar gap certifications are appropriate for products that achieved 2007 certification."
Thursday, September 3, 2009
Health Wonk Review - call for submissions
Health Wonk Review will be hosted at Healthcare Technology News on Thursday September 17. With Obama scheduled to address a joint session of Congress on Health Care Reform on September 9th, this promises to be an extraordinary edition of the Review.
"Health Wonk Review is a biweekly compendium of the best of the health policy blogs. More than two dozen health policy, infrastructure, insurance, technology, and managed care bloggers participate by contributing their best recent blog postings to a roving digest, with each issue hosted at a different participant's blog. For participants, it's a way to network and share ideas, and for those readers who don't live in this space every day, it's a way to sample some of the latest thinking and the 'best of the best.'"
Submissions are due by 9 AM Wednesday September 16. Please include information on the article (including URL, title, description and author) and the blog (title and URL). Send your submission to healthwonkreview@avancehealth.com
In the meantime, you can check out the latest Health Wonk Review at the Lucidicus Project.
Monday, August 31, 2009
"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:
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."
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