Problems with Modular Solutions for Electronic Health Records

I have posted the following comment on the ONC Health IT Blog (I'd be interested in your thoughts):

I’m not so sure that taking a modular approach to achieving meaningful use is going to work with the latest guidance from ONC. It seems that they are taking a back door approach towards reinstating the all or nothing requirements that were scaled back from the proposed rule to the final rule.

ONC posted on its website an FAQ stating that hospitals must have EHRs that have been certified against all 24 objectives of meaningful use, not just the 19 they plan to use to demonstrate meaningful use. This means that hospitals will need to purchase and implement technology beyond that required to comply with the meaningful use requirements, delaying many hospitals’ efforts to become meaningful users.

The ONC FAQ takes away the flexibility to defer objectives and requires hospitals and physicians to have in place EHRs certified against all 24 objectives of meaningful use. http://healthit.hhs.gov/portal/server.pt/community/onc_regulations_faqs/3163/faq_17/20779

It reads:

Question [9-10-017-1]:

Under the Medicare and Medicaid EHR Incentive Programs Final Rule, eligible health care providers are permitted to defer certain meaningful use objectives and measures and still receive an EHR incentive payment. However, it is our understanding that in order for us to have our EHR technology certified, we must implement all of the applicable capabilities specified in the adopted certification criteria regardless of whether we intend to use all of those capabilities to qualify for our EHR incentive payment. Is our understanding correct?

ONC Answer:

Yes, this understanding is correct. The flexibility offered as part of the Medicare and Medicaid EHR Incentive Programs Final Rule is not mirrored in the Initial Set of Standards, Implementation Specifications, and Certification Criteria Final Rule because we believe that it is important to accommodate eligible health care providers’ ability to achieve meaningful use. We recognize that in some circumstances an eligible health care provider may not know which meaningful use measures they will seek to defer until they begin implementation and in others an individual provider (even within a specialty) will want to choose different measures to defer based on their local situation and implementation experience. Thus, in order to possess EHR technology that meets the definition of Certified EHR Technology, it must be tested and certified by an ONC-ATCB to all applicable certification criteria adopted by the Secretary.


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So, to qualify for the incentive payments, hospitals must have an EHR certified against all 24 objectives of meaningful use, while demonstrating meaningful use against only 19 objectives. Thus, they will need to buy now technology that CMS does not require them to use until later, and which may need to be replaced or upgraded when new certification criteria are adopted for later stages of meaningful use. As an example we will need to purchase or upgrade to the technology to support reporting of biosurveillance and immunization data to public health departments directly from the EHR, even if the public health departments in our state are not capable of receiving the data in the standardized electronic formats required by ONC and CMS. This guidance has seriously muddied the water towards using modular EHR solutions…

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Direct Project and the New Health Internet

After nine months of gestation, we are witnessing the birth of a new platform for health information communication. In the post below, we outline some of the developments of the Direct Project (formerly NHIN Direct) and hopefully give a sense of the exciting future for the Health Internet. Arien Malec and Brian Behlendorf have worked to shepherd the project, along with a host of volunteers, through to this point. The project is not complete, but we have achieved some major milestones. Arien, the leader of the project working with the Office of The National Coordinator, sent out a message of thanks last week to those who have been working so hard to bring this baby into the word. He said:

“A little under 9 months ago, we launched this project with the sketch of a dream: universal addressing and secure transport that would enable health information exchange reaching patients and providers where they are and where they are going in support of meaningful use and improved health outcomes.

In that 9 months, we've agreed and disagreed, formed, stormed, normed and performed, and accomplished great things. We have two specifications that are content complete (needing editorial review and revision); two reference implementations that are at a 1.0 state and can "out of the box, just add trust" enable exchange with a simple install and configuration; some amazing documentation, from the elegant generalist overview, to the most geeked out installation and programming guides; a compelling presentation; solid best practices and security reviews to protect privacy, security and trust; and some incredible implementation geographies integrating directed exchange into physician workflow to enable meaningful use and improved quality. We are seeing multiple organizations, from commercial HIT organizations to public-private health information exchange organizations building Direct specifications into their products and building Direct implementations into their business plans and missions.

It has been incredibly humbling being part of this process, because the Direct Project has truly been about "we": an organization of glorious individuals who have come together on a volunteer basis to accomplish great things. None of what we have accomplished would be there without you, and the energy, brilliance and hard work you have put into this project.”

There has been a great deal of effort so far, but there is still a need for coders and developers, especially those with skills in open source, to work on stuff that matters in the healthcare arena. Check out the different Workgroups and see where you might fit in and be sure to attend the free NHIN University. A group of us have been working in the Communications Workgroup of the project, and three of us collaborated on the post below. Read on for a glimpse of what has been accomplished so far and where we are heading…

Healthcare Messages Over the Internet: The Direct Project

This post was co-authored by Brian Ahier, Rich Elmore and David C. Kibbe.

The Direct Project announced today the completion of its open-source connectivity-enabling software and the start of a series of pilots that will be demonstrating directed secure messaging for healthcare stakeholders over the Internet.

The Direct Project specifies a simple, secure, scalable, standards-based way for participants to send encrypted health information directly to trusted recipients over the Internet.

Also announced:

• A new name: the Direct Project was previously known as NHIN Direct.
• An NHIN University course, "The Direct Project - Where We Are Today," to be presented by Arien Malec, Nov. 29 at 1 PM ET, sponsored by the National eHealth Collaborative.
• More than 20 health IT (HIT) vendors have announced plans to use the Direct Project for message transport in connection with their solutions and services.
• Presentations at the HIT Standards Committee on Tuesday, Nov. 30, where three or more vendors will be announcing their support for the Direct Project.
• A thorough documentation library, including a Direct Project Overview.
• Best practice guidance for directed messaging based on the policy work of the Privacy and Security Tiger team.
• A new website at DirectProject.org.
• A new hashtag, #directproject, for following the Direct Project on Twitter.

The Direct Project is the collaborative and voluntary work of a group of healthcare stakeholders representing more than 50 provider, state, health information exchange (HIE) and HIT vendor organizations. More than 200 participants have contributed to the project. Its rapid progress, transparency, and community consensus approach have established it as a model of how to drive innovation at a national level.

(continue reading at O'Reilly Radar)


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Give Thanks with a Grateful Heart

I have so much to be thankful for and this year and I am very grateful that so many of you have read and commented on this blog. I love to share information freely and really do appreciate you. I also especially want to urge anyone reading this to consider discussing end-of-life issues with their family this year at Thanksgiving time. This is really a perfect time to have these conversations and it is also an important family responsibility.

In our family we have had to deal with some troubling decisions that could have been eased by thoughtful planning. At only 57 years old my mother was diagnosed with early-onset Alzheimer's disease (an uncommon form of dementia that strikes people younger than age 65). The disease progressed rapidly and she soon needed to be put in long term care. But the care didn't turn out to be be very long term - she could not feed herself and quickly lost the ability to swallow. Her mental condition swiftly degraded and we were faced with a very difficult and painful family decision. How extraordinary should be the measures we would take to keep the husk of our mother breathing, and when would we allow her to leave this earth? With modern technology she could have been kept alive for many years with zero quality of life. Our family wrestled with these and other decisions without much preparation. We eventually decided to provide only comfort measures and very soon my mother passed away at 64 years old.

This was five years ago, and the pain still lingers, but I encourage you to have these difficult conversations as a family during this holiday season. Death is completely natural, and as a Christian I have great hope beyond this mortal life. We do not always get to choose the manner of our passing, so being prepared and letting your family know your wishes is an important way of showing your love.

I wish you all a very blessed and happy Thanksgiving and please read the post below:

Things we are grateful for this year

For three years running now, many of us bloggers have participated in what we’ve called a “blog rally” to promote Engage With Grace – a movement aimed at making sure all of us understand, communicate, and have honored our end-of-life wishes.

The rally is timed to coincide with a weekend when most of us are with the very people with whom we should be having these unbelievably important conversations – our closest friends and family.

At the heart of Engage With Grace are five questions designed to get the conversation about end-of-life started. We’ve included them at the end of this post. They’re not easy questions, but they are important -- and believe it or not, most people find they actually enjoy discussing their answers with loved ones. The key is having the conversation before it’s too late.

This past year has done so much to support our mission to get more and more people talking about their end-of-life wishes. We’ve heard stories with happy endings … and stories with endings that could’ve (and should’ve) been better. We’ve stared down political opposition. We’ve supported each other’s efforts. And we’ve helped make this a topic of national importance.

So in the spirit of the upcoming Thanksgiving weekend, we’d like to highlight some things for which we’re grateful.

Thank you to Atul Gawande for writing such a fiercely intelligent and compelling piece on “letting go”– it is a work of art, and a must read.

Thank you to whomever perpetuated the myth of “death panels” for putting a fine point on all the things we don’t stand for, and in the process, shining a light on the right we all have to live our lives with intent – right through to the end.

Thank you to TEDMED for letting us share our story and our vision.

And of course, thank you to everyone who has taken this topic so seriously, and to all who have done so much to spread the word, including sharing The One Slide.

We share our thanks with you, and we ask that you share this slide with your family, friends, and followers. Know the answers for yourself, know the answers for your loved ones, and appoint an advocate who can make sure those wishes get honored – it’s something we think you’ll be thankful for when it matters most.

Here’s to a holiday filled with joy – and as we engage in conversation with the ones we love, we engage with grace.

To learn more please go to www.engagewithgrace.org. This post was written by Alexandra Drane and the Engage With Grace team.

Accelerating Healthcare Innovation

With U.S. healthcare expenditures projected to double by 2035, reforming payment and delivery systems is essential to reining in costs and achieving higher-value care. The Center for Medicare and Medicaid Innovation (CMI)—created by the new Patient Protection and Affordable Care Act—has the potential to accelerate, optimize and speed health care payment and delivery innovation.

On October 18, the Engelberg Center for Health Care Reform at Brookings hosted a forum focused on key themes for accelerating health care innovation, including the importance of strategic public and private collaboration and alignment of investments to effect system-wide improvements in payment and delivery. Following keynote remarks by Donald Berwick, administrator of the Centers for Medicare and Medicaid Services, experts discussed methods to spur rapid identification, execution and evaluation of promising payment and delivery reform models, as well as issues surrounding CMI implementation. This paper (PDF) makes a great companion to the video below. The entire transcript is available here (pdf).



via brookings.edu


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Update on Provider Directories

The Information Exchange Workgroup met on November 15, 2010 and discussed Entity Level Provider Directories in preparation for their report to the HIT Policy Committee on Friday, November 19, 2010. the slides and audio of the meeting are below:

Facebook CEO Mark Zuckerberg at Web 2.0 Summit

This interview of Facebook CEO Mark Zuckerberg is very interesting. If you have an hour it is well worth watching...





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mHealth Summit

The mHealth Summit was held November 8-10th at the Walter E. Washington Convention Center in Washington, D.C. The summit was organized by the Foundation for the National Institutes of Health, the mHealth Alliance and the National Institutes of Health. I was unable to attend, but followed the tweet stream and read some great blogs and watched videos from the event. I will tweet more videos as they are released.

Some of the great posts included:

Dr. Felasfa Wodajo on Better Health

Brian Dolan on MobiHealthNews

Kevin Clauson on his blog

Below is a bnetTV interview of Todd Park, Chief Technology Officer for the US Department of Human and Health Services at the 2010 mHealth Summit held in Washington DC.



And then Ted Turner founder and chairman of the UN Foundation and David Aylward Esecutive Director mHealth Alliance also spoke on the state of mobile health and its applications for the future.

Discussion with Deputy National Coordinator Mostashari

Farzad Mostashari, MD, ScM serves as Deputy National Coordinator for Programs and Policy within the ONC. I spoke with him after his presentation at the NextGen Users Group meeting in sunny Orlando, Florida (while the snow was actually starting to fall back home :-) Watch below as he talks about continuing development of standards and certification criteria and more:



Previously, Farzad served at the New York City Department of Health and Mental Hygiene as Assistant Commissioner for the Primary Care Information Project, where he facilitated the adoption of prevention-oriented health information technology by over 1,500 providers in underserved communities. Dr. Mostashari also led the Centers for Disease Control and Prevention (CDC) funded NYC Center of Excellence in Public Health Informatics and an Agency for Healthcare Research and Quality funded project focused on quality measurement at the point of care. Prior to this he established the Bureau of Epidemiology Services at the NYC Department of Health, charged with providing epidemiologic and statistical expertise and data for decision making to the health department.

He did his graduate training at the Harvard School of Public Health and Yale Medical School, internal medicine residency at Massachusetts General Hospital, and completed the CDC’s Epidemic Intelligence Service. He was one of the lead investigators in the outbreaks of West Nile Virus and anthrax in New York City, and among the first developers of real-time electronic disease surveillance systems nationwide.

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EHR ~ Goin' Mobile

EHR Mobile applications that can be used on mobile devices such as the iPhone or Droid are in high demand by physicians, especially younger ones and tech savvy docs. At the NextGen User Group Meeting 2010 I had a chance to play with NextGen's latest mobile EHR. I have to admit I'm fairly impressed. With NextGen Mobile providers can make better medical decisions because they have quicker access to patient data, including labs, X-rays, and test results right on their mobile device. Nurses are even more enthusiastic about the solution, because providers no longer have to depend on them to access clinical information, and they have more time to spend with their patients. The feedback from clinical staff has been remarkable. And NextGen mobile also runs nicely on the iPad. There certainly needs to be an app developed that runs natively on both iOS and Droid, but so far NextGen has done a decent job of bringing something quickly to market running in the browser - and this is a vast improvement over what they had a year ago. The new NextGen Mobile EHR seems really optimized for smartphone use.

While at the conference I have been seeing some nice developments and I'm really looking forward to Farzad Mostashari's keynote presentation tomorrow. More on that later... Today I was able to get a behind the scenes peek at NextGen Mobile; however, in order to use any of the content I had to include a disclaimer (see below) to avoid running afoul of any FTC rules. So don't make any investments based on what you read here - which is probably really good advice anyway! I have never been paid to write anything, and I am going to keep it that way. So all that being said below is a video that explains the product:



So some of the features that are retrieve and view only are: patient lookup, where you can view patient demographics, histories, procedures, medicines, and allergies; appointments, where you can see the schedule for today, last week or next month; and orders & lab Results, where you can view patient’s unsigned, signed-off, and lab tests ordered. You can also document phone calls and view, prescribe, renew, update medications. There is a comprehensive medication module with functions including ePrescribing, and a custom Sig builder. You can view add, update, review, and remove patient allergies, procedures and both resolved and unresolved diagnoses. You can also view completed tasks by task groups, accept or reject received tasks, link attachments or patients to a task. Overall, tis product is going to make a lot of current NextGen users pretty happy and I suspect will also be a good selling point for those providers that are looking for mobile functionality when choosing an EHR. As Jeff Brandt is fond of saying, ""Smartphones will one day be the remote control for our healthcare." And vendors are finally starting to catch on...

Disclaimer
Safe Harbor Provision of the Private Securities Litigation Reform Act of 1995
During the course of this presentation, we may make forward-looking statements within the meaning of the Private Securities Litigation Reform Act of 1995 including, but not limited to, certain forward looking statements that are based on the current beliefs of QSI Management as well assumptions made by and information currently available to QSI Management. Wherever practical QSI will identify these forward looking statements by using words such as may, will, expect, anticipate, project, believes, intends, estimates, could or similar expressions. We would like to caution you that such statements reflect only our current expectations and that actual events or results may differ materially. In addition, these forward looking statements are subject to a variety of risks and uncertainties which could cause QSI actual results, performance, prospects or opportunities in 2007 and beyond to differ materially from those expressed and/or implied by these statements. We refer you to the risk factors and cautionary language contained in our reports filed with the Securities and Exchange Commission from time to time, including, but not limited to, those risks and uncertainties listed in QSI's Annual Report on Form 10-K filed with the Securities and Exchange Commission and QSI's most recent Quarterly Report on Form 10-Q. Except as required by Federal Securities laws, QSI undertakes no obligation to publicly update or revise any forward looking statements whether as a result of new information, future events, changes circumstances or any other reason after the date of this presentation.

The Magical Kingdom of Meaningful Use

I am at the NextGen User Group Meeting 2010 attending some workshops on meaningful use. I have been particularly impressed with Sarah Corley, MD who has a deep understanding of the requirements and what it will take for providers to achieve meaningful use and grab a hold of some of that sweet stimulus cash. Sarah serves as Chief Medical Officer of NextGen Healthcare, while continuing to practice part-time as a primary care internist in the Washington, DC area. NextGen is extremely fortunate to have this incredible resource.

Additional presentations are being provided by Jessica Kasirsky, DO, a board certified physician in emergency medicine and a physician resource with NextGen. She also works as an emergency room physician at a community hospital in Westchester County, New York. Jessica also presented an excellent webinar earlier this year which is available from her blog posting here.

NextGen has achieved complete EHR certification through CCHIT and you can view the certification criteria detail at the ONC CHPL (the Chapel). Later this week I will be looking at the continued development of cloud based offerings, which is where I believe the future of EHRs lies... The NextGen SaaS model could be particularly attractive to small practices and solo practioners looking to implement an EHR.

Stay tuned for more updates from Disney World this week...


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Provider Directory Update

On Wednesday, November 3, 2010 the Provider Directory Task Force updated the Information Exchange Workgroup of the Health IT Policy Committee. The slides and audio are below:

Election 2010 ~ The Healthcare Effect

The 2010 mid-term elections have given Republicans control of the House of Representatives while the Democrats have maintained control of the Senate. There were also some Republican gains in Governor's races around the country. These results will have some effects on healthcare in the United States.

Healthcare and the United States Senate

With Democrats remaining in charge in the Senate, there is likely to be little change in the dysfunctional nature of this body. If anything we may see more gridlock, as the Republicans have increased their filibuster opportunities. Senate committees will continue to be under Democratic control, so there may be some shuffling of the deck chairs, but there will likely not be much of a change in healthcare policy coming from the Senate for the next two years.

Healthcare and the United States House of Representatives

Now that Republicans have control of the House of Representatives, there will be some changes in the roll out of health reforms. One immediate impact next year will be the change in leadership of the House committees and subcommittees, particularly those with oversight over healthcare. New chairpersons armed with subpoena power and the ability to influence policy on the health reform legislation is going to have a significant impact over the next two years.

Healthcare and the States

With Republicans winning at least nine new Governor's offices, giving them a clear majority, there could be additional challenges to health reform legislation. There are still some key races to be decided and the razor thin margins in traditionally Democratic controlled states could create new dynamics regardless of outcomes. Voters in Arizona and Oklahoma amended their state constitutions Tuesday with measures designed to block the new federal mandate on individuals and some employers to buy health insurance, while voters in Colorado defeated a similar initiative. Most states are operating under huge deficits, and unlike the federal government, they can't just print more money. There will be intense budgetary pressure on the states, which can have an impact of the ability to match federal funds.

HITECH Act and Health Reform

I think there is virtually no chance that the unspent stimulus funds designated for incentives for the adoption and meaningful use of electronic health records will be rescinded. However, the threat of possible reduction in funding to states, combined with their inability in many cases to match the future funding, will cause some states to possibly spend the funds too quickly without adequate planning. The House of Representatives will also be having radically different committee meetings and there is little doubt that there will be a sharp focus on CMS and the ONC and their activities. While it unlikely that the HITECH Act will be repealed or unfunded, the election results have made it much more difficult for the Obama administration to implement its broader healthcare agenda.


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The Ahier Diary

Clarence Percy Ahier was from Jersey, born in 1892 and served as an artilleryman at the Somme and Ypres in the Great War.

Many of those serving during the war recorded their memories, some became famous accounts, and others were locked away in cupboards and lofts.

The war diary of one of my ancestors, Clarence Ahier falls, into the second category.

This everyman's tale of an artilleryman serving in horrific conditions was donated to the Societe Jersiaise.

It was discovered in a loft in Jersey and was handed to the Societe in a plastic carrier bag.

The diary, telling his story from first enlisting in 1915 through to the return to his island home in 1919 is a typically understated British tale.




More on this important historical document from the BBC...


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