Windows 8 Could be a Winner in Healthcare

At the recent Dell World conference I had the opportunity to try out a slew of new Windows 8 devices. I was struck by how many potential healthcare applications this new platform and the mobile devices it has spawned will be available. Windows 8 could have some significant ramifications for use in healthcare. As Denise Amrich, RN and a healthcare advisor for the U.S. Strategic Perspective Institute in her ZDNet post "Why Windows 8 may be the ideal tablet OS for healthcare" said, "Windows 8, like Windows 7 before it, integrates beautifully with Windows server technologies. Windows 8 adds additional security features and works smoothly with Exchange, SharePoint, Windows 2008 and Windows 2012 Server. Of particular interest to healthcare professionals, Windows 8 also supports Microsoft Lync secured messaging, so IM messages that go between medical professionals can be both instant and rock-solid secure." The ability to seamlessly integrate Windows 8 tablets into the enterprise, and to run legacy Windows based EHRs will allow clinicians to finally have the mobile form factors they have been looking for.

Dell's Latitude 10 Windows Tablet

Bill Crounse, MD the Senior Director of Worldwide Health for Microsoft, in a blog post laid out what he sees as the top 3 attributes of Windows 8 that make it a compelling choice for clinicians:

1. It keeps health information secure
2. It works the way you do
3. It facilitates communication, collaboration and productivity without compromise

I agree with Bill's assessment and in particular think that the new tablet devices will be very attractive for use in healthcare. At Dell World I tested quite a few of the new form factors available on the Windows 8 platform including the XPS 10 tablet, the XPS 12 convertible Ultrabook, and my favorite the Latitude 10 Tablet (thanks to Dr. Joseph Kim for letting me have his place in line to purchase one at a steep discount :). I think the form factor and usability of the Latitude 10 approaches that of the iPad, and for all the reasons listed above make it a much more suitable device for the healthcare industry. Using the Dekstop app gives me a full featured Windows desktop that can run all my applications, and other medical apps running native to Windows 8 and RT are sure to be developed. NextGen Healthcare has already released an app called Medicine Cabinet which allows consumers to create, store, track and share personal medication records. I expect the next year to see a great influx of new apps appearing on the scene.

Microsoft has also demonstrated (see below) a prototype of an application for Windows 8 it is calling "Rounds," which is designed to streamline healthcare professionals workflow in hospitals as they communicate within their care teams. Clinicians can click on a grid of patients, view data from EHRs, and hold a video conference with a specialist. Although it is just a prototype at this point, it nicely showcases the touch screen capabilities of Windows 8 tablets. This app is one example of how Windows 8 can combine the functionality of a full PC within the interface of a tablet.

Another very interesting feature of Windows 8 is Windows To Go. Windows to Go allows Windows 8 Enterprise to boot and run from mass storage devices such as USB flash drives and external hard disk drives. Basically it enables administrators to configure an image of Windows 8 onto a USB stick. Using a personal tablet or other mobile device to access a hospital network through Windows to Go is a good way to deal with some of the security concerns of BYOD and mobile device management.

Microsoft seems to have bet the farm on Windows 8, and so far the bet appears to be a good one. With greater emphasis on security and mobility the new platform looks to be a winner, and unlike Vista will likely be adopted fairly quickly. Previously devices and applications have been slow to meet the productivity and security requirements of the healthcare industry. As these new devices continue to improve in usability and more apps are developed on the Windows 8 platform, I expect to see some pretty broad deployment of both the platform at the enterprise level as well as many of the new mobile devices in the healthcare industry.

President Bill Clinton at Dell World

I was fortunate to be invited to Dell World last week and I'll be writing more about some of the new products and services unveiled, especially as they relate to healthcare. I was quite happy to see that many of the sessions were livestreamed and made available around the world. The keynote address by Dell Founder Michael Dell and President Bill Clinton is well worth watching. It is very interesting to see the interaction between these two men who come from some different, although not diametrically opposed, political viewpoints. First Mr. Dell gave a rather quick overview of the company's repositioned business in the new economy, then the former President gave a lengthy speech discussing the importance of collaboration and how society needs to think more ab.out the future. One thing that was front and center as an enabler of innovation and collaboration: the Internet. I encourage you to watch the video of the keynote address and check out some of the other sessions at the DellWorldOnline website...

Check out President Clinton's cowboy boots ;-)

2012 ONC Annual Meeting

The ONC held their 3rd Annual Meeting on 12/12/12. Some of my favorite videos from the webcast are below. If, like me, you were unable to make this years meeting, then you will find them very interesting.

The Year of Meaningful Use: Leaders of the ONC State MU Acceleration Challenge



Introduction:

Mat Kendall, Director, Office of Provider Adoption Support, ONC

Speaker:

Farzad Mostashari, MD, ScM, National Coordinator, ONC

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Stakeholder Roundtable



Moderator:

Todd Park, U.S. Chief Technology Officer, White House

Panel Members:

David Lansky, CEO, Pacific Business Group on Health

Craig Sammit, MD, CEO, Dean Health Systems

Bill Walsh, Senior Advisor, Health Portfolio, AARP

Scott Whyte, Vice President of IT Connectivity, Dignity Health

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Patient Engagement and Health IT



Moderator:

Jodi Daniel, JD, Director, Office of Policy and Planning, ONC

Panel Members:

Lygeia Riccardi, Acting Director, Office of Consumer e-Health, ONC

Dan Kraft, MD, Executive Director, Future Med

10 Billion Dollars in Electronic Health Record Incentives

EHR incentive payments have reached over $9 billion to 177,100 physicians and hospitals through November and are estimated to reach $10 billion by the end of the year. Robert Anthony, from the CMS Office of eHealth Standards and Services, gave an update at the December 5, 2012 meeting of the Health IT Policy Committee (see below). “We saw a large number of hospitals come in November: 525 hospitals were paid by either Medicare or Medicaid,” he said. This was in addition to the 12,250 new EP's paid during that month. "The incentive payments were almost $1 billion more in November. We are on track for the end of December to hit the $10 billion mark for EHR incentives," he added.

Mr. Anthony reported that the most popular meaningful use menu objectives for physicians are those related to drug formulary, immunization registries; and generating patient lists. For hospitals they were advance directives, drug formulary, and clinical laboratory test results. For e-copy of health information a large majority of physicians and hospitals took exclusions due to patients not requesting a copy of there health information. However performance on this measure was very high where it applied. Hopefully in this next year consumers will begin to demand greater access to their health information.

He also reported data from the Regional Extension Centers which showed some the unresolved practice issues, provider engagement and administrative being the biggest challenges. This data also showed unresolved vendor issue challenges, with delays in implementation and problems with upgrade being substantial problems. This data is also broken out by practice type and it is interesting to see the results stratified by hospital or practice setting and especially the differences in rural and underserved areas.

EHR Incentive Program Update to HIT Policy Committee 

A recent HHS Office of Inspector General (OIG) report found that the Medicare portion of the meaningful use program is vulnerable to fraud and abuse. After an article in the New York Times highlighting the report, some have been saying that this is a nail in the coffin for the program, and that the report points to the failure of the efforts and the funding so far has been wasted. There is even talk that the EHR Incentive Program should be sacrificed on the fiscal cliff altar. I think it would be wise examine the details of the report, and also look to the future as we continue down this path.

The OIG report states that CMS didn’t verify the information doctors and hospitals self-reported about how their EHR systems function and recommended that CMS "obtain and review supporting documentation from selected professionals and hospitals prior to payment to verify the accuracy of their self-reported information.” But CMS told the OIG that "prepayment reviews would increase the burden on practitioners and hospitals and could delay incentive payments."

Linda Fishman, from the American Hospital Association, said, "The OIG report contains no evidence of improper payments," Fishman said. "Hospitals take seriously their obligations to provide accurate reports to Medicare, and are working diligently to comply with the highly complex regulatory requirements in the meaningful use program. In addition, CMS is currently conducting audits of hospitals that have received meaningful use payments." Echoing these sentiments American Medical Association Board Chair Steven J. Stack, MD said, "We oppose prepay audits in the meaningful use program, as they would impose additional burdens on physicians who already face separate program requirements for multiple Medicare health IT and quality programs."

While there have certainly been some challenges, I think we need to give the program time to work. As Congress looks for ways to avoid the "fiscal cliff" and find places to reduce federal expenditures, they should think very carefully before breaking the promise to providers and hospitals who have made some serious investments on this meaningful use journey. As Farzad Mostashari recently said, "We have crossed to a new shore and the boats are burned behind us. There is no going back..."

Reason for Optimism About Health Information Exchange

The stars seem to be aligned for rapid progress in health information exchange. We are fast approaching a point in the development of the Health Internet where ubiquitous exchange of health data to improve care coordination and health care quality and ultimately lower costs might be possible. We still face some problems, and standards and policies must be aligned, but there is some great synergy in play that will help drive this vision forward. There are a variety of different initiatives which are coalescing, but there is also a great deal of work still left to do.

Continue reading on iHealthBeat

Is “Meaningful Use” Delivering Meaningful Results?: An Examination of Health Information Technology Standards and Interoperability

On Wednesday, November 14, 2012, the Subcommittee on Technology and Innovation of the Committee on Science, Space, and Technology held a hearing entitled "Is 'Meaningful Use' Delivering Meaningful Results?: An Examination of Health  Information Technology Standards and Interoperability" to examine progress on the development and implementation of interoperable technical standards and conformance testing procedures for health information technology (HIT). (Video archive here) The Subcommittee reviewed the activities of the Office of the National Coordinator for Health Information Technology (ONC) and the National Institute of Standards and Technology (NIST) in promoting interoperability through the development of technical standards for HIT, and will examine the implementation of the Health Information Technology for Economic and Clinical Health (HITECH) Act, including the recently announced final rule for Stage 2 meaningful use of HIT under the Act.

Witnesses included:

• Dr. Farzad Mostashari, National Coordinator for Health Information Technology, The Office of the National Coordinator for Health Information Technology, U.S. Department of Health and Human Services.
• Dr. Charles H. Romine, Director, Information Technology Laboratory, National Institute of Standards and Technology.
• Mr. Marc Probst, Chief Information Officer and Vice President, Information Systems, Intermountain Healthcare.
• Ms. Rebecca Little, Senior Vice President, Medicity.
• Dr. Willa Fields, DNSc, RN, FHIMSS, Professor, School of Nursing, San Diego State University.

These witnesses were asked to address the following questions in their testimony:

1. What is the goal for health information interoperability under the HITECH Act?
2. How are Stage 1 and 2 meaningful use requirements and supporting standards advancing us towards this goal?
3. How have the lessons learned from the implementation of Stage 1 meaningful use requirements and supporting standards been applied in drafting Stage 2 requirements and Stage 3 proposals?
4. How does the ONC engage Federal agencies and other stakeholders (National Institute of Standards and Technology, vendors, and providers) in developing the meaningful use requirements and technical standards?
5. How does the HIT Standards Committee balance the need for common IT standards with the diversity of the healthcare industry? How does the Committee account for technology development and innovation in its standards recommendations?
6. How effective have HHS and the ONC been in establishing long-term goals and benchmarks for HIT adoption, interoperability, and provision of care?
7. What recommendations would you make for Federal policy makers as we consider future HIT policies?

After giving an overview of the EHR Incentive program, Dr. Mostashari discussed how the ONC has been working with NIST. "In 2009 and 2010, NIST provided standards and conformity assessment technical expertise as ONC established the regulatory framework for EHR certification, a HITECH requirement designed to ensure the availability of EHR products that enable health care providers to meet meaningful use criteria. NIST continues to play a key role in supporting the design, implementation and maturation of the ONC HIT Certification Program, including the accreditation of testing laboratories, and the test procedures and testing tools/infrastructure used by them," said Dr. Mostashari. "We have also worked closely with NIST on issues of measuring and improving the usability of EHR products, including through several workshops. Experts from NIST also participate in various capacities on the Health IT Policy Committee and Health IT Standards Committee, as well as through the Standards and Interoperability Framework, a forum for stakeholders to use to identify and resolve standards-based issues impeding progress in the marketplace."

Dr. Romine stated, "NIST’s Information Technology Laboratory (ITL) and ONC are collaborating with industry, healthcare informatics-related standards organizations, consortia, and government agencies to develop consensus-based complete and unambiguous standards and to build tools and prototypes to advance the adoption of IT within healthcare systems. NIST focuses its efforts on developing the key standards that ONC needs for current and future meaningful use criteria."

Marc Probst, of Intermountain Healthcare and a member of the HIT Policy Committee, said that progress has been made as a result of the HITECH Act towards greater health information technology (HIT) interoperability, but much needs to be done. He gave an analogy of the Australian railroad to provide an example of the importance of standards. "In Australia, railroads developed independently, one by one. While trains and tracks did get built, the railroad system was constructed with many different gauges of rail, preventing railroad cars on one set of tracks from running on others. After many years of subpar train service, expensive work‐arounds, and increasing costs, Australia defined a standard gauge system. The process of standardizing the gauges was expensive and disruptive, but efficiencies continue to be realized today," he said.

Mr. Probst added, "The vast majority of these Meaningful Use requirements deal with functions that an EHR should be able to perform and requirements for what functions or data should be shared between EHRs. The existing HIT systems, be they vendor developed or self‐developed, also were built one‐by‐one and applied differing standards (the great thing about healthcare standards is there are so many to choose from). Although very effective for each institution, heroics are required to share even basic data between them. We now essentially have our own Australian railroad and fixing it will require leadership and investment."

Rebecca Little, from Medicity said "We supply the 'plumbing,' the intelligent plumbing, rather, that allows electronic medical records, electronic health records, lab services, pharmacies, hospitals, doctors’ offices, and other providers to connect with one another. To continue with the metaphor, it doesn’t matter what Electronic Medical Record (EMR — or fixture— a provider uses. Our plumbing can connect any type of fixture to another so that health information and patient data can be safely and securely transmitted."

Dr. Willa Fields, the new Chair of the Board of Directors of HIMSS gave a description of the HIMSS Electronic Medical Record Adoption Model (EMRAM) system. She provided seven recommendations for Congress from HIMSS:

1. Continue its strong bipartisan support for the adoption and use of electronic health records and interoperability.
2. Continue to support and sustain the Meaningful Use and Electronic Health Records Programs.
3. Direct the administration to initiate an appropriate study of a nationwide patient data matching strategy with a report back to Congress.
4. Support harmonization of federal and state privacy laws and regulations to encourage the exchange of health information across health systems, payers, and vendor systems.
5. Continue to support programs and services to educate providers and provider organizations on how Health IT can and should be used to engage patients.
6. Continue to support and sponsor pilot programs addressing the collection, analysis and management of clinical data for quality reporting purposes to assist providers and provider organizations make informed decisions for public health, patient care and business purposes.
7. Preclude any additional delay in the nationwide implementation of ICD-10, International Classification of Diseases beyond the current October 1, 2014 deadline.

During the Q&A, responding to a question from Chairman Ben Quayle from Arizona, Dr. Mostashari explained how there are exemptions for specialists for requirements that are considered out of scope for their practice. These exemptions are in place for stage 2, which will allow many providers to avoid penalties. He also stated that we have made great progress on interoperability in meaningful use, but there is still work to be done. All of the panelists agreed with this assessment. Although Mr. Probst added that simply exchanging health information is not enough, but true interoperability goes to a much deeper level being integrated into clinical workflow. Everyone stressed the need for greater efforts at national standards development.

Asked to elaborate on the necessary compromises between the aspirational goals we want to achieve and the reality of where the market is, Dr. Mostashari explained that we need to be sure to allow an on ramp for small providers to meaningful use of EHR technology. When questioned on the much discussed issue of increased billing through the use of EHRs he stated that a thorough investigation is taking place and announced an upcoming summit of stakeholders to further address this issue. Dr. Romine added that NIST is exploring ways to begin conformance testing for EHR usability.

Representative Suzanne Bonamici, from Oregon asked how healthcare professionals can be included in the design of EHR technology to help ensure usability. Dr. Romine stated that NIST does not have great clinical experience, so they partner with the healthcare community, standards organizations, and the ONC. Dr. Mostashari claimed that the EHR products available now are much more usable than just a few years ago. He said the difference "is like night and day."

Dr. Mostashari discussed the need for a continued patient-centered approach, and remarked that the patient is the most underutilized resource in healthcare. He noted the critical importance of patients having access to their own health information if they are going to be engaged and empowered to participate in their care. He also highlighted the fantastic Blue Button program, which started within the Veteran's Administration, and is now being deployed all over the country. Dr. Fields pleaded that Congress allow the investigation and study of patient identification issues using a national patient identifier. Congress currently prohibits the use of appropriated funds for these types of studies and HIMSS has asked that this be reconsidered.

It was a very interesting hearing and certainly highlighted the need for continuing standards development work. While there was some opposition from certain members to the amount of money being provided for incentives, I was encouraged by the tone and tenor of the hearing and very gratified at the strong bipartisan support for health information technology. There are likely to be many legislative battles ahead, but this hearing foreshadowed what is likely to be a continued strong bipartisan support for using health information technology to improve healthcare and lower costs.

Using Health IT to Support Population Management

At the Health Tech Council Semi-Annual Meeting Dr. Douglas (Doug) B. Fridsma, MD, Ph.D., Chief Scientist & Director of Science & Technology at the ONC was presented with the ‘Best of HealthTech Award.’ Dr. Fridsma led a session on using innovative analysis of data and information sharing with mobile technologies in healthcare organizations. The main focus of the keynote entitled “Using Health IT to Support Population Management” was how using these strategies to support population management can reduce costs in healthcare institutions.

With much of the healthcare industry focused on population management as a means of reducing costs and improving the quality of care, health IT has quickly emerged as the foundation on which successful population management efforts must be built. Through innovative use and analysis of data, information sharing, and mobile technologies healthcare organizations are now able to care for their entire population, which becomes increasingly important as pay for performance models are increasingly adopted in the industry. During his keynote Dr. Fridsma discussed how IT supporting population management and how standards and interoperability play a critical role to the success of this movement.



HealthTech is a sister organization to the well-known and widely respected Government Technology Research Alliance (GTRA), a 10,000+ member organization serving the government IT community by providing executive-level opportunities for collaboration and the exchange of best practices and lessons learned in areas such as information sharing, enterprise architecture, cyber security and infrastructure modernization.

Daffy Duck for President

In the heated election season I thought it would be a nice break to remind ourselves of our constitutional form of government via a humorous civics lesson from Bugs Bunny.



Daffy Duck for President is a children's book, published by Warner Bros. and the United States Postal Service in 1997 to coincide with the release of the first Bugs Bunny U.S. postage stamp. The book was written and illustrated by Chuck Jones, edited by Charles Carney, and art directed by Allen Helbig. It was Jones' last published book before his death in 2002.

In 2004, Warner Bros. released a four-minute animated short of the same name based on the book. The film was produced by Tony Cervone, Spike Brandt, and Linda M. Steiner. It was considered for a 2005 Academy Award for Best Animated Short.

Doctors Using Electronic Health Records Provide Higher Quality Healthcare

The use of electronic health records is linked to significantly higher quality care, according to a new study¹ by Lisa Kern and her team, from the Health Information Technology Evaluation Collaborative in the US. Their work appears online in the Journal of General Internal Medicine, published by Springer.

Electronic health records (EHRs) have become a priority in the US, with federal incentives for 'meaningful' use of EHRs. Meaningful use entails tracking and improving specific patient outcomes, as well as gathering and storing information.

Kern and colleagues examined the effect of EHRs on ambulatory care quality in a community-based setting, by comparing the performance of physicians using either EHRs or paper records. They assessed performance on nine specific quality measures for a total of 466 primary care physicians with 74,618 patients, from private practices in the Hudson Valley region of New York.

The quality measures included: eye exams, hemoglobin testing, cholesterol testing, renal function testing for patients with diabetes, colorectal cancer screening, chlamydia screening, breast cancer screening, testing for children with sore throat, and treatment for children with upper respiratory infections.

Approximately half of the physicians studied used EHRs, while the others used paper records. Overall, physicians using EHRs provided higher rates of needed care than physicians using paper, and for four measures in particular: hemoglobin testing in diabetes, breast cancer screening, chlamydia screening, and colorectal cancer screening.

The specific quality measures included in this study are highly relevant to national discussions. Of the seven quality measures expected to be affected by EHRs, all seven are included as clinical quality measures in the federal meaningful use program. There has been little evidence previously that using EHRs actually improves quality for these measures.

This study took place in a community with multiple payers. This is in contrast to integrated delivery systems, such as Kaiser Permanente, Geisinger, and the Veterans Administration, all of which have seen quality improvements with the implementation of health information technology. Most health care is delivered in “open” rather than integrated systems, thus increasing the potential generalizability of this study.

The authors conclude: "We found that EHR use is associated with higher quality ambulatory care in a multi-payer community with concerted efforts to support EHR implementation. In contrast to several recent national and statewide studies, which found no effect of EHR use, this study's finding is consistent with national efforts to promote meaningful use of EHRs."

1: Kern LM et al (2012). Electronic health records and ambulatory quality of care. Journal of General Internal Medicine; DOI 10.1007/s11606-012-2237-8

Study: Exercise as a Vital Sign Improves Patient Care

Exercise is now a “vital sign” for all Kaiser Permanente members. While they have their weight, height and blood pressure measured before a doctor visit, patients are asked how often they exercise so that doctors can follow up.

A Kaiser Permanente study 'Initial Validation of an Exercise “Vital Sign” in Electronic Medical Records' published in the journal Medicine & Science in Sports & Exercise examined the electronic health records of 1,793,385 Kaiser Permanente Southern California patients ages 18 and older from April 2010 to March 2011 and found that 86 percent of all eligible patients had an exercise vital sign in their record. Of those patients who had an exercise record, one third were meeting national guidelines for physical activity, and two thirds were not meeting guidelines. Of those not meeting guidelines, one third were not exercising at all.

“There is no better indicator of a person’s health and longevity than the minutes per week of activity a patient engages in,” said Robert E. Sallis, M.D., one of the authors. Kaiser Permanente began using the exercise vital sign in October 2009. Patients at Kaiser are routinely asked questions about their usual daily levels of activity and are assigned a minutes-per-week value based on their answer. Using a regression model, this study demonstrated that a greater disease burden increased the likelihood of physical inactivity among the sample patient population. As expected, researchers also found lower activity levels among patients who were older, obese or members of ethnic minorities.

"Embedding questions about physical activity in the electronic medical record provides an opportunity to counsel millions of patients during routine medical care regarding the importance of physical activity for health," said study lead author Karen J. Coleman, PhD, of the Kaiser Permanente Southern California Department of Research & Evaluation. "In addition, the Exercise Vital Sign has the potential to provide information about the relationship between exercise and health care utilization, cost and chronic disease that has not been previously available."

Check out the video below featuring Dr. Jed Weissberg, Senior Vice President for Hospitals, Quality, and Care Delivery.

"…The medical assistant asks the patient, ‘How many days a week do you exercise, and on those days, how many minutes do you exercise? So that is adding exercise to the set of vital signs, just like we added cigarette smoking as a vital sign so that it could be right up there at the top of the medical information for the doctor to engage in a discussion with the patient."

Living by Numbers: Wired Health Conference

I am now at the WIRED Health Conference, which is being simulcast in a free live-feed at www.wiredhealthconference.com. The WIRED Health Conference will be an exploration of the challenges and opportunities of data-driven medicine. This is going to be a great launching point for me to head to San Francisco for Strata Rx (more on that in a later post ;-)

I'd encourage you to watch the live feed, follow along on the Twitter hashtag #WIREDhealth and check out the Living By Numbers: A Wired E-Book. This is just the start of what promises to be an awesome event!

The agenda includes:

KEYNOTE SPEAKER ASHTON EATON
Gold Medalist, Olympic Decathlon World Record Holder, Decathlon and Heptathlon

KEYNOTE SPEAKER MICHAEL GRAVES
Founding Partner, Michael Graves & Associates/Michael Graves Design Group

KEYNOTE SPEAKER CRAIG VENTER
Founder, Chairman & President, J. Craig Venter Institute; CEO & President, Synthetic Genomics

KEYNOTE SPEAKER STEPHEN WOLFRAM
President & CEO, Wolfram Research

YOU CAN NOW WATCH THE ARCHIVE OF THE EVENT HERE

Digital Health Conference

I'll be starting this week at the NY eHealth Collaborative’s (NYeHC) Digital Health Conference. This conference brings together a diverse group of healthcare professionals to hear insights, ideas, and analysis from leaders in the health IT community. With keynote speakers like David J. Brailer, MD, Ph.D., the Chairman of Health Evolution Partners and Stephen J. Dubner, the bestselling author, Freakonomics and Superfreakonomics, it is sure to be an excellent event. I'll be on a panel "Taking a Healthy Risk: Best Practices and Creative Use of Social Media in Healthcare" with Twitter superstars John Lynn, Amy Dixon RN, and Wen Dombrowski MD. We'll explore best practices, discuss risks and benefits, and share ideas for creative uses of online tools and platforms for providers, administrators, patients, and healthcare organizations. There are going to be some interesting tweets at the hashtag #DHC12 throughout the event.

One thing that will be very cool is the inaugural class of the NY Digital Health Accelerator (NYDHA) to be announced at the conference. The 8 selected companies will be announced by NY State DOH Commissioner Dr. Nirav Shah on Day 1. In addition, they'll be demonstrating their products and solutions in our exhibit hall and during a dedicated conference session on Day 2. The NYDHA is $4.2 million program run by the New York eHealth Collaborative & the New York City Investment Fund for early- and growth-stage digital health companies that are developing cutting edge technology products for some of the largest healthcare providers in NY state.

“The Accelerator provides much-needed, valuable tools for providers in support of New York State's Medicaid Redesign initiative," New York State Health Commissioner Nirav R. Shah, M.D., M.P.H. said. "The initiative, which promotes a shift from the costly fee-for-service model to a more effective and efficient managed care approach, is resulting in better care - at lower cost - for patients across the continuum of care. The Accelerator is an essential first step to stimulate the market and nurture innovation within the entrepreneurial community.”




The NYDHA is a program run by the NYeHC and the Partnership for New York City Fund for early- and growth-stage digital health companies that are developing cutting edge technology products in care coordination, patient engagement, analytics and message alerts for healthcare providers.

The 9 month program will provide up to $300,000 of funding per company from a syndicate of leading venture capital and strategic investors, along with direct mentorship and feedback from senior-level executives at a broad network of provider organizations in New York State.

“We are creating the next generation of healthcare applications that will transform the healthcare delivery system,” said NYeC Executive Director David Whitlinger. “These companies are the first software development vendors to have direct access to the SHIN-NY, a secure platform that embodies all of the federal and state policies for usage of patient data by the community.”

The 8 companies announced include:

AdhereTx: KnowMyMeds web-based, interoperable software supports team-based medication management and reconciliation for high-risk patients at the point of care. KnowMyMeds enables healthcare practitioners to perform clinically validated, cost-effective medication review for high-risk patients, including “dual eligibles” and the chronically ill, to reduce their drug-related hospitalizations and readmissions. (www.adhertx.com)

Aidin: Aidin is a web-based referral platform for hospitals discharging patients to post-acute care.  Aidin collects hard data about how well post-acute providers perform and makes it easy for hospital staff to present that information to patients when they are choosing their post-acute provider - helping patients choose better providers for better outcomes. (www.myaidin.com)

Avado: Avado allows clinicians and patients to securely communicate, track, and manage health information. They centralize data from many EHR’s and make it usable for all stakeholders.  Providers can take comfort knowing that Avado exceeds Meaningful Use requirements for patient engagement while also addressing requirements for medical homes and accountable models. (www.avado.com)

CipherHealth: CipherHealth helps hospitals avoid government penalties by reducing preventable readmissions, improving outcomes, better coordinating care, and creating a positive patient experience.  CipherHealth reaches out over the phone, through tablets, via email, text, or the web, better engaging patients in their care and building stronger relationships between patients and providers. (www.cipherhealth.com)

Cureatr: Cureatr will improve how healthcare providers communicate and coordinate patient care. Their lightweight, user-friendly HIPAA-secure group messaging system integrates with existing directory, scheduling and paging systems, making it easy to use while coordinating care within or between organizations. (www.cureatr.com)

MedCPU: MedCPU delivers accurate real-time clinical care advice through its revolutionary Advisor Button technology. It uniquely captures the complete clinical picture from clinicians’ free-text notes, dictations and structured documentation entered into any EMR, and analyzes it against a growing library of best-practice content, generating real-time precise prompts for best care consideration. (www.medcpu.com

Remedy Systems: Remedy Systems leverages the power of mobile to lower the cost and improve the quality of healthcare via its flexible care coordination platform that enables physicians and nurses to concentrate on delivering the highest quality of care possible while fostering engagement from patients and family/friends. (www.remedysystems.com)

SpectraMD: SpectraMD maximizes the value of data across the continuum of care with business intelligence solutions. Their FOCUS™ Actionable Analytics platform enables stakeholders in hospitals and ambulatory care settings to improve outcomes, increase revenues, succeed in quality-based initiatives including Reducing Preventable Readmissions and leverage analytics for the Health Home initiative. (www.spectramd.com)

Twenty highly influential healthcare provider organizations will participate in the program, including New York Presbyterian, NYU Medical Center, Albany Medical Center, and the New York City Health and Hospitals Corporation.

With an initial investment of $4.2 million, the NYDHA will create approximately 1,500 jobs over five years. In addition, it is expected that the companies will attract upwards of $150-200 million in investment from the venture capital community post-program. The NYDHA will stimulate a new marketplace, creating the next generation of healthcare tools while positioning New York a hub for the health IT entrepreneurial sector.

Announcement of eHealth Exchange Compliance Test Body

On October 11, 2012 the EHR|HIE Interoperability Workgroup,  a New York eHealth Collaborative (NYeC) led consortium of states and vendors; and Healtheway, the newly formed public-private partnership of the eHealth Exchange (formerly referred to as the Nationwide Health Information Network (NwHIN) Exchange) made a joint announcement on the selection of the Compliance Test Body (the CTB). The Exchange Coordinating Committee, in conjunction with the EHR-HIE Interoperability Workgroup (IWG), issued a joint request for proposals to select a CTB. The CTB will facilitate testing for both the Exchange and support testing for participating state HIE programs. They selected the Certification Commission for Health Information Technology (CCHIT) to carry out the testing. As the CTB, CCHIT will certify that the interfaces between the HIT and HIEs are consistent across multiple states and systems. CCHIT is also an Office of the National Coordinator (ONC) authorized certification body and is an accredited testing laboratory for EHRs.

"Today's announcement brings together several activities supported by ONC over the past years: a core set of national standards, an Accredited Certification Body, the Public-private partnership that has emerged from the Nationwide Health Information Network Exchange, and the convening power of New York and other State Health Information Exchange grantees," said Dr. Farzad Mostashari, the National Coordinator for Health Information Technology. "We look forward to working with this consortium to continue progress on interoperability and secure health information exchange, and to reflect what is learned in national standards as necessary."

To expand nationwide HIE, Healtheway and NYeC formed a strategic partnership to enable technology systems, public and private providers and health information organizations (HIOs) to have access to more efficient testing. The coalition harmonized a set of functional, technical and test specifications that enable true plug and play connectivity to simplify EHR and HIE development.

"The collaboration between the states and vendors to address a shared marketplace gap and work toward a mutual vision has been one of the remarkable aspects of this effort," said David Whitlinger, Executive Director of NYeC. "And momentum is building within both communities as states grow their HIE networks by working with the EHR and HIE vendors to provide seamless integration and clinical workflow, taking the market to a new level for the benefit of patients."

Vendors have agreed to bring their products for testing according to these specifications and participating states have agreed to promote the value of EHR and HIE products certified in the program. The program will ensure that providers' EHR software has the capability to connect to their local HIE and enable communities and states to share patient health information.

"The testing program Healtheway has developed with NYeC is the key to realizing secure and interoperable exchange of health information across organizational and geographic boundaries," said Michael Matthews, Healtheway President and Board Chair. "The launch of a compliance testing program will enable the eHealth Exchange to more than double participation and connectivity over the next nine to 12 months."

There will be an announcment with more details this afternoon. For more information see hiehitnews.org

Politics and Health Reform

On October 4, 2012, Politico hosted a conversation about the role and future of accountable care organizations and their effect on providers and patients. Guests included former CMS Administrator Don Berwick, America's Health Insurance Plans (AHIP) President and CEO Karen Ignagni, Bruce Fried of SNR Denton, Premier VP Joseph Damore, and Robert Laszewski of Health Policy and Strategy Associates (see video below).

"It’s a great law, complex and complicated... but there is a continuing job to communicate how it works," Don Berwick said. He went on to state his views on health reform and some of the political implications.

"The Affordable Care Act is a great step in America towards making health care a human right in our country where if you’re an American you can get healthcare, which isn’t true now, lots of people are left out of the system, people have to worry they’re going to lose their insurance if they get sick, or if they have a preexisting condition, they can’t find insurance," said Berwick.

"The Affordable Care Act overcomes that: it says, ‘No, if you’re an American you can have health care. We’ll find one way or another,’ in partnership with the private sector to make sure that you get the health care that you need,” he said. "That’s a very important step."

Berwick claimed, and other experts on the panel agreed, that the accountable care organizations (ACOs) being promoted by the health law would continue regardless of who wins the presidential election. "Both sides endorse ACOs because it’s a good policy," Berwick said.

Health plans and large employers have tried for some time to direct patients to preferred providers as a way to control costs. This has become even more important as mounting evidence shows that high costs do not necessarily signal high quality. HMOs directed patients to particular providers by using closed networks in the mid-1990s. Robert Laszewski, who is also a former insurance executive, said there is bipartisan support for ACOs because they don’t limit patient choice of doctors like the HMOs of the 90s did. But he warned that ACOs may not save fast enough to adequately control the rising costs of Medicare. "We don’t have lots of time," he said.

Karen Ignagni, president of AHIP, also dismissed the political implications of ACOs. "I don’t think it has anything to do with the political dynamic," Ignagni said. “It has everything to do with what employers are telling health plans and their providers. They can’t afford it."



Even before the federal government launched its accountable care organization programs, ACO-style payment arrangements already had been adopted by private payers. Value-based provider networks are an attempt to help consumers make informed decisions about their care, while still maintaining their ability to choose a provider. I believe that the efforts in moving to a system that pays for value rather than volume underway in the private market will continue whatever happens politically.

KILL THE FAX!!!

The ONC’s Direct Project gives healthcare organizations the opportunity to exchange structured and free-form content.

“I’d like to make a bumper sticker,” says Brian Ahier, president of Gorge Health Connect, Inc. “It would say, ‘Kill the fax.’”

Fax machines have been a staple in the health information exchange (HIE) process for years, but Ahier and others are questioning their continued usefulness as vehicles to transmit sensitive data. In the modern era, where Olympics coverage can be streamed on our smartphones and tweets can lead to revolution, isn’t there a better way to share health data?

Ahier is among those who think there is. “The fax machine is not a secure way of exchanging information. There’s no way to audit that you read and received the information,” he says.

That’s one reason he was eager to work on the Direct Project, a program sponsored by the Office of the National Coordinator for Health Information Technology (ONC) that brought the healthcare community together to figure out a way to exchange information more securely, easily, and efficiently. “[The ONC] developed an open and collaborative approach to developing standards and services that enable direct, secure messaging over the Internet for health information,” Ahier explains.

Doug Fridsma, MD, PhD, chief science officer and director of the Office of Science and Technology at Health and Human Services, says the Direct Project grew out of the passage of the HITECH Act. “We charged the HIT Standards Committee with looking at the nationwide health information network and the specifications that we had in there and the way in which the nationwide health information network was organized to see how we could leverage that to meet some of the things we needed to accomplish for meaningful use.”

see For The Record magazine for complete article...

National Strategy for Trusted Identities in Cyberspace (NSTIC) Pilots

The National Strategy for Trusted Identities in Cyberspace (NSTIC) is a White House initiative to work collaboratively with the private sector, advocacy groups and public-sector agencies overseen by U.S. Department of Commerce’s National Institute of Standards and Technology (NIST). Five companies working to develop trusted electronic identity technologies to combat identity theft, protect online transactions and secure information sharing were given more than 9 million dollars in grants by NIST for NSTIC pilots. The pilot programs, said NTSIC, span multiple sectors, including health care, online media, retail, banking, higher education, and state and local government and will test and demonstrate new solutions, models or frameworks that don't exist in the marketplace today.

NSTIC envisions an “identity ecosystem” in which technologies, policies and standards support greater trust and security when individuals, businesses and other organizations conduct sensitive transactions online. The private-sector-led Identity Ecosystem Steering Group provides an open process for organizations to participate in development of the ecosystem. The group’s goal is to craft a framework for identity solutions that can replace passwords, allow individuals to prove online that they are who they claim to be, and enhance privacy. These pilot projects are going to bring the theoretical work into the real world developing solutions that will help in many industries, but especially healthcare. There is a lack of confidence and assurance that people and organizations are who they say they are online, and the de-facto requirement in the current online environment is for individuals to maintain dozens of different usernames and passwords.

Resilient Network Systems (Resilient) has been awarded one of the NSTIC grants as the prime contractor building a new system that guarantees trusted identities in the areas of healthcare and education. Our health information exchange organization Gorge Health Connect (GHC) is one of the subawardees on the healthcare project working with the San Diego Beacon eHealth Community. The pilot, called Patient-Centric Coordination of Care, will enable convenient multi-factor, on-demand identity proofing and authentication of patients, physicians, and staff on a national scale. This will facilitate coordination of care among a select group of primary care physicians and cardiologists. Resilient is also partnering with the American Medical Association, Aetna, the American College of Cardiology, ActiveHealth Management, Medicity, LexisNexis, NaviNet, the Kantara Initiative, Krysora, and the National eHealth Collaborative.

The project is designed to successfully deploy a working pilot system that will provide tangible benefits to patients, physicians and online service providers within twelve months. This pilot will demonstrate:

• A collaborative identity ecosystem that interoperates across disparate identity providers and relying parties
• Ability to create real-time Trust Graphs linking identities and relationships of doctors, staff and patients
• Use of multiple, discrete identity providers (both public and private) to “syndicate” identities
• Codifying and enforcement of appropriate governance policies (e.g. identity, access, use, privacy, etc.)
• Cloud-based services that rely on the network for identity and policy, thus retaining minimal transaction data
• Expanded system capabilities to share protected data, documents and application services across boundaries

Using four new types of Internet infrastructure – the Access Server, Trust Broker, Identity Broker and Zero-Knowledge Services – the pilots will coordinate secure interactions among existing systems to allow organizations and people, that don’t necessarily know each other or have trust relationships, to collaborate and share sensitive information and resources without having to disclose personal identifying information (PII) to other parties.

The pilots will utilize a Trust Network which will create a decentralized, pervasive identity system, with supporting directory, discovery, matching and verification of identities for people, organizations, and information. It is an open network with a technology and vendor neutral architecture, allowing disparate standards and systems, including federated systems, to be linked together and leveraged without requiring users to understand the underlying infrastructure. The Trust Network will enable new type of “identity syndicate”, which is a collective of virtually combined, independent identity and attribute databases that can be used for matching, verifying and searching identities. It works even if the participating systems do not agree on how to identify people, and even if they are unwilling to disclose the identity attributes they have to each other.

I am very happy to work with Resilient Networks, the San Diego Beacon Community, and our other partners on this project. I will post updates as we make progress, and look forward to learning a lot from what works, and what doesn't.

Consumer Health IT Summit - Government as Catalyst

Kicking off National Health IT Week the U.S. Department of Health and Human Services (HHS) in conjunction with the Office of the National Coordinator for Health Information Technology (ONC) hosted the second Consumer Health IT Summit on Monday, September 10, 2012. The Summit was geared towards individuals who are trying to advance consumer access to health information and brought together government leaders with leaders in the private and non-profit sectors. It was a great event and certainly brought into focus the critical importance of patients being involved in their care and having access and control of their own health data.

Dr. Farzad Mostashari, National Coordinator for Health IT, ONC, and Lygeia Ricciardi, Acting Director, Office of Consumer eHealth, Office of the National Coordinator for Health Information Technology, HHS, discussed some their strategies for engaging customers. Lygeia highlighted three primary elements of this strategy:

• Access: getting information into the hands of patients and caregivers;
• Action: engaging consumers to actually use the information in an effort to improve health
• Attitudes: how access and action can shift attitudes about the traditional roles of patients and providers

Farzad gave a rousing call to action to let the developer help. He encouraged programmers and developers, entrepreneurs and innovators to join in the effort to empower patients to be more engaged partners in care. They also announced the winner of the "What's In Your Health Record" video challenge which went to Mark's Story, which talked about the importance of having access to health records when travelling.

[UPDATE] Lygeia also mentioned the establishment of Consumer/Patient Engagement Workgroups for both the HITPC and HITSC to focus on policy and standards issues related to strengthening the ability of consumers, patients, and lay caregivers to manage health and healthcare for themselves or others.  ONC is pushing forward in this area on multiple fronts, and they will be seeking input from the advisory committees. They'll be putting out an announcement in a few weeks, and inviting people who would like to be on one of the workgroups to submit their information online.



Peter Levin, Chief Technology Officer, Department of Veterans Affairs and Farzad discussed the Blue Button project - progress so far and what lies ahead. Then Todd Park, U.S. Chief Technology Officer announced announced the first class of “Presidential Innovation Fellows” and the selection of the Fellows who will be working on Blue Button for America. He also quotes my friend Leonard Kish who said that "Patient Engagement is the Blockbuster Drug of the Century."

Now Is Not the Time for Regulations on NwHIN Governance

In the hyper partisan atmosphere of a national election there is a great debate on the proper role of government and the utilization of regulations versus free market approaches. I have always believed the meme promulgated by Tim O'Reilly and others that government functions best as a platform for innovation in the role of convener and collaborator. This is one of the bedrock principles of government 2.0. I'd encourage you to read "Open Government"  if this is a topic you are interested in. There is a great deal of overlap between open government and health information technology, especially as we look to digitize health records and provide interoperability while engaging patients in their care.

I have long thought that one of the best agencies within the federal government exemplifying government 2.0 and open government principles is the Office of the National Coordinator (ONC) for Health IT (see my post here for previous examples). Dr. Farzad Mostashari, the current National Coordinator, has continued and improved on this tradition. An example of that is the flexible and thoughtful approach taken to governance and health information exchange.

When the ONC asked for comments on their proposed governance for the nationwide health information network there was a chorus of responses that resoundingly asked to put the brakes on and take a more measured approach. One of the primary issues the governance attempted was to help create a framework for a strong trust fabric, which is necessary for health data exchange to scale. The rules were meant to provide the policies necessary to create and maintain this network of networks that would result in robust nationwide exchange. The HITECH has specific language which requires the ONC to establish a governance mechanism for the nationwide health information network.

NwHIN RFI had 66 questions regarding areas of proposed governance focusing on 5 areas:

• The establishment of a set of conditions for trusted exchange (CTEs)
• Validation process for entities to demonstrate conformance to the CTEs (and subsequently become an Network Validated Entity (NVE))
• Processes to update and retire CTEs
• Establishment of a process to classify the readiness of technical standards and implementation specifications to support interoperability related CTEs
• Approaches for monitoring and transparent oversight

There was very strong push back from the exchange community and many industry stakeholders were concerned that the process was moving much too quickly and a lighter approach should be considered. I joined with many groups in the process of responding to the RFI and shared many of these concerns. The NwHIN Power Team of the HIT Standards Committee also had some similar concerns. Across the board the comments indicated that the community thought that regulation at this time would actually slow the development of trusted exchange if it is implemented prematurely. And with the emerging governance activities of Healtheway for the eHealth Exchange (formerly NwHIN Exchange) and the work being done by DirectTrust.org to develop a strong trust fabric for the Direct community, a regulatory framework could actually stifle the process.

Well, the ONC was listening and have responded with a new approach. Dr. Mostashari and Jodi G. Daniel, JD, MPH who serves as Director of the Office of Policy and Planning at ONC gave an update to the HIT Policy Committee  on September 6, 2012 to outline their new approach to governance. Dr. Mostashari also posted a blog on the topic. It is important to note that the statutory requirement is to establish a governance mechanism, and that may not necessarily require rulemaking, but could leverage existing mechanisms. In any event there is no current legislative timeline requirement, so I appreciate that ONC is taking their time and being careful and flexible in their approach. I would encourage everyone to watch the webinar below:

ONC’s Proposed Strategy on Governance for the Nationwide Health Information Network Following Public Comments on RFI 

Nationwide Health Information Network Comes of Age

The Nationwide Health Information Network Exchange (NwHIN Exchange, or just Exchange) has been operating as an ONC program since 2007. For the past three years, a rapidly growing community of public and private organizations (Exchange Participants) has been routinely sharing information in production. That community now represents thousands of providers and millions of patients. Healtheway is new a non-profit, public-private partnership that will operationally support the eHealth Exchange (formerly referred to as the NwHIN Exchange).

On August 1, 2012, the Exchange Coordinating Committee appointed three representatives to serve on the Healtheway Board of Directors, including: Michael Matthews (CEO, MedVirginia), Paul Matthews (CTO, OCHIN) and Jan Root (CEO, Utah Health Information Network). These individuals, along with Healtheway’s Interim Executive Director, Mariann Yeager, will serve as the initial board of directors for the non-profit. The remaining Healtheway board seats will be filled by up to nine elected Healtheway members. The company launched its Member Program in August 2012, with elections for the member board seats expected in the Fall 2012.

"Transitioning the eHealth Exchange from a federal program initiative to a sustainable public-private endeavor marks a significant milepost for HIE in the U.S. The eHealth Exchange is demonstrating that secure, trusted and interoperable health information exchange on a nationwide scale is viable. As we look forward, we realize that success will only be possible through active collaboration with our public and private partners and with industry to shepherd nationwide HIE in the US to its full potential," said Mariann Yeager, Interim Executive Director of Healtheway.

In order to foster continued growth and advancement, there is a common goal to transition Exchange to an independently sustainable public-private partnership by October 2012. This will encompass at least 4 federal agencies (CMS, DoD, SSA, and VA) as well as 21 non-federal entities that can all share patient records for episodes of care. A year ago 500 hospitals were already connected, 30,000 clinical users, 3,000 providers, and a patient population coverage area of 65 million people, and 1 million shared records. These number have certainly continued to grow, and Healtheway will support the continued progress by supporting and enabling health information exchange that is trusted, that scales, and enhances quality of care and health outcomes by supporting comprehensive longitudinal health records.

Michael Matthews, CEO of MedVirginia, and a Healtheway board member and President said, "Will Rogers once said, even if you’re on the right track, you’ll get run over if you just stand there. We’re very proud of being on the “right track” with Exchange over the past few years. Much has been accomplished….and, there’s much left to be done. We are confident and excited about the Healtheway processes and business model to support the scalability and growth of Exchange. We are driven by the value created from the continued expansion of Exchange."

The Exchange Coordinating Committee has been working since 2009, and the primary purpose is to enhance trust relationships between participating organizations by fulfilling responsibilities described in the Data Use and Reciprocal Support Agreement (DURSA). The Coordinating Committee is the group that is managing this effort, voted on March 1, 2012 to approve a plan that maps out the strategy, sustainability model, and operational transition of NwHIN Exchange to a non-profit organization. As the planning process has unfolded, it is important to note the DURSA remains in full force and effect and the Coordinating Committee retains all authorities as specified in the DURSA. The Healtheway board will not have any oversight responsibilities with respect to Exchange, but will operate under a Master Services Agreement with the Coordinating Committee so that the Exchange trust framework remains unchanged.

There has been a Joint Exchange/EHR–HIE Interoperability Workgroup (IWG) Testing Task Group to collaborate on the development of test packets that satisfy both programs. The IWG and Exchange plan to use the work products vetted by this group for a robust conformance and interoperability testing and certification process of EHR-HIE systems. The Testing Task Group includes representatives from states, federal agencies, HIEs, health systems and vendors. In addition, ONC Authorized Testing and Certification Bodies (ATCBs) have observed and contributed as subject matter experts. The latest proposed test approaches are available here.

There are clear benefits already to NwHIN Exchange. The VA is sharing patient records among not only numerous VA hospitals but also non-military and private providers. There is also work under way to use Exchange to enable smoother transitions of care between the DoD, VA and the private counterparts that provide more than 50 percent of a military veteran’s care. At the Social Security Administration sharing data via NwHIN-Exchange has dramatically cut disability determination with 10 percent of claims filled in one to two days. Ultimately the value of this infrastructure is huge for all patients.

I am very excited about the progress made so far and look forward to the exciting new phase of the nationwide health information network Exchange. We are truly entering a new era...

Stage 2 Meaningful Use - Patient Engagement and HIE

Some of the most important changes in the rules for Stage 2 Meaningful Use and the 2014 Edition Standards & Certification Criteria (S&CC) are around patient engagement and health information exchange. While these requirements were backed off some from the proposed rule, there is still a strong emphasis on these aspects of the program. I think these are two of the most critical aspects of meaningful use and could help us eventually achieve the goals of improving the patient experience and lowering healthcare costs.

One new Stage 2 Meaningful Use Core Objective that all providers must meet is to use secure electronic messaging to communicate with patients on relevant health information. Another new Stage 2 Core Objective that all providers must meet is to provide patients the ability to view online, download and transmit their health information within four business days of the information being available. The specifics require that 50% of all unique patients are given access to information, and that five percent (down from 10% in the proposed rule) are able to view, download or transmit to a third party relevant health information. These measures require patients to take action in order for a provider to achieve meaningful use and receive an EHR incentive payment.

In the proposed rule CMS would have required 10% of patients to send a secure message, and 10% to actually view, download or transmit relevant information contained in the longitudinal record. But the final rule reduced these thresholds to 5%. The continued implementation of patient portals and PHRs incorporated into EHR functionality could make this an achievable goal if care providers implement and then offer them to their patients.

The American Hospital Association had reacted strongly to the proposed rule, stating that the requirements "raise the bar too high and are not feasible for the majority of hospitals to achieve." And in a statement indicated they were still not entirely pleased with the final rule. "While we appreciate that CMS has allowed for a shorter meaningful use reporting period for 2014," they said, "we are disappointed that this rule sets an unrealistic date by which hospitals must achieve the initial meaningful use requirements to avoid penalties. In addition, CMS complicated the reporting of clinical quality measures and added to the meaningful use objectives, creating significant new burdens."

The Health Information Management and Systems Society (HIMSS) noted in a statement that the final rule both adopts and concurs with a number of HIMSS recommendations made in comments on the proposed rule. Specifically they were pleased that the rule appears to streamline the administrative process of certifying EHR products. However, there did not appear to be any emphasis on utilizing mobile technology. I spoke with Pam Matthews, RN, MBA, the Senior Director of Regional Affairs at HIMSS who said, "We had made comments in several places where mobile could be considered in terms of being a benefit for patient engagement and data exchange, yet in the final rule they remained silent on mobile. HIMSS supports the development of guidelines to achieve transitions of care through patient centered mobile interfaces. We encourage consideration of including mobile health technology in future stages of meaningful use."

Stage 2 criteria also place an emphasis on health information exchange between providers to improve care coordination for patients. One of the core objectives for both eligible providers (EPs) and eligible hospitals and Critical Access Hospitals (CAHs) requires providers who transition or refer a patient to another setting of care or provider of care to provide a summary of care record for more than 50% of those transitions of care and referrals.

There are also new requirements for the electronic exchange of summary of care documents:

• For more than 10% of transitions and referrals, EPs, eligible hospitals, and CAHs that transition or refer their patient to another setting of care or provider of care must provide a summary of care record electronically.
• The EP, eligible hospital, or CAH that transitions or refers their patient to another setting of care or provider of care must either 

1. conduct one or more successful electronic exchanges of a summary of care record with a recipient using technology that was designed by a different EHR developer than the sender's, or
2. conduct one or more successful tests with the CMS-designated test EHR during the EHR reporting period.

There is also a movement in the right direction for interoperability under the S&CC rule with the cementing of data content utilizing Consolidated CDA, CCD/C32 and CCR standards which is imperative to a platform all stakeholders can now design for. Also, including Direct Project as a requirement for transport is a smart move. You can use it with XDM, or with XDR (over the Exchange SOAP Stack)

The exchange requirements are a bit weaker than in the proposed rule and elicited some robust discussion from a post by Wes Rishel on the subject. The discussion thread is very interesting and Wes adds some clarity to his comments. The whole issue is from statements made by Farzad Mostashari, MD, ScM the National Coordinator for Health Information Technology. I highly recommend you listen to them HERE. He gives an artistic and eloquent rendering of a segment of the final rule, which also contains a warning:

"We continue to believe that making vendor-to-vendor standards-based exchange attainable for all meaningful EHR users is of paramount importance. In that regard, and as we look toward meaningful use Stage 3, we will monitor the ease with which EPs, eligible hospitals, and CAHs engage in electronic exchange, especially across different vendors EHRs," Dr. Mostashari read, "If we do not see sufficient progress or that continued impediments exist such that our policy goals for standards-based exchange are not being met, we will revisit these more specific measurement limitations and consider other policies to strengthen the interoperability requirements." 

He the said, "I want there to be no question about the seriousness of our intent on this issue. The bottom line is it's what's right for the patient and it's what we have to do as a country to get to better healthcare and lower costs."