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."

Rules for Stage 2 Meaningful Use

The U.S. Department of Health and Human Services has announced the release of the final rule for Stage 2 of meaningful use and ONC has updated the standards and certification criteria. When these rules were proposed they received over 6000 comments.

Through the Stage 2 requirements of the Medicare and Medicaid EHR Incentive Programs, the Centers for Medicare & Medicaid Services (CMS) hopes to expand the meaningful use of certified EHR technology. Certified EHR technology used in a meaningful way is one piece of a broader health IT infrastructure needed to reform the health care system and improve health care quality, efficiency, and patient safety. “The changes we’re announcing today will lead to more coordination of patient care, reduced medical errors, elimination of duplicate screenings and tests and greater patient engagement in their own care,” Secretary Sebelius said.

The Office of the National Coordinator for Health Information Technology (ONC) rule proposes the capabilities and related standards and implementation specifications that Certified EHR Technology will need to include to, at a minimum, support the achievement of "meaningful use" by eligible health care providers beginning with the EHR reporting periods in FY/CY 2014. The rule also provides revisions to the permanent certification program for health information technology, which include changing the name of the program to the "ONC HIT Certification Program."

In this rule, CMS will maintain the same core and menu structure for the program for Stage 2. For Stage 2 EPs must meet or qualify for an exclusion to 17 core objectives and 3 of 5 menu objectives. Eligible hospitals and CAHs must meet or qualify for an exclusion to 16 core objectives and 2 of 4 menu objectives.

There are at least three focus areas in the requirements for stage 2 meaningful use:

• Standard data formats that allow health data to be captured and shared
• Patients must have the ability to download, view and transmit their health information
• Quality reporting is expanded

The Stage 2 Meaningful Use requirements will:

• Make clear that stage two of the program will begin as early as 2014. No providers will be required to follow the Stage 2 requirements outlined today before 2014.
• Outline the certification criteria for the certification of EHR technology, so eligible professionals and hospitals may be assured that the systems they use will work, help them meaningfully use health information technology, and qualify for incentive payments.
• Modify the certification program to cut red tape and make the certification process more efficient.
• Allow current “2011 Edition Certified EHR Technology” to be used until 2014.

The CMS final rule also provides a flexible reporting period for 2014 to give providers sufficient time to adopt or upgrade to the latest EHR technology certified for 2014. In the Stage 1 meaningful use regulations, CMS established an original timeline that would have required Medicare providers who first demonstrated meaningful use in 2011 to meet the Stage 2 criteria in 2013. The Stage 2 rule delays the onset of Stage 2 criteria. Any provider that attests to Stage 1 of meaningful use in 2011 or 2012 will attest to Stage 2 in 2014 instead of 2013. Therefore providers will not be required to demonstrate Stage 2 of meaningful use before 2014. A fact sheet on CMS’s final rule is available at http://www.cms.gov/apps/media/fact_sheets.asp.

Changes in the rule from Stage 1 Meaningful Use include:

• Substituting “transitions of care” for “exchange of key clinical information” as a core objective, and providing patients electric and online access to their health records instead of providing electronic copies of the information.
• Adding two new core objectives: using secure electronic messaging to communicate with patients, and automatically tracking medications from order to administration using assistive technologies in conjunction with an electronic medication administration record (eMAR.)
• Allowing a batch reporting process for attesting to meaningful use, allowing information to be submitted in one file.
• Reducing the patient engagement thresholds from 10 percent to 5 percent.
• Reducing the threshold for sending summary-of-care records for care transitions and referrals from 65 percent to 50 percent, and requiring at least one exchange with a provider using EHR technology from a different vendor.

The ONC rule describes standards and certification criteria changes, including:

• Adopting certification criteria for transitions of care ensuring EHR technology supports standards-based electronic health information exchange.
• Requiring that test reports for EHR certification be publicly available, with developers following specific price transparency practices.
• Allowing “gap certification” for certain criteria, which ONC says will make the process more efficient.

I will be publishing a deeper analysis after reviewing the new regulations.

UPDATE

After reading Steven Posnack's tweet below I uploaded the slides and embedded them:

Check out "do you have CEHRT"infographics healthit.gov/policy-researc…
— Steven Posnack (@HealthIT_Policy) August 23, 2012

Do you have EHR Technology that meets the new Certified EHR Technology definition for Meaningful Use Stage 2? 

Do you have EHR Technology that meets the new Certified EHR Technology definition for Meaningful Use Stage 1? 

Automate Blue Button Initiative

There has been significant progress in the Blue Button Initiative and some new initiatives that will tie into this work. Out of a collaboration convened by the Markle Foundation, several agencies of the federal government have taken leadership roles in developing Blue Button. The U.S. Department of Veterans Affairs, Medicare, and TRICARE developed their Blue Button offering as part of a robust public and private sector collaboration and now offer hundreds of thousands of individuals the ability to download their medical records or claims information from their secure websites. Now several other organizations from both the public and private sector have pledged to offer similar download capabilities for their patients and members. The whole concept of Blue Button came about from the idea that people should be able to access and download their own health information.

Blue Button lets patients download their own health information in a simple, readable format that they can share with their doctors or other people they trust. Blue Button actually began back on August 2, 2010 when the President announced that Department of Veterans Affairs beneficiaries would be able to download their personal health information from their online accounts due to the new Blue Button offering. After the VA's Blue Button became operational the initiative was made nationally available in October 2010. Since then, Medicare and TRICARE have begun offering their beneficiaries a Blue Button, and private payers have implemented the technology as well. In January 2012 the Office of Personnel Management asked health insurers in the Federal Employees Health Benefit Program to add Blue Button functionality to their websites. UnitedHealthcare and Aetna have also begun offering Blue Button access to their Personal Health Record (PHR). President Barack Obama signed Executive Order 13571: Streamlining Service Delivery and Improving Customer Service in April 2011. This Executive Order called on U.S. government agencies to improve how they delivered customer service and required each agency to announce a "signature initiative" to improve customer service using technology.

I attended the Health Data Summit at the Whitehouse in June of 2012 where we discussed the idea of allowing automated Blue Button downloads based on trigger events and patient preferences. An array of individuals, groups, and organizations signed up at the meeting to help in a project to achieve this. We also heard about the new Presidential Innovation Fellows program, which seeks developers for short-term technology assignments, and includes a project designed to spread the use of the Blue Button. Shortly after the summit a new S&I Framework Initiative called RESTful Health Exchange (RHEx) was launched which seeks to develop specifications for secure RESTful transport for healthcare exchange.

ONC has now announced the new effort called the Automate Blue Button Initiative (ABBI) to develop standards and specifications that would allow patients to not only download their health information, but also to privately and securely automate the sending of that data to their preferred holding place. This is going to be a really big deal. This project needs developers to pilot the technology and patients and providers to then test that it works. There will be some valuable use cases that will potentially be deployed. For example, this initiative could enable patients to have their doctors or insurance companies automatically “copy them” on any updates to their personal health information. In another scenario, patients could “subscribe” to feeds that privately and securely give them updates to their health information, much as they currently subscribe to podcasts and news feeds.

The kick off call for the project is on August 15th at 4:00 pm Eastern Time. Then in September ONC will host the 2012 Consumer Health IT Summit where we should hear about the rapid progress I am expecting this initiative to achieve. A highlight from last years summit (which was webcast live) was the talk from former CMS Administrator Don Berwick, MD where he discusses the properties of goodness of a healthcare system:
safe, effective, patient-centered, timely, efficient, and equitable care. He also shares some personal stories about health IT and the importance of empowering patients with data and making them partners in their care. The ABBI will help bring his vision to fruition.

HIMSS Oregon Celebrates National Health IT Week

Health information technology improves the quality of healthcare delivery, increases patient safety, decreases medical errors, and strengthens the interaction between patients and healthcare providers.
To mark the important role health information technology plays in improving healthcare delivery in America, HIMSS Oregon and others across the U.S. have joined together to celebrate National Health Information Technology (NHIT) Week , September 10-14, 2012.

With the NHIT Week theme: One Voice, One Vision: Transforming Health and Care, HIMSS Oregon will hold a Tech Talk entitled “Coordinated Care Organizations ~ Where Oregon is Now” which will take place Thursday September 13th, 5:00pm - 9:00pm at OHSU’s BICC Building in the Gallery, 3181 SW Sam Jackson Park Rd., Portland, OR 97239.

“Our participation in National Health IT Week highlights our organization’s commitment to ensure health information technology is integrated, interactive, interoperable, and intelligent to provide the best patient outcomes, said Mark Fromuth, HIMSS Oregon Chapter President. “By working together we can leverage the technology to promote for the betterment of our healthcare system.”

The event on September 13th will bring HIT practitioners together to discuss where Oregon is headed with health care IT, and will officially be conducted as a part of HIMSS’ National Health IT Week. The briefing is open to the public.

Cost: $15.00 for HIMSS members and Students; $25.00 for non-members.

Drinks and Appetizers will be provided while a panel of CCO specialists interact and share Oregon’s developments and progress.

To register: Please go to website: https://secure100.telusys.net/tcsc-bin/sregdisplay?&ctid=1696121847441156&rtid=3642555352861863

Credentialed media representatives please RSVP to Raina McSherry, raina.mcsherry@himss-oregon.org, 503-970-9105.  For additional information about National Health IT Week, visit www.healthitweek.org .

About HIMSS Oregon
The Oregon Chapter of the Healthcare Information and Management Systems Society is a professional organization dedicated to the development of healthcare information technology professionals throughout the state Oregon and southwest Washington. Our mission is to bring healthcare professionals together with their clinical and business partners in educational settings to explore issues of common concern, network with peers, and grow professionally by sharing knowledge and experience and by learning about new tools, methods and technologies.

About National Health Information Technology Week
Now in its seventh year, National Health IT Week is a collaborative forum assembling key healthcare constituents—vendors, provider organizations, payers, pharmaceutical/biotech companies, government agencies, industry/professional associations, research foundations, and consumer protection groups— working together to elevate national attention to the necessity of advancing health IT. Log onto www.healthitweek.org  for more information.