Health Information Exchange

It is time for the U.S. to begin implementing health IT smartly

From a national policy perspective, ICD-11 is not found anywhere on the U.S. dial.   Not even a preliminary roadmap to ICD-11 has been proposed.   I believe this to be a serious risk to our nation’s health IT planning efforts, and this risk has been inherent to U.S. health IT planning for decades.   The recent ICD-10 delay magnifies this strategic flaw.   It is time for CMS to take a deep breath, re-evaluate our national strategy, address the unmitigated strategic risks and determine whether any mid-course corrections are needed before deciding on the new ICD-10 implementation date.  It is time for the U.S. to begin implementing health IT smartly.  

What I see right now is the U.S. planning to achieve a short-term tactical goal of getting off antiquated ICD-9 while the rest of the world is focusing on the long-term strategic goal of developing and adopting the new-century ICD-11.   Unless we take action now, we are destined to be in the same predicament in the 2020s when we will be struggling to get off of last century’s ICD-10.   

But the stakes will be much higher in the 2020s.  

Most physicians and hospitals will be using EHRs, health information exchange will be flourishing, SNOMED-CT will be the common vocabulary used by clinicians and big data analysis will be... well, big.  We will be stuck, though, with an ICD-10 taxonomy that was developed before the Internet came into common use.   We will be clamoring for ICD-11 because it was developed in alignment with SNOMED and for other reasons I and others have previously described.  Delays will likely be encountered.  And we will probably be amnesic about how we got into such a predicament.  

To avoid this we need a U.S. roadmap to ICD-11 before deciding when to implement ICD-10.   We need to determine our long-term goals and then align our short-term tactical plans to those goals.   What if ICD-10 is delayed another year?   Would it then be time to leapfrog to ICD-11?    What if the delay is 2 years?   How about 3 years?   Or maybe to meet our long-term goals it is actually time to leapfrog now.   But without establishing long-term goals and developing a proposed roadmap to ICD-11,  we cannot really make an informed decision. 

Yes, we have to get off ICD-9, but not at any and all costs.   I want the U.S. to change health IT planning efforts from one that risks derailment from ostrich-style decisions to one that smartly develops long-term strategic goals and aligns them to tactical plans.  I want us to be a country that leads the world in the use of health IT to improve quality of care and one that smartly plans to optimize health IT use each decade.

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MM


EHR Interoperability is a Nervous System

For those familiar with using email applications such as Outlook, Gmail or Apple Mail, it might not seem like it should be very hard to send and receive electronic health information.   But as it turns out, maintaining privacy, security, HIPAA compliance and electronic patient consent is very complex when exchanging electronic health data over the Internet.   It is not easy even for physicians and hospitals using fully functional EHRs.

Virtual Scenario:  Imagine that your patients’ electronic medical records are packaged in individual charged impulses that can propagate along the axons of a national health IT nervous system. This neuronal circuit provides the infrastructure needed to send one of those charged impulses containing the right information on the right patient to the right receiving provider whenever and wherever needed. As physicians know, the charged impulses will propagate along the tubular-shaped axon until they reach the terminal end, which does not directly connect with another axon. Instead, there is a gap or synapse which prevents the impulses from proceeding unless an intermediary event occurs. This constraint prevents chaotic, asynchronous transmissions of impulses that would result in unwanted movements or seizures. So, trusted intermediaries (i.e. neurotransmitters, ions) are needed at the gaps or synapses to enable axons to “talk” with one another in a standard and controlled manner. This allows the charged impulses to proceed in a synchronous manner. The axons, gaps, synapses and intermediaries must work together, or be “interoperable”, so that the charged impulses travel in a secure, coordinated manner all the way to their intended destination.

In this scenario the imaginary national health IT nervous system is analogous to the real-life health IT infrastructure being developed at the national and state levels through National Health Information Network (NHIN) Direct project and the State Health Information Exchange (HIE) Cooperative Program.   The charged impulses represent each patient’s electronic health information.  The axons represent each physician’s cable to the Internet.   The gap or synapse represents the present-day constraints on our ability to send and receive electronic health information to one another.   The trusted intermediaries represent local health information exchanges (local HIEs) and health information service providers (HISPs) that allow each physician’s axon to communicate through the Internet with axons from other physicians and hospitals.  The interoperability needed among all parts of the virtual health IT nervous system is analogous to the interoperability needed among all parts of the real-life health IT infrastructure including EHRs, local HIEs and HISPs.

The Nationwide Health Information Network (NHIN), through the NHIN Direct project, defines standards, services and policies at a national level for health IT interoperability.  At the core of NHIN Direct are trusted intermediaries that physicians can connect to in order to allow electronic health information to traverse the synapses between their axons and those from other physicians and hospitals.   These trusted entities are called health information service providers (HISPs). HISPs are able to authenticate the senders and recipients of electronic health information.   This provides verification regarding who really sent information and who really received it while also maintaining privacy and security while the data passes across the axonal synapses.

The Office of National Coordinator for Health IT (ONC) is making an effort to trickle down NHIN Direct standards and protocols to each state.   Through the State HIE Cooperative Program, ONC grants funds to states who submit plans to build statewide health IT infrastructure to support interoperable health information exchange.   In order to be funded the states must adhere to NHIN Direct standards.

For example, the Texas Health Services Authority (THSA) is using the grant funds to serve as a statewide convening entity that has gained consensus from a broad base of healthcare stakeholders on a three-pronged strategic plan for HIE in Texas:

  1. Local HIE Program— Local HIEs are another type of trusted intermediaries, like HISPs, that physicians can connect to in order to allow electronic health information to pass across the synapse to the axons of other physicians, labs, radiology centers, hospitals or others with electronic health information. Twelve local HIEs were launched in 2011-2012 with partial funding through the THSA’s Local HIE Grant Program. Some are currently operational and actively providing HIE connectivity to physicians and hospitals in their area 
  2. State-level IT infrastructure and services—The goal is to develop statewide infrastructure and services that can be used by local HIEs to help them provide HIE services locally as well as to enable exchange of data from one HIE to another (statewide HIE services); also to support a transparent governance structure and develop policies and strategies that guide maturation of statewide health IT infrastructure
  3. “White Space” initiative—The goal is to make available basic health information exchange services to physicians and hospitals in regions of the state without local HIEs (the “white space”) by creating a marketplace of health information service providers (HISPs); physicians can apply for “vouchers” from THSA to offset the initial costs of connecting with the HISP they select.
Physicians should stay abreast of health IT interoperability efforts like these, especially those in their own communities like the local HIE efforts in Texas.  Physician input and involvement in these initiatives helps ensure health IT is spliced into the healthcare industry's genome in way that promotes high quality care.

Keep the data collection cart behind the trailblazing horse

In today's Health IT News there is an article expressing dissappointment with the recently released proposed rules for Stage 2 of the Electronic Health Record (EHR) Incentive Program.   Some alarming viewpoints are evident in this article regarding the collection of data for use by the federal government to improve public health .

The proposed rule for Meaningful Use Stage 2 on page 13702-13703 specifically states that the purpose of Stage 2 Meaningful use is to "“encourage the use of health IT for continuous quality improvement at the point of care and the exchange of information in the most structured format possible”.    No where in the rule does it state that the primary purpose of Stage 2 Meaningful Use is to collect data for use by the federal government as is suggested by concerns expressed in this article.   Let's keep the data collection cart behind the trailblazing horse so that it does not aimlessly roll down the steepest part of the hill instead of steering toward most beneficial path.   Stage 2 objectives draw a sensible roadmap to the next planned destination where we can finally begin realizing the maximum potential value of health IT and EHRs.   We currently have the horse trotting around potholes toward the widespread adoption and successful use of EHRs, the development of robust HIE networks, the maturation of EHR product functionalities and an improved understanding of safe EHR usage.   If we fail to align Stage 2 activities with Stage 2 goals by taking unplanned shortcuts to collect and use data in hopes of improving care now, I fear the cart will crash and cripple the momentum that Stage 1 has initiated.


Progress being made to splice information technology into the healthcare industry's genome in Texas

It's amazing-the progress being made to splice information technology into the health care industry's genome.   When I first dove into health IT a decade ago the use of electronic health records (EHRs) was dismal and healthcare stakeholders rarely sat at the same table with mutually beneficial, collaborative objectives in mind.   Even within the same healthcare organization it was not uncommon for individual department leaders to disrupt an integrated health IT effort in order to protect some of their department's self-interests.   Less than 5% of hospitals had implemented fully functional computerized provider order management (CPOM) systems; less than 1 in 5 physicians were using an ambulatory EHR; and less than 5% of those were fully functional EHRs.    Today the percentage of physicians and hospitals using robust EHRs is rising at a rate that was unthinkable back then.  

This progress parallels the launch of health IT initiatives established through the federal HITECH funds such as the EHR Incentive Program.   In the past two years these funds have been a catalyst here in Texas to engage diverse groups of healthcare stakeholders  to use health IT to improve quality of care.   As a result:  

  • Increasing numbers of Texas physicians are using EHRs (approaching 50%)
  • More and more hospitals are using CPOM
  • Over a dozen of community-wide health information exchanges (HIEs) are up and running
  • New health IT workforce training programs are established
  • Four regional extension centers were formed covering all geographic areas of the state and are doing a phenomenal job assisting thousands of physicians with EHR selection, implementation and meaningful use
  • Texas became the first state to have it’s HIE plan approved by ONC
  • Texas was one of the first states to stand up the Medicaid EHR incentive program making our program a model for other states
  • Texas was one of four to receive a SHARP grant
  • And Texas leads the way with the number of physicians attesting to meaningful use; Texas physicians and hospitals have received over $270 Million in EHR incentives

This rate of progress is only possible when individuals with diverse backgrounds and from different healthcare stakeholder groups are able to collaborate.  In Texas these stakeholders have demonstrated an ability to park their self-interests in order to drive forward with a common vision to improve the quality and delivery of patient care in our communities.


Health Information Exchanges and Physicians Share Accountability for Safe Patient Care

The $800 billion 2009 American Recovery and Reinvestment Act (ARRA) set aside $36 billion toward health information technology (health IT) initiatives, including over $500 million for the State HIE Cooperative Program.  This federal program provides funds to each state for the successful planning and development of infrastructure that supports the exchange of electronic health data between physician electronic health records (EHRs), hospital EHRs, lab systems, radiology centers and other clinical IT systems.    For example, in Texas we are using these funds to support the development of local health information exchange entities, called HIEs, across the state and to concurrently develop the policies, standards and infrastructure needed to safely/securely connect these HIEs to each other.     The statewide HIE network will also be built to be compatible with national standards and efforts.      

Each state's effort to develop a network of community HIEs and/or a statewide HIE will be more successful with physicians involved upfront with governance and policy development.   When working with local HIEs most physicians will generally understand and appreciate the importance of protecting the privacy and security of electronic patient health information.  Their inherent knowledge on this issue will help guide policies in the right direction.   A more complex issue for physicians to understand is the relationship between HIEs and patient care.   A heightened awareness of this issue will allow physicians to properly inform HIE policymakers about the need to establish an environment where local HIEs, HIE networks and physicians share accountability for safe patient care.   

To deepen physician's understanding of this issue I encourage them and others to think about an HIE as a tool physicians use as a part of patient care, similar to a surgical tool.   If a patient is harmed by a surgical tool that broke because the physician used it incorrectly, the physician is negligent.  If the physician used the tool correctly but it still broke, but it has only broken 8 times in over 10,000 surgeries and the patient consent explains this remote risk of breakage, then no one is negligent.  However, if it broke and the issue had been reported to the vendor by many physicians on a repetitive basis, but the vendor failed to investigate the issue and fix the problem, or failed to inform physicians and patients of the increased risk in the meantime, then the vendor is negligent. 

This perpsective will help physicians advocate for policies that lead to an environment where HIEs and physicians share accountability for safe patient care.   Effective policies will lead to contracts and agreements which acknowledge that:

  1. HIEs and HIE infrastructure are tools used by physicians during the course of patient care
  2. HIEs are responsible for informing patients and doctors about the inherent risks of  the electronic health information exchange including changes in risks when issues are identified
  3. HIEs have a responsibility to continually monitor for and mitigate risks associated with their services that may impact quality of care provided by physicians

 


Bipartisan Health IT Support and ARRA Insulate EHR Incentive Funds From Budget Cuts

A physician colleague recently asked me why I am confident that CMS will not cut off EHR incentive funding in the future.   This question is important to him and other physicians who plan to qualify for up to $44,000 in CMS incentive payments by achieving the meaningful use of EHRs.   They fear that the dragging economy and political discord will result in budget reductions that will cut this and other important health IT funding programs.    What I see, though, is a decade-long track record of bipartisan support for health IT initiatives and a 2009 federal law that requires CMS to provide funding for the EHR incentives and other health IT programs.

In his 2004 State of the Union speech President Bush envisioned the adoption of EHRs for all Americans by 2014.   Since then bipartisan support at both the state and federal levels for health IT initiatives toward the achievement of that vision has held strong.   At the federal level CMS  not only established a new office in 2004 to support health IT, the Office of the National Coordinator of Health IT (ONC) but has also increased funds to support ONC initiatives which promote the adoption and use of EHRs.  CMS works collaboratively with ONC and has consistently shown an understanding that the broad adoption and effective use of EHRs are necessary to better manage spiraling healthcare costs.   CMS understands that the data captured by EHRs is superior to claims-based data when attempting to analyze quality and establish benchmarks.    Physicians have long complained that claims-based data is incomplete and does not fairly demonstrate the quality of care they provide.     EHRs must be broadly adopted in order to capture accurate and meaningful data that can then be used to improve quality or save costs.  

It is important to recognize that CMS is required to provide EHR incentives to physicians by law.   Specifically, the $800 billion American Recovery and Reinvestment Act (ARRA) of 2009, commonly refered to as the Stimulus Bill, allocates over $36 billion to health IT programs through the Health Information Technology for Economic and Clinical Health (HITECH) Act.   This funding includes an estimated $34 billion for the Medicare and Medicaid EHR Incentive Program and over $300 million to support state-wide health information exchange efforts.

In order to cut funding for EHR incentives, this means that bipartisan support would have to be garnered in the House and Senate to rescind ARRA or part of ARRA.   The intent of ARRA  initiatives is to stimulate economic activity and produce jobs.   In the current economic environment it would seem very risky, perhaps even foolish, for a politician to drum up support for new legislation that eliminates economic stimulus activity, especially if that activity is already producing jobs.

So, is the EHR Incentive Program stimulating the economy and producing good jobs?   I am not an economic expert, but from what I see around me the answer is clearly, "yes".    I see job openings in the local paper for healthcare system IT analysts and other staff, I speak with IT consultants most of whom are actively seeking personnel, I hear about physician offices investing into the economy $10,000-$70,000/doctor to implement EHRs or upgrade other office technologies, I read about physicians receiving $44,000 federal incentive payments and about hospitals receiving larger amounts, some of which is surely returned into local economies.  The graph below is a composite view of the 3-year stock performance of the health IT sector since 2009.   EHR vendors and other health IT companies appear to be thriving well since ARRA was passed despite the depressed economy.

HIT Sector performance

I suspect that several years from now when experts analyze the impact of the $800 billion stimulus package, the puny $36 billion provided to health IT initiatives through the HITECH portion of ARRA will go down as perhaps the most bang for the buck in terms of stimulating the economy.  

The EHR incentive funds appeared to be well insultated from budget cuts for these same reasons. 


Texas Medical Association video provides in-depth look at meaningful use, how RECs can help physicians

This video does a good job of describing Meaningful Use, the electronic health record (EHR) incentive program and how the four regional extension centers (RECs) in Texas leverage federal grants to subsidize services for physicians that help them select/implement or upgrade an EHR, and then use their EHR to improve quality of care and meet the Meaningful Use requirements.  

The four RECs in Texas currently charge primary care physicians only $300 for consulting services valued at $5,000.  These services include:

o    Select and implement a certified EHR (or upgrade your current EHR to a certified version)

o    Optimize your practice workflow,

o    Achieve meaningful use,

o    Qualify for EHR incentives, and

o    Obtain CME credit hours      

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Community HIE decisions are best made in collaboration with local physicians who use EHRs

Physicians who use electronic health records (EHRs) in their offices are increasingly being called upon in their communities to participate in the development of local health information exchanges (HIEs).    During the early stages of HIE planning there are important decisions that are best made in collaboration with local physicians.   As with any health information technology usage, the anticipated benefits of exchanging electronic health data must be balanced against the inherent risks of the technology.   Physicians who use EHRs already have valuable experience with some of the inherent risks associated with electronic health data usage, but may not have experience with the clinical risks associated with the exchange of electronic health data.    The following case scenarios are intended to raise awareness and understanding of key patient safety risks associated with the clinical use of electronic personal health information (PHI) that could be obtained through a community-wide HIE.  

Conflicting data scenario:  A nurse records a penicillin allergy in the hospital EHR when a patient experiences GI symptoms after receiving a penicillin injection.   The next day, the patient is seen by her primary care physician (PCP).   After reviewing the history, the PCP is convinced that the reported symptoms were unrelated to the penicillin injection.   She records “No Known Allergies” in her office EHR.   The local HIE retrieves “allergies” from both EHRs and displays this patient’s allergies as both “no known allergies” and “penicillin.”  

In such cases, the physician will have to reconcile the data by considering the sources, dates, and times of each and decide whether additional investigation is necessary.   

Segmented data scenario (this applies only if the HIE will allow patients to exclude some or all of their data as a part of the consent process):   For privacy reasons an HIV patient decides to exclude his diagnoses from the HIE which results in a problem list so that it does not disclose his HIV status.   He also excludes data from two sources: his psychiatrist and a psychiatric hospital.   This patient had suffered an episode of neuroleptic malignant syndrome secondary to an antipsychotic medication a year ago while under the care of the psychiatrist at that hospital.   Since records from the psychiatrist and hospital are excluded, the HIE will not contain this information.   A physician viewing the patient’s information through the HIE will see no record of the patient’s susceptibility to a life-threatening event from a certain class of medications.  

Informing the viewing physician that the patient has excluded some data from the Problem List and some data from both a physician and a hospital may prompt important additional questions and dialogue with the patient that could prevent an avoidable adverse event.  

 Clinical Risk Management

Community-wide HIE initiatives are increasingly turning to local physicians who use EHRs to assist with assessments of both the benefits and risks associated with the clinical use of electronic health data shared across their community.  The clinical risks outlined in these scenarios can be managed through the following principles: 

1.  An HIE must provide physicians access to the source, date and time for all displayed data

 2.  An HIE must alert clinicians when data or data sources are excluded  

  • The alert should specify the type of data (“lab results”) or type of source (“hospitals”) that have been excluded from the HIE through the patient consent process

3.  An HIE must inform physicians about:

  • The patient consent policy used by the HIE (and of policy changes when they occur
  • A list of the specific types of data they are generally able to access through the HIE
  • A list of the specific sources of data that the HIE exchanges with

Improve Physician Leadership Through Recruitment, Education and Training

A recent discussion among my colleagues about increasing physician leadership in this age of electronic health records (EHRs), Meaningful Use, healthcare reform and Accountable Care Organizations (ACOs) caused me to think about how a physician even starts to go about becoming a leader.   I considered physicians in my own community who are recognized leaders and appreciated that their rise to leadership started by simply getting involved in something.   Their leadership was born out of getting involved just like my colleagues were doing when they began discussing solutions to this particular issue!

Getting involved is a common attribute of physician leaders because there is obviously little merit or trust when a physician leads an effort without previously participating in a similar effort.   Participation is the initial step to gain such trust.   Once a physician gets involved with a successful initiative their community deposits a “coin of trust” into his pocket.    If the physician obstructs progress, though, some coins of trust are removed.   A physician who eventually collects a pocketful of coins is looked upon as a trusted “community leader” who is knowledgeable and experienced, even if he did not actually “lead” any effort.  This is because many successful healthcare initiatives are known to be moved forward by people who are catalysts for collaboration and effective at resolving conflicts between stakeholders.   One does not have to be an ACO board chairman or a formal project leader to be such a catalyst.  In fact, it is often advantageous to be in a more neutral position when exerting that type of influence.

So an increase in physician leadership will initially involve an increase in physician participation in healthcare initiatives.   A good place to start is with local health initiatives such as a Regional Extension Center (REC), health information exchange (HIE)  or Accountable Care Organization (ACO).   Participating in a local initiative provides physicians with the valuable experience of working together, perhaps for the first time, with multiple stakeholders.  Physicians will see the types of communal efforts that are successful at promoting change.  They will gain valuable knowledge about healthcare reform, health IT or other important topics.   They will learn how public policy is developed. They will encounter the frustrations and complexity of efforts that fail.   But they will learn to keep their focus on the long term and not be deterred by a short term failure that they come to realize will not matter at all in 40 years.     

Understanding this process illuminates a path to increase physician leadership.  It starts with the active recruitment of physicians into local, statewide or national activities.  It is accelerated through concurrent education and training to hone leadership skills.  County and state medical societies, who have established physician relationships and are experienced with physician education/training, are ideal entities to facilitate the growth of leadership.  The medical societies could actively identify new and ongoing healthcare initiatives and contact them to ensure there is adequate physician participation.   They could also assist with physician recruitment and training when needed.


Why should primary care physicians enroll for Regional Extension Center services?

Why should primary care physicians sign up for REC services?   What are the unique selling points and assistance they will receive as compared to other consultant organizations?  

These are excellent questions I am hearing from physicians in Texas regarding the four RECs that cover our entire state.  The RECs are subsidized by the federal government through the Health Information Technology for Economic and Clinical Health (HITECH) Act which appropriated $640 million in REC grant funds to create 62 RECs across the nation, including the four in Texas. 

Primary care physicians in Texas should use REC services because they will receive a steep discount for high quality services that are provided through a trustworthy, physician-centric organization that was specifically created to meet the technological needs of physicians in their region.

In Texas the four RECs have collaborated to develop a shared business plan that leverages the federal subsidies to provide onsite technical consulting for a token fee of $300.    For this $300 enrollment fee Texas physicians receive over $5,000 in consulting services which include:

  • EHR implementation and project management;
  • HIT education and training; 
  • Vendor selection and financial consultation; 
  • Practice and workflow redesign; 
  • Privacy and security compliance education; 
  • Meaningful use analysis, tracking, and monitoring; 
  • Assistance in meeting meaningful use requirements for CMS incentives; 
  • Collaboration with state and national health information exchange (HIE); 
  • Ongoing technical assistance; and 
  • Opportunities for CME credit hours

In addition to this steeply discounted enrollment fee, the Texas Medical Association (TMA) works closely with the RECs to help ensure that the RECs are physician-centric and focused on meeting physician needs.    Physicians hold 50% of the seats on each REC's governing board as a result of the TMA’s early efforts.

Another unique selling point is that the REC technical consultants are specifically focused on, and experienced with, the small physician practice.    Other IT consultants naturally give priority to large practices or healthcare systems where they get large amounts of money from a small number of contracts.    The REC consultants, on the other hand, only get a small amount of money per contract, but they get a large number of them.    This business strategy allows them to become more experienced with and more focused on the small practice.    The REC administrative staffs enable this strategy by facilitating the enrollment of a large number of physicians and by using the REC federal grant funds to offer physicians the steep discount.

The four RECs in Texas are: