Health Information Exchange

Crossing the Quality Synapse: Interoperability is the Neurotransmitter Propagating 21st Century Healthcare

Yesterday at the 2010 ONC Grantee Meeting in Washington, D.C  I was invigorated by the optimistic energy, realistic networking and paucity of pessimism from over 1,000 participating grantees whose collective repository of health IT knowledge is astounding.   And it got me thinking, maybe the Institute of Medicine (IOM) got it wrong and that it is not actually a chasm...maybe we are...crossing the quality synapse?

Imagine for a moment that electronic health information is a charged impulse using health IT neuronal circuitry to propagate 21st century healthcare.  This neuronal circuit provides the infrastructure needed to enable charged impulses of the right information on the right patients to be sent or received wherever it is needed, whenever it is needed.  However, as we physicians know, the neuronal circuit is made up of many individual neurons that are not physically connected to one another.  Each neuron can individually propagate a charged impulse along its long, tubular-shaped axon, but the axon ends blindly at its terminal end.  Between it and the next neuron there is a space, called the synapse, across which the electrical impulse cannot travel.  This constraint prevents an individual neuron from transmitting the electronic impulse to its final destination.  On the other hand, an absence of such constraints and uncontrolled releases of electrical charges between the neurons of our brain would result in seizures.   So, some type of trusted intermediary is needed to enable the neurons to talk with one another in a standard and controlled manner...to be an interoperable neural circuit that coordinates and directs the traffic of electrical charges to their permitted destinations.     

In medicine we recognize the complexity of this synapse.  Although we have learned much about it, we remain humbled by what we do not yet know.  What we do know is that at the "receiving" end of a neuron there are tiny tentacles, or dendrites, that stick out into the synapse toward the "sending" neuron's axonal terminal.  When the charged impulse reaches the axon terminal, the action potential stimulates the chemical release of neurotransmitters from the terminal into the synapse.    The neurotransmitters physically travel across the synapse to the dendrites.  At that point the neurotransmitters become a catalyst for the transformation of the chemical process back into an electrical one.  The new electrical impulse travels from the dendrite into the neuronal axon and propagates down to the next synapse, where interoperability will again have to occur. 

Health IT interoperability is the 21st century neurotransmitter that is catalyzing the transformation of the healthcare system.  Without interoperability we know that electronic health information is severely devalued as it remains trapped in individual silos, just as an an absence of neurotransmitters would limit electrical impulses to a single neuron. 

Concurrent with ongoing neuroscience research on the complex synaptic neurotransmitters, medical researchers used what we already knew to initiate trials and studies in an effort to improve psychiatric care.  Breakthrough research demonstrated that a synaptic deficiency of one of the neurotransmitters in our brains, serotonin, can cause depression.  Through additional trials and experience we then discovered that SSRI medications, which elevate serotonin levels by inhibiting their "reuptake" in the synapses after being released, are useful when treating people with depression and other mood disorders.   Similarly, a deficient level of interoperability between EMRs depresses our ability to transform our healthcare system.  We need to use what we already know about interoperability to initiate trials and studies in an effort to raise our interoperability to optimal levels that will propel our healthcare system into the 21st century.     


Watch Recording of Dr. Blumenthal Speaking to Texas Medical Association on EMRs, Meaningful Use and Quality Medicine

Dr. Blumenthal anticipates that Regional Extension Centers (RECs), such as the North Texas Regional Extension Center (www.ntrec.org), will be helpful to physicians who want to successfully implement electronic medical records (EMRs) and use them to enhance our ability to provide high quality of care.  He notes that the federal EMR incentive payment program (through the HITECH legislation) is a one-time offer from the government that physicians should strongly consider, especially if they plan to still be practicing medicine in 10-15 years when EMR use is likely to be an expectation. 

http://www.ustream.tv/recorded/10218624


EMRs create a new medical liability risk-- physician's failure to chase after the non-compliant patient

It is clear that electronic medical records (EMRs) improve patient safety and quality of care in many ways.  It is unclear, however, whether these improvements will result in an overall reduction in medical liability risks and costs.  Consider the following scenarios:

Scenario 1: You are the doctor and you have a 20 year-old female patient, Ann, with insulin-dependent diabetes mellitus who has been an ideal and compliant patient.  When you last saw her 3 months ago you wrote an office note about how her paper log of glucometer readings (that she faithfuly brings in each visit) showed an exellent trend of glucose levels and compliance with her diet and insulin regimen.  A Hgb A1C test was done and the result satisfactory.  Today an emergency room doctor calls you and reports that Ann is comatose with a blood sugar of 650 with other signs of severe ketoacidosis.  You admit her to the intensive care unit where she is treated aggressively but cerebral edema develops resulting in a stroke.  Upon recovery from her metabolic crisis she requires rehabilitation for residual left-sided weakness.  As you piece together her story you discover that since you last saw her she had apparently become acutely depressed after breaking up with her boyfriend.  She now admits to straying from her usual dietary restrictions, failing to take her insulin regularly and not monitoring her blood sugar.  You explain to Ann and her family that her depression obviously led to non-compliance with her diabetes therapy which unfortunately resulted in her poor outcome.

Scenario 2: You are the doctor and you have a 20 year-old female patient, Ann, with insulin-dependent diabetes who has been an ideal and compliant patient.  You last saw her 3 months ago and in your EMR you noted an excellent trend in her daily blood sugar readings that she faithfully sends to your office in real-time (by connecting her home glucometer to the internet through her Xbox).   A Hbg A1C test was done and the result satisfactory.  Today an emergency room doctor calls you and reports that Ann is comatose with a blood sugar of 650 with signs of severe ketoacidosis.  You admit her to the intensive care unit where she is treated aggressively but cerebral edema develops resulting in a stroke.  Upon recovery from her metabolic crisis she requires rehabilitation for residual left-sided weakness.  As you piece together the story you discover that since you last saw her she had apparently become acutely depressed after breaking up with her boyfriend.  She now admits to straying away from her usual dietary restrictions, failing to take her insulin regularly and not monitoring her blood sugar.  When you look in your EMR it is obvious that she stopped sending in her glucose levels 8 days ago.  You were on vacation and the alerts generated by the IT tools were somehow missed by your office personnel.  You explain to Ann and her family that her depression obviously led to non-compliance with her diabetes treatment which led to a severe ketoacidosis complicated by a stroke.  Ann’s parents ask why you would not have checked up on her when she stopped sending in the glucose readings.  They blame you for the poor outcome and file a medical liability suit against you for failing to follow-up on their daughter after your records showed she had become non-compliant. 

The above scenario demonstrates one of several new liability issues raised by the use of electronic health records (EHRs) and other health information technology (IT) tools.  Technology not only changes the way clinicians manage patient care, but also creates new patient care issues to manage.  Other situations prompted by health IT and prone to liability issues include: 

  1. New ways physicians manage population health
  2. Access to previously unavailable patient information through the use of health information exchange (HIE)

EMRs have been shown to improve patient care and patient safety which will hopefully serve as a strong counterbalance to any new liability risks.  However, if medical liability insurance companies discover a need to raise premiums on physicians who adopt health IT tools, then there needs to be open dialogue over who pays for the increase.  Any rise in liability premiums due to health IT adoption needs to be shared by all stakeholders (liability insurance companies, health plans, consumers, employers, hospitals, government, etc...) and not just the doctors.  The rule of thumb for health IT adoption is that, since it is for the public good, all stakeholders get to play and all stakeholders have to pay


Texas Physicians With Other Stakeholders Collaborate on Local and Statewide Health IT Funding Decisions

New federal funding for the adoption and use of electronic medical records (EMRs) is accelerating progress on many existing health information technology (HIT) initiatives, providing a jump-start for some languishing HIT efforts and triggering other innovative activities.   Most of the additional funding is designated as incentive payments to physicians and hospitals that successfully adopt and use EMRs.   Some of the new funding is targeted for the development of technical infrastructure and processes that are needed to maximize the value of EMR usage by clinicians. 

Over the next year decision-makers at the federal, state and local levels will determine how billions of dollars will be spent on HIT over the next decade.   Physician participation in these decisions will help maintain a focus on using HIT to improve quality of care and patient safety.  The following information is an overview of the HIT landscape at the federal, state and local levels.

Physician Incentives

The American Recovery and Reinvestment Act of 2009 (ARRA), commonly referred to as the $800 billion Recovery Act, designates $19 billion toward the adoption and use of EMRs.  In particular, the bill provides $17 billion of incentive payments to individual physicians and hospitals who demonstrate "meaningful use" of EMRs.  Medicare physicians may qualify for a maximum of $44,000 based on 75% of their annual Medicare payments (see chart below).  The Medicaid incentive payment formula is different and based on the actual implementation and operating costs of the office EMR.  Physicians with a Medicaid patient mix >30% may qualify for up to $63,750 and those with a Medicaid mix of 20-30% may qualify for 2/3s of that amount. 

ARRA Schedule

 "Meaningful Use"

In order to qualify for incentive payments ARRA requires physicians  to demonstrate "meaningful use" of an EMR.  The Department of Health and Human Services (HHS) is defining "meaningful use" based on the following guidelines:

Qualifying physicians must:

   

  1. Use an EMR certified for "meaningful use" by HHS (different than CCHIT certification)
  2. Use e-prescribing
  3. Be able to "connect" their office EMR to other health IT systems (such as a lab or a state immunization registry) and exchange data
  4. Be able to report on specified quality measures

HHS has released details on the preliminary definition of "meaningful use" and the final definition is expected later this winter or early spring.  A website hosted by the Office of the National Coordinator of Health IT (ONC) provides more details and ongoing updates on physician incentives and meaningful use. 

HIT Regional Extension Centers (RECs)

ARRA funds are also available to create about 70 RECs spread geographically across the nation.  Their purpose is to provide assistance to physicians in the successful selection, implementation and meaningful use of EMRs.  RECs will focus assistance on small physician groups and rural physicians. 

In Texas there are four non-profit entities that are collaborating with each other and have segmented the state to assure full coverage of every county.  These four grant applicants are anchored by UT Health Science Center Houston, the Dallas-Fort Worth Hospital Council, Texas A&M Health Science Center and Texas Tech Health Science Center.  The Texas Medical Association (TMA) and other state organizations are working collaboratively with each of the grant applicants.   Each REC has committed to a 50% physician representation on their governance boards.  Under the proposed plans local Tarrant County physicians will have access to the North Texas Regional Extension Center (NTREC) where Matt Murray, MD (Fort Worth), David Bragg, MD (Dallas) and Kenneth Haywood, MD (Tyler) are physician board members.  The federal REC grants are expected to be announced in March 2010. 

Health Information Exchanges (HIEs)

Technology and processes exist that can provide physicians access to a consolidated set of patient data that was entered into electronic systems at hospitals, labs, pharmacies, radiology centers, emergency rooms or even other physician offices who use different EMRs in the community.  An entity that provides this "connecting" infrastructure is called a health information exchange (HIE).  The value of an ambulatory EMR increases significantly if there is a local HIE to connect to that provides the physician online access to data about his patients that has been entered in other systems across the community. 

At a national level the National Health Information Network (NHIN) effort is establishing standard models for the exchange of health information between EMRs.  The federal HIE Cooperative Agreement Program created in 2009 will provide federal grants to each of the 50 states to develop HIE infrastructures at the state level.  In return the states are expected to align their HIE models with NHIN standards.  

HIE Cooperative Agreement Program Funds in Texas

In December, 2009, HHS announced that the Texas Health and Human Services Commission (HHSC) will receive $28.81 million over four years to fund the planning and implementation of HIE networks.  HHSC contracted with the Texas Health Services Authority (THSA) to develop strategic and operational plans that describe how Texas will create a robust HIE infrastructure.  THSA consequently created four workgroups and, with assistance from the TMA, appointed at least one Texas physician on each workgroup:

Governance and Finance:   Susan Blue, MD (Fort Worth)

Technical Infrastructure:   Matt Murray, MD (Fort Worth) and James S. Walker, MD (Refugio) 

Privacy and Security:   James Merryman, MD (Austin)

EHR Adoption and Consumer Engagement:   Tim Barker, MD (Waco)

There are currently over a dozen HIE entities in Texas in various stages of development.  Sandlot is an operational HIE in Fort Worth.  The DFW Hospital Council is leading another local HIE effort that is in a developmental stage.  Lessons learned and work already completed by existing HIE entities will be leveraged as the Texas HIE model develops.

Texas Medicaid HIE Pilot 

House bill 1218, 81st Legislature, Regular Session, 2009, requires HHSC to establish an HIE pilot for the exchange of Medicaid-related data.  A 16-member HIE Advisory Committee with Joe Schneider, MD (Dallas) serving as chairman was appointed to assist with the development and implementation.  The TMA worked to ensure adequate physician representation on this advisory committee as it is likely that the Medicaid pilot project will influence the statewide HIE model development going forward.

Building consensus among providers, payers, consumers, HIT vendors and other public, private and government entities is difficult but vital for technology to be successfully used in health care.   Perhaps the most encouraging trend over the past year is the increasing number of successful collaborative efforts such as those outlined in this overview. 

First published in Tarrant County Physician, January 2010 (reprinted with permission)

by Matt Murray, MD 

 

 

 

 

 

 


Why Will Government Pay Physicians Up to $63,750 to Adopt, Use EMRs? And Hospitals Millions More?

The 2009 American Recovery and Reinvestment Act (ARRA) includes a $19 billion investment to modernize the nation’s health information technology (IT) infrastructure. Over $17 billion are set aside for incentive payments to individual physicians and hospitals who can qualify by implementing and meeting the requirements for “meaningful use” of electronic medical records (EMRs). There are also $2 billion allocated to build the IT infrastructure needed to allow EMRs to “connect” with each other and share data in a private, secure and effective manner.

ARRA Funds

 

Individual physicians who achieve meaningful use of EMRs can qualify for $44,000 under the Medicare rules or $63,750 under the Medicaid rules. Hospital incentives are based on a complex formula that starts with a $2 million base with additional funds calculated on total discharges if they achieve meaningful use of an EMR.

ARRA delegates the responsibility for defining “meaningful use” to the Department of Health and Human Services (HHS). Currently HHS plans to finalize the definition for “meaningful use” by the end of this year or early in 2010. Although we do not know what the final definition will be, HHS has overseen the development of a Meaningful Use matrix that is published and posted on the Office of the National Coordinator of Health IT (ONCHIT) website. The final definition will likely be based on this matrix.

Why provide billions of dollars to physicians and hospitals for using health IT?   Health information technology has been shown to improve the quality of care and to reduce the cost of health care. The maximum benefits of electronic medical records (EMRs), however, cannot be reached until the majority of physicians and hospitals are actively using EMRs and share data between them.  The prevalence of EMRs among physicians and hospitals are currently too low to garner the full value of health IT:

Low EMR Adoption Rates

Low Adoption

Although nearly 50% of large physician practices have adopted electronic medical records (EMRs), most medium and small practices have not. So despite efforts to encourage adoption of health IT in the past decade, only 17% of physicians are actively using EMRs. Also, less than 10% of physicians using an EMR have a fully functional EMR with advanced features such as e-prescribing, real-time eligibility verification and secure physician-patient messaging according a New England Journal of Medicine study. Similarly, hospitals continue to lag in the adoption of advanced clinical technologies.

Studies have shown that cost is the predominate obstacle for both the adoption and use of EMRs and that providing financial incentives would be a facilitator of EMR adoption.

Facilitators to Broad Adoption of Health IT 

EMR Facilitators

According to a Congressional Budget Office (CBO) report last year, the upfront cost of an ambulatory EMR ranges from $25,000 - $45,000 per physician.  Smaller offices tend to be in the upper end of this range.  Annual operating costs range from 12 – 20% ($3,000 - $9,000) per physician.  The total cost of EMRs tends to be higher for systems that are able to do more.  Although EMRs that are purchased under an ASP model will have much lower upfront capital cost, the significantly higher annual operating costs will, at a minimum, level out total cost over the long term.  Operating costs include software fees, technical support, IT maintenance, equipment replacement/upgrades and other vendor fees-for-service.  

The HHS definition of "Meaningful Use" will detail what physicians and hospitals have to do in order to qualify for the ARRA incentive payments. Although we do not know the final definitions at this time, we do know that demonstrating “meaningful use” will require the physicians to:

  1.  
    1. Use an HHS-certified EMR
    2. Use e-prescribing
    3. Be able to connect their EMR to other health information systems (information exchanges)
    4. Be able to produce quality reports on specified quality measures

From a high-level perspective, the Meaningful Use matrix recommendations are to gradually “bend the curve” towards a transformed, modernized healthcare system. In 2011-12 the incentives are based on the adoption of EMRs that can capture quality data. In 2013-14 the incentives bend the curve by requiring not only capturing data in an EMR, but also reporting on the data and improving processes. In the final phase during 2015-16 the incentives bend the curve further by focusing on the use of quality reports to improve patient outcomes.

Bending the Curve Towards Transformed Healthcare
Achieving Meaningful Use of Health Data

Bend Curve

 

With the ongoing absence of other significant triggers, the ARRA health it incentives could provide the boost of momentum necessary to modernize the nation’s healthcare infrastructure. At the least these incentive payments will accelerate our nation’s slow adoption of EMRs which is suppressing the value that health IT can bring to healthcare.


EMR Selection: Physician Champions

 

Selecting an EMR: Ready, Set…Go Compare!  is a series of blogs that serves as a resource for physicians who have decided to select and implement an ambulatory electronic medical record (EMR).

 

An enduring axiom about electronic medical record (EMR) implementations remains unchanged: “If no physician champion, then don’t implement”.  The physician champion’s role in an EMR implementation is to keenly focus on strategic implementation decisions, education of colleagues on the EMR, process/work flow redesign and on the design, configuration, build and testing of the EMR.

In a June 30th Digitized Medicine blog (High Demand Persists for Chief Medical Information Officer (CMIO) and Health IT Physician Champion Roles) the evolution of the role of physician champions within health information technology (HIT) is described.  In the 1970s physician IT champions typically served as clinical "subject matter experts" to ensure that clinician's needs were identified and met by IT projects.  Since the 1990s the implementation of more expensive and increasingly complex clinical technologies, such as EMRs with computerized physician order entry (CPOE), has led to the need for an executive CMIO role at a majority of hospitals.  As described in the blog, the CMIO role is different than the physician champion role of the 1970s. The CMIO, in fact, needs to recruit , mentor and infuse the clinical expertise of physician champions from within the organization into health IT implementations.  Similarly, an office practice should identify a physician champion before selecting and implementing an EMR.

Most of the work involved in successful EMR implementations is not technical, but instead involves changes in process and work flow. The physician champion must be closely involved in the redesign of processes and work flow to ensure the changes align well with how the clinician works and thinks best.  The physician champions also are the “subject matter expert” for the EMR’s clinical design, configuration and build. They work on structured documentation templates, order sets, clinical decision support tools and, most important of all, work flow redesign to optimize how the EMR design is used. The champion is a key figure for strategic decisions that need to be made during an EMR implementation. The physician champion works with colleagues to identify their unique needs. At the same time he/she educates colleagues on the value of and garners their support for standardizing their template-based documentation and orders as much as possible.

The effort needed to garner support, design the EMR and redesign processes/work flow is often underestimated.  Implementations that proceed without physician champions or without enough time for the physician champion to adequately participate are more likely to encounter significant problems when the EMR “goes-live”.  Examples of such problems are:

  • Documentation takes too much time because there are too many required answers that the physician has to enter
  • Documentation takes too much time because of work flow issues
  • Inability to easily get quality reports that were expected from the EMR, because the data is entered differently or in different places by different doctors
  • Pick-lists have so many choices that it frustrates the doctors
  • Poor template design makes it easier for clinicians to just free text; data needed for quality reports does not get entered into discrete fields that allow it to be reported on
  • Poor work flow redesign slows down patient flow in the office, productivity goes down

Decisions about what quality data needs to be entered in the EMR and standardization over where it gets entered are needed before even designing templates.  Limiting the amount of “required fields” to these pre-determined data needs helps prevent documentation templates that are to elaborate to enter data quickly. This is important for the physician champion to drive because physicians generally expect to be able to capture quality data, produce quality reports and exchange information with registries or other health information exchange entities in their area once they have an EMR. These reports and registries are tools physicians expect from EMRs to help them improve population care.

Capturing and reporting on quality data will be required to qualify for “meaningful use” incentive payments for physicians using EMRs (under the ARRA/Stimulus package) most likely starting in 2013.  The physician champion will have a key role helping the practice qualify for these incentive payments as “meaningful users”.

The physician champion has strategic roles and post-implementation roles as well.  The physician champion will be a key participant in strategic decisions that the practice will have to make during the EMR implementation, including the go-live strategy ("big bang" vs. phased in) and what to do with the current paper charts or old EMR data.  Post-implementation the physician champion helps optimize and maintain templates, order sets, decision support rules and other EMR tools.  He/she should be the main point of contact with the EMR vendor and manage the timing and scope of future updates and upgrades to the EMR.

The importance of strong physician leadership is stressed in much of the EMR implementation literature. The following characteristics help this lead physician be effective:

  • Well-respected as a clinician
  • Strong interpersonal skills
  • Ability to “makes things happen”
  • Teaching mentality (a typical trait of most physicians)
  • Strong negotiating skills
  • Commitment to successful EHR implementation
  • Ability to sell EMR benefits to other physicians and office staff
  • Sets realistic expectations

It should be noted that although an interest in computers is helpful, technical skills are really not needed for this role. Much more important than technical proficiency is a willingness to learn and teach.

There is one final caveat based on personal experience that this author would like to share. Unless it is a small 1-3 doctor practice, the physician who is the designated EMR physician champion should not be the individual who develops, monitors and coordincates all of the tasks of the EMR implementation project plans. This is discussed further in "EMR Selection: Project Team, Project Manager and Decision Making".  The physician champion’s role is to keenly focus strategic implementation activities, process/work flow redesign and on the design, configuration, build and testing of the EMR.  Larger practices should consider compensating the champion for the time and effort required to successfully accomplish these tasks.

EMR Selection Guide provides an outline of additional topics on the selection process

 EMR Implementation Guide provides an outline of topics on the implementation process


Comments on ONC's Preliminary Definition of "Meaningful Use"

On June 16th the Office of the National Coordinator for Health Information Technology (ONC)  announced a 10-day period for comments on their preliminary definition of "Meaningful Use".  This definition is important to clinicians and hospitals who could qualify for incentive funds if they are "meaningful users" of health information technology (HIT).  The federal stimulus program, through the American Recovery and Reinvestment Act (ARRA), includes $20 billion for these incentive funds.  ONC has posted on their website a preliminary definition in the form of a Meaningful Use Matrix document.  Comments on this preliminary definition can be sent to ONC through their website until June 26th at 5:00pm.  The rules for incentive payment qualification that the Department of Health and Human Services (HHS) will announce  later this year will be guided by the recommendations made by ONC.  

Participating with two organizations who are preparing to submit comments to ONC has clarified for me that the most important aspect of this matrix is the "Measures" column.  The "Measures" column lists the detail for what physicians and hospitals will be expected to do in order to be qualified for incentive payments as meaningful users.  Assessments and comments should therefore focus on the "Measures" in the matrix.  It appears that the Objectives column includes things that are expected to occur as providers achieve the measures, but are not specifically required for reimbursement. This should, however, be further clarified by ONC.

If you are interested in submitting comments to ONC or you are just interested in seeing more details, please click here to see a list of my comments on the preliminary definition of "meaningful use".  One thought that struck me as I worked on this is that the incentive payment program will create new opportunities for vendors to provide "services" to physicians by streamlining the effort that will be required to receive incentive payments over the next 6 years.  

drmattmurray


Meandering Means to Make Meaning of "Meaningful Use"

Unless one is closely following the day-to-day activities of the government as it relates to the health information technology (HIT) world, the importance of "meaningful use" and how it is coming to be defined is hardly stimulating. Acronyms make matters worse. Just when common information technology (IT) acronyms, such as "IT", are becoming increasingly familiar, unfamiliar phrases like "meaningful use" are turning into "MU". As a consequence, the average person attempting to follow these activities will quickly feel as though overdosed on a CNS depressant...oh, and that reminds me, medical acronyms like CNS (central nervous system) are also being thrown into the mix. So in today's blog entry let's see if an explanation of the importance, timeline and participation in the current "meaningful use" activities can be simplified. Here we go!

Importance: The American Recovery and Reinvestment Act (ARRA) authorizes the Department of Health and Human Services (HHS) through the Centers for Medicare & Medicaid Services (CMS) to provide incentive payments to physician and hospital providers who are "meaningful users" of "certified" electronic health records (EHRs). These incentive payments begin in 2011 and gradually phase down. Starting in 2015, providers are expected to have adopted and be actively utilizing a "certified" EHR in compliance with the "meaningful use" definition or they will be subject to financial penalties under Medicare and Medicaid. Who gets part of the $20 billion of incentive payments is dependent on how  "meaningful use" and "certification" are defined.  ARRA created two advisory committees, the HIT Policy Committee and the HIT Standards Committee, to make recommendations to HHS on the incentive payment roadmap. Both Committees report to the Office of the National Health IT Coordinator (ONC) which operates under HHS and is led by the "health IT czar" David Blumenthal, MD. How "meaningful use" is described will essentially set the priorities for the Standards Committee and be a major influence on how "certification" is defined.  The Policy Committee is developing key objectives that they want "meaningful use" to achieve and establishing metrics for each of those objectives.  These specific objectives and measures will describe what physicians and hospitals will need to do in order to qualify for part of the $20 billion incentive payments.  This has caught the attention of many.

Timeline: The HIT Policy Committee formed a Meaningful Use Workgroup earlier this year to begin hammering out a proposed definition of "meaningful use." The HIT Policy Committee held their first meeting this week on Tuesday, June 16 and discussed the draft proposals from the Workgroup. The Policy Committee will meet again on July 16 to discuss revisions that the Meaningful Use Workgroup makes to their proposals based on this week's meeting and public comments. HHS will consider the recommendations provided by these groups and is expected to issue rules by the end of this year.  This is by necessity an extremely short timeline considering the complexity of EHRs and other health IT tools, the length of time it takes to successfully implement these tools and the fact that "meaningful use" requirements are attached to the 2011 incentive payments.   

Participation: Since the HIT Policy Committee is operating under the transparency of the Federal Advisory Act (FACA), it makes available a public transcript of the June 16 meeting on the ONC website and has provided for a 10-day period of public comment on the proposals. For those interested, the period open for public comment on the initial draft ends on June 26. Included in the public transcript of the June 16 meeting is a draft of the Meaningful Use Matrix which appears to be the core tool that will be used to define "meaningful use". It is a matrix design because the definition of meaningful use is phased in, becoming more challenging in each of the 5 years. The focus of comments to ONC right now should be on the specific objectives and measures proposed in this matrix since incentive payments will be based on these. It has not been decided whether another comment period will be offered after the July 16 presentation.

The Meaningful Use Matrix can be summarized at a very high level by this slide from the Workgroup's presentation.  It shows that incentive payments will begin in 2011 with "Pay-For-Reporting", phase into "Pay-For-Using" and mature into "Pay-for-Outcomes" by 2015.  In other words, initially the incentive is to get providers using EHR tools to capture certain health data and be capable of reporting on that data.  The next phase is to incenticize providers to actually use IT tools and health data during patient encounters.  The last phase is to stimulate providers to demonstrate improvements in patient outcomes through the use of the IT tools.  

So, there above lies the simplified explanation of the importance of the current "meaningful use" activities. For insomniacs, "take" two readings of this blog for the full CNS depressant effect! 

drmattmurray

 


The Conundrum of Physician Adoption of HIT, Health Information Exchanges (HIEs) and Stimulus Funding

Despite an increasing amount of literature and anecdotal evidence that electronic medical records (EMRs) improve quality of care, many clinicians harbor lingering doubts about the value they will gain by implementing an ambulatory EMR in their office.  The concern is not without merit.  EMRs today do provide value to the physician by providing real-time access to legible patient data, clinical decision support tools and reporting capabilities; with attentiveness to work flow redesign during implementation this value can be gained without unacceptable impact on physician time.  However, it is dissappointing to physicians that there is a significant gap between the value EMRs bring today and the largely untapped potential value of connecting EMRs in order to confidentially share patient data across the community.  Current EMR technology makes possible physician access to critical patient data in disparate EMRs entered by other community providers, hospitals, labs, radiology departments, emergency rooms and other credible sources. The technology infrastructure that allows this exchange of patient data between EMRs is called a health information exchange (HIE).  The value of ambulatory EMRs increases significantly when connected to an HIE infrastructure that enables access to and display of exchanged community-wide patient data whenever, wherever the physician needs it for patient care.   

This additional value of ambulatory EMRs cannot be fully realized until a critical mass of providers in a community are using EMRs and the community has the HIE infrastructure available to connect EMRs. For example, if 99% of medical records are paper and only 1% are entered electronically across a community, the value to a physician for connecting with the HIE would be minimal.  The conundrum is that the business model to allow HIEs to thrive is also dependent on a critical mass of providers using EMRs because EMRs provide the HIE with its commodity which is patient data.  HIEs in communities with low EMR usage therefore have difficulty sustaining their existence for financial reasons.  

HIE infrastructure is growing but is still not prevalent in our communities; also, less than 10% of U.S. physicians are using a fully functional EMR according to the New England Journal of Medicine (NEJM, Volume 359:50-60, July 3, 2008, No. 1).This conundrum is addressed by the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH) portion of the federal economic stimulus program.  HITECH provides not only incentive payments to physicians who adopt EMRs, but also funding opportunities for the development of HIE infrastructure, policies/regulations for privacy/security and "Regional Centers" to help coordinate this effort.  The purpose is to not only stimulate enough momentum for physician adoption of EMRs to reach a critical mass, but also to concurrently stimulate the development of more robust community HIE infrastructure.  The conundrum requires a concurrent effort so that, as doctors adopt EMRs, new HIE infrastructure adds value by enabling physicians to access a comprehensive set of patient data from the community in a practical, useful and confidential manner.  

drmattmurray


AMA Meeting Next Week to Discuss ARRA and Health Information Exchanges (HIEs); Physicians Need to Maintain Ownership of Patient Health Information

The American Medical Association (AMA) is meeting in Chicago next week to discuss President Obama's federal econonomic stimulus package (ARRA) as it relates to the healthcare industry.  The Department of Human Services will have representatives present.  The Texas Medical Association and other state medical societies will concurrently participate in peer-to-peer meetings to discuss the role that state medical societies can and should have regarding the health information technology incentives and the health information exchange (HIE) infrastructure.  In order for physicians to gain value from implementing ambulatory EMRs, there must be an infrastructure (and policies/procedures) in place that allows patient information to be accessible whenever and wherever it is needed.  This infrastructure will succeed only if it garners the public's trust that the privacy of their health information will be maintained.  It is my belief that the public is far more likely to trust their local doctor with private health information than they will any government entity or other anonymous public-private HIE entity.  Local doctors typically are members of their local county medical society, and these county medical societies roll up to the state's medical association, such as the Texas Medical Assoication.  One strategy is to allow local physicians to maintain "ownership" of private health data by having their county medical society establish a community data repository.  The physician's medical society would become "the owner" of the data, protecting the patient's privacy while providing appropriate access to providers who need the data to provide high quality care during patient encounters.   This idea has surfaced in the state medical association arena.  As digitized patient health information becomes more prevalent and therefore more valuable to exchange, the financial difficulties HIEs encounter today will wane.  At that point garnering and maintaining public trust will become a primary challenge for HIE sustainability.  Leaving ownership of private health information data repositories to the providers is one way to achieve public trust.  It will be interesting to follow up with state medical associations following next week's meetings concerning the state and national HIE infrastructure strategies.  

drmattmurray