Meaningful Use

flying cadeuciiAll of you Meaningful Use and Health IT junkies should read Data for Individual Health  Although long, it’s definitely worth a scan by everyone who cares about health tech. This is the third JASON-related report in a year out of ONC and it comes a month or so before the planned release of the first details of ONC’s announced 10yr plan. I think there’s a reason for that much of it introduced by ONC’s earlier post.

There are three key points I would highlight:

First, and most important, this report suggests that HIPAA Covered Entities (mostly hospitals, doctors and their EHRs) are no longer the center. The future, labeled as the Learning Health System, now makes mobile and patient-centered technology equally important as part of the architecture and talks about interoperability with them rather than “health information exchange” among HIPAA CE’s and their Meaningful Use mandates.

Second, this JASON report, unlike the previous two, does not talk about Meaningful Use any more. That money is spent. A lot of orgs are lobbying against any more MU mandates and, although I’m pretty sure there will be a Stage 3, it could be toothless or very much delayed.

Third, Direct, the original Blue Button, Blue Button Plus Push, and CCDA files are pretty much history.  Although the JASONs don’t say it as plainly as I am, document-based interoperability has failed and we’re moving on to Application Programming Interfaces (APIs) that don’t use CCDA or any of the stuff mandated by MU 1 and 2. Blue Button Plus Pull and FHIR, both with a modern industry-standard OAuth security scheme, are the future for all sorts of good reasons which you need to read the JASON reports with some care to understand. It’s all there.

Continue reading “ONC Signals a Shift From Documents to Interfaces”
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Bob WachterThe policy known as Meaningful Use was designed to ensure that clinicians and hospitals actually used the computers they bought with the help of government subsidies. In the last few months, though, it has become clear that the policy is failing. Moreover, the federal office that administers it is losing leaders faster than American Idol is losing viewers.

Because I believe that Meaningful Use is now doing more harm than good, I see these events as positive developments. To understand why, we need to review the history of federal health IT policy, including the historical accident that gave birth to Meaningful Use.

I date the start of the modern era of health IT to January 20, 2004 when, in his State of the Union address, President George W. Bush made it a national goal to wire the U.S. healthcare system. A few months later, he created the Office of the National Coordinator for Health Information Technology (ONC), and gave it a budget of $42 million to get the ball rolling.

Continue reading “RIP Meaningful Use Born 2009 – Died 2014???”

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Karen DeSalvo, MD, the national coordinator for health information technology for HHS, is leaving her post to to address public health issues, including becoming a part of the Department’s team responding to Ebola. She took over as the ONC head in January, 2014.

The ONC’s COO Lisa Lewis will serve as the agency’s acting national coordinator.

HHS spokesman Peter Ashkenaz told THCB:

“HHS Secretary Burwell asked National Coordinator for Health IT Karen DeSalvo to serve as Acting Assistant Secretary for Health, effective immediately. In this role she will work with the Secretary on pressing public health issues, including becoming a part of the Department’s team responding to Ebola. Dr. DeSalvo has deep roots and a belief in public health and its critical value in assuring the health of everyone, not only in crisis, but every day.

Lisa Lewis, ONC’s chief operating officer, will serve as the Acting National Coordinator. However, Dr. DeSalvo will continue to support the work of ONC while she is at OASH.”

The transition comes at a time when critics are asking tough questions about the government’s Meaningful Use program and providers’ lackluster progress qualifying for Stage 2.

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It’s time to think carefully and look at the large systems (human and technical), institutions, and individuals that contributed to Mr. Duncan’s death. Systems should be designed to protect people and prevent human errors. Certainly we rely on the healthcare system to improve our health and to protect our privacy, especially our rights to health information privacy.

Looking at the death of Mr. Duncan, the poorly designed Epic EHR was a critical part of the problem: the lack of clarity, poor usability, hard to find critical information, and no meaningful quality testing to ensure the system prevents critical errors contributed to his death and endangered many others. Why wasn’t the discharge of a patient with a temperature of 103 from the ER flagged?

EHRs are one of several critical systemic problems.

Current US EHRs were not designed or tested to ensure patient safety or privacy (patient control over the use of PHI for TPO).  The Meaningful Use requirements for EHRs don’t address patient safety or ensure patients’ legal rights to control use of PHI. Let’s face it, the MU requirements were set up by the Health IT industry, not by a federal agency charged with protecting the public, such as NIST or the FDA. Industry lobbying resulted in industry ‘self-regulation’, which has failed to protect the public in every other sector of industry. Industry lobbying is another critical systemic problem.

Our public discourse also is a critical systemic problem.  The 24/7 US media drives us to play the ‘blame game’—and look at what happens: it’s a sham. A massive public and social media exercise substitutes for a crucial scientific and ethical oversight process by government and industry to face or examine the systemic causes and key actors—both people and institutions.  We end up with no responsibility being assigned or addressed.  Or the media hoopla and confused thinking leads to the opposite conclusion: everyone and everything is responsible and blamed, which has the same effect: it lets everyone and everything off the hook. Either way, no one and no institutions are to blame.

Continue reading “Ebola, EHRs, and the Blame Game”

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Lygeia RiccardiMaking Sense of Blue Button, Meaningful Use, and What’s Going on in Washington  …

At the recent Health 2.0 Conference in Santa Clara, co-chair Matt Holt expressed frustration about the difficulty of getting copies of his young daughter’s medical records. His experience catalyzed a heated discussion about individuals’ electronic access to their own health information. Many people are confused about or unaware of their legal rights, the policies that support those rights, and the potential implications of digital access to health data by individuals. The Health 2.0 conference crowd included 2000 entrepreneurs, consumer technology companies, patient advocates, and other potentially “disruptive” forces in healthcare, in addition to more traditional health system players.

Why is this topic so important? Until now, most people haven’t accessed their own health records, whether electronically or in paper, and I believe that making it easier to do so will help tip the scales toward more meaningful consumer/patient engagement in healthcare and in health. Access by individuals and their families to their own health records can empower them to coordinate care among multiple healthcare providers, find and address dangerous factual errors, and take advantage of a growing ecosystem of apps and tools for improving health-related behaviors, saving money on health services, and getting more convenient, personalized care.

A shorthand phrase for this kind of personal empowerment through access to digital health data is “Blue Button,” which is also the name of a public-private initiative in which hundreds of leading healthcare organizations across the US participate. The Blue Button Initiative is bolstered by the electronic access to health information requirements for patients in the “Meaningful Use” EHR Incentive Program, which is administered by CMS (the Centers for Medicare & Medicaid Services) with companion standards and certification requirements set by ONC (the Office of the National Coordinator for Health Information Technology). Continue reading “Getting Your Own Health Records Online: The Good and the Not So Good”

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flying cadeuciiThe Meaningful Use program is at a critical inflection point.  On one hand, the payers could jump on the MU bandwagon, follow Medicare’s example and demand provider MU attestation.

On the other hand, they could throw private practice a bone and help them weather the storm until MU goes away or loses its teeth. Let me explain.

Payers could take the easy money and penalize according to the upcoming ACA “adjustment” schedule.  Lots of people think this is inevitable. This would certainly provide an easy way to increase payer revenue and is as simple as letting the practices [continue] to do all the work.

However, this would be incredibly short-sighted.

Meaningful use, as things stand in 2014,  has not been shown to improve patient care. Indeed, it is common for Stage 1 attesting MDs to abandon the program during Stage 2, with many doctors citing lack of efficacy of the program. Stage 3 MU is projected to have even worse results.

What this tells me is that the stress and time-cost of MDs and their staff is not worth the benefits of Meaningful Use.  Don’t get me wrong – there are some great things in the MU guidelines, and we are implementing them in the software we create, but they are overshadowed by the onerous, less-effective 5% and it’s all or nothing. There is no MU wiggle-room.  These days you have to have real grit and determination to stay in private practice, no matter your specialty.

Without financial support or legislative reform, Meaningful Use will eventually drive independent doctors out of business.

That’s bad news for payers.

Continue reading “The Case For Payers to Oppose Meaningful Use”

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flying cadeuciiAs a result of the determined efforts by Massachusett’s politicians, businesses, health insurance companies, hospitals, individual physicians and the Massachusetts Medical Society, nearly 100% of patients in Massachusetts now have health insurance. This is something all the healthcare players in Massachusetts can be proud of, and “universal insurance” enjoys broad public support here in Massachusetts

In an attempt to improve healthcare quality and reduce cost, Massachusetts is moving away from the “fee-for-service” system and replacing it with “physician groups” which contract with insurance companies. Most of these contracts include financial incentive/disincentive clauses about “quality” and “cost.” As a result, in Massachusetts, it is now almost impossible for a solo practitioner to obtain a contract directly with one of the state’s largest insurance companies. Almost all contracts are mediated through a local physician organization, such as an IPA, PHO or ACO.

As a result, health insurance companies now have much greater influence over the Massachusetts healthcare industry. These large insurance companies define the terms of the contract and can tell the small or medium-sized hospitals/physician contracting group their contract is a “take it or leave it” proposition. Needless to say, it is impossible for any small or medium-sized hospital/physician contracting group to refuse to accept the insurance contract when their financial viability is predicated on having access to the insurance company’s patient panel.

Originally Certified EMRs and Meaningful Use policies were created so as to provide the financially incentive to encourage primary care physicians to adopt electronic medical record programs and then use these electronic medical record programs according to specified “meaningful use” mandates. It was the hope that the appropriate use of EMRs would improve the quality or reduce the cost of healthcare. Since the program’s introduction, Meaningful Use has been expanded to almost every medical specialty and subspecialty, regardless of the appropriateness/relevance.

There has now been a fair amount of data accumulated regarding the effectiveness of electronic medical record programs. Unfortunately, most of the published data is not high quality and the majority of clinical trials are now being funded by the EMR industry. As we have seen with clinical trial sponsored by the pharmaceutical industry, only an irrational person would accept the results of a vendor sponsored EMR trial on face value.

Recently, The Office of the National Coordinator for Health Information Technology (HHS)  asked the RAND corporation to review all EMR data. RAND created the “Health Information Technology: An Updated Systematic Review with a Focus on Meaningful Use Functionalities

Continue reading “The Misuse of Meaningful Use, Part II”

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flying cadeuciiWhen building software, requirements are everything.

And although good requirements do not necessarily lead to good software, poor requirements never do.   So how does this apply to electronic health records?   Electronic health records are defined primarily as repositories or archives of patient data. However, in the era of meaningful use, patient-centered medical homes, and accountable care organizations, patient data repositories are not sufficient to meet the complex care support needs of clinical professionals.   The requirements that gave birth to modern EHR systems are for building electronic patient data stores, not complex clinical care support systems–we are using the wrong requirements.

Two years ago, as I was progressing in my exploration of workflow management, it became clear that current EHR system designs are data-centric and not care or process-centric. I bemoaned this fact in the post From Data to Data + Processes: A Different Way of Thinking about EHR Software Design.   Here is an excerpt.

Do perceptions of what constitutes an electronic health record affect software design?  Until recently, I hadn’t given much thought to this question.   However, as I have spent more time considering implementation issues and their relationship to software architecture and design, I have come to see this as an important, even fundamental, question.

The Computer-based Patient Record: An Essential Technology for Health Care, the landmark report published in 1991 (revised 1998) by the Institute of Medicine, offers this definition of the patient record:

A patient record is the repository of information about a single patient.  This information is generated by health care professionals as a direct result of interaction with the patient or with individuals who have personal knowledge of the patient (or with both).

Note specifically that the record is defined as a repository (i.e., a collection of data).   There is no mention of the medium of storage (paper or otherwise), only what is stored.   The definition of patient health record taken from the ASTM E1384-99 document, Standard Guide for Content and Structure of the Electronic Health Record, offers a similar view—affirming the patient record as a collection of data. Finally, let’s look at the definition of EHR as it appears in the 2009 ARRA bill that contains the HITECH Act:

ELECTRONIC HEALTH RECORD —The term ‘‘electronic health record’’ means an electronic record of health-related information on an individual that is created, gathered, managed, and consulted by authorized health care clinicians and staff.  (123 STAT. 259)

Even here, 10 years later, the record/archive/repository idea persists.  Now, back to the issue at hand: How has the conceptualization of the electronic health record as primarily a collection of data affected the design of software systems that are intended to access, manage, and otherwise manipulate said data?

Continue reading “Is the Electronic Health Record Defunct?”

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Screen Shot 2014-06-26 at 2.07.25 PMThe new mantra for the medical practice is upgrade, integrate, and outsource according to the results of the Black Book Rankings™ 2014 Survey. Each year, Black Book gathers over 400,000 viewpoints on information technology through an interactive online survey and telephone discussions. The result is an annual barometer of HIT satisfaction and experiences.

This year, three clear trends emerged for practices looking to stay independent in a changing and challenging time in healthcare. While each trend holds its own unique benefits, it is clear from the survey that many practices are looking to implement all three—upgrade technology, implement integrated solutions, and outsource business functions like revenue cycle management.

According to the survey, nearly 90% of physician practices agree their billing and collections systems need upgrading. Over 65% of those practices are considering a combination of new software and outsourcing services. Here are the trends:

Move to Upgrade Outdated Software

Even with recent changes in the CMS EHR Incentive program, delaying the required use of a 2014 Edition CEHRT, many practices do not currently have an EHR that will enable them to attest for meaningful use. In addition, 91% of business managers fear that the ramifications of their outdated and/or auto-piloted revenue cycle management (RCM) systems, particularly those not integrated to EHRs, will force their physician to sell.

As a result of these challenges and other impending changes like ICD-10, 21% of practices are considering an upgrade of their RCM software within the next six to twelve months, and 90% of those are only considering an EHR centric module.

Practices considering upgrades to cloud-based solutions can see other benefits including reduced costs, seamless upgrades, more flexible access, and reduced concerns around storage and security. Continue reading “2014 Black Book Survey Says Majority of Medical Practices Want Updated Software”

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Ashish JhaAdverse events – when bad things happen to patients because of what we as medical professionals do – are a leading cause of suffering and death in the U.S. and globally.  Indeed, as I have written before, patient safety is a major issue in American healthcare, and one that has gotten far too little attention. Tens of thousands of Americans die needlessly because of preventable infections, medication errors, surgical mishaps, and so forth.  As I wrote previously, according to Office of Inspector General (OIG), when an older American walks into a hospital, he or she has about a 1 in 4 chance of suffering some sort of injury during their stay.  Many of these are debilitating, life-threatening, or even fatal.  Things are not much better for younger Americans.

Given the magnitude of the problem, many of us have decried the surprising lack of attention and focus on this issue from policymakers.  Well, things are changing – and while some of that change is good, some of it worries me.  Congress, as part of the Affordable Care Act, required Centers for Medicare and Medicaid Services (CMS) to penalize hospitals that had high rates of “HACs” – Hospital Acquired Conditions.  CMS has done the best it can, putting together a combination of infections (as identified through clinical surveillance and reported to the CDC) and other complications (as identified through the Patient Safety Indicators, or PSIs).  PSIs are useful – they use algorithms to identify complications coded in the billing data that hospitals send to CMS.  However, there are three potential problems with PSIs:  hospitals vary in how hard they look for complications, they vary in how diligently they code complications, and finally, although PSIs are risk-adjusted, their risk-adjustment is not very good — and sicker patients generally have more complications.

So, HACs are imperfect – but the bottom line is, every metric is imperfect.  Are HACs particularly imperfect?  Are the problems with HACs worse than with other measures?  I think we have some reason to be concerned.

Continue reading “Penalizing Hospitals For Being Unsafe”

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