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PCAST HIT Report Becomes a Political Piñata

The PCAST Report on Health IT has become a political piñata.

Early Feedback on PCAST

Like many of my colleagues, I was taken aback by the release of the Report in early December 2010 — I didn’t know quite what to make of it. Response in the first week of release after Report was:

  • Limited. The first commentaries were primarily by technical and/or clinical bloggers. The mainstream HIT world had remarkably little initial reaction to the Report.
  • Respectful of the imprimatur of “The President’s” Report and noting some of the big names associated with the report (e.g., Google’s Eric Schmidt and Microsoft’s Craig Mundie.)
  • Focused on technical and/or clinical perspectives around two broad themes.
    • The vision is on target:  “extraordinary”, “breathtakingly innovative”.
    • These guys didn’t do all their technical homework. The range varies, but the message is consistent.

Today’s POV on PCAST

What  a difference a six weeks makes.

The Office of the National Coordinator for Health IT (ONC) requested comments on the Report. The comments were due by January 19 and a number of influential organizations have already made their comments public.

After having read 10 early commentaries submitted to ONC, I’ll (admittedly subjectively) divide them into 3 schools of thought:

1) PCAST is a frontal attack on mainstream clinical, technical, and economic stakeholders in existing U.S. health IT. While there are some good ideas in the report, almost all of them are already in the works.  Bury PCAST ASAP.

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Obtaining Meaningful Use Stimulus Payments

Many clinicians and hospitals have asked me about the exact steps to obtain stimulus payments.

On January 3, 2011, CMS began registering clinicians for participation in meaningful use programs.    Every region of the United States has Regional Extension Centers which can help answer any questions. Here’s an overview of the steps you need to take.

1.  Choose between Medicare and Medicaid programs.  If you qualify, Medicaid offers greater incentives and does not require you to achieve meaningful use before stimulus payments begin.
a.  To qualify for Medicaid, 30% of your patient encounters must be Medicaid patients. (20% for pediatricians)
b.  To qualify for Medicare, keep in mind that meaningful use payments are made at 75% of Medicare allowable charges for covered professional services in the calendar year of payment, per the payment maximums below:

Year 1  $18,000
Year 2  $12,000
Year 3  $8000
Year 4  $4000
Year 5  $2000

Thus, a total of $44,000 is available at maximum, but could be less if your allowable Medicare charges are less than

Year 1 $24,000
Year 2 $16,000
Year 3 $10,667
Year 4 $5333
Year 5 $2667

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Updates on Proposed Stage 2 and 3 Meaningful Use Criteria

The Health IT Policy Committee has published proposed Stage 2 and 3 Meaningful Use Recommendations and they’re open for public comment until February 25.

I’ll share a couple of particularly useful and well written analyses and commentaries by colleagues.

Health IT guru and thought leader Dr. John Halamka writes about The Proposed Stage 2 and 3 Meaningful Use Recommendations.

This is a great article to get a thumbnail overview of all the proposed recommendations. John lists 38 criteria and provides a quick commentary on how challenging he sees each of them. (Keep in mind that he’s CIO at one of the most HIT-advanced health systems in the country — your definition of “easy” and his might not be alike.)

It caught my eye that the more challenging criteria generally are ones involving inter-organizational health data exchange, care coordination and care management. See his comments on the following criteria: 7, 17, 20–21, and 23–34.

Dr. Halamka concludes:

…areas of concern are chemotherapy automation, recording patient communication preferences, judging clinician performance based on patient adoption of PHRs, EMAR implementation, maturity of HIE capabilities,  widespread rollout of longitudinal care planning, and public health readiness.

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Ready, Set…ACO?

Happy New Year, everyone!  2010 was certainly action-packed, and 2011 promises the same.

I hear a lot of thunder about getting ready for ACOs.

This isn’t a crystal ball forecast, but I see hospitals spending tons of capex on new HIT from old-fashioned “software-based” companies, and it seems like the EMR is the new “pavilion.”  I see hospitals buying medical practices using arrangements that are certain to require the hospital to subsidize doctor income.  [For another take: Paul Levy on ACO.]

These two major waves are explained by clients and prospects alike as “readiness for ACO.”

I have three thoughts:

  1. Don’t worry.  We at athenahealth will do our part.  If and when ACO payment models emerge, you won’t need to buy a new “module” from us in order to get payment.  We will go get you that money the same way we are getting you the “Meaningful Use” stimulus payments, the P4P money, and the plain old health care reimbursements that we have always delivered.  The changes to our technology and service needed to accomplish all that will be on us.
  2. Don’t turn blue holding your breath waiting for the big bonus opportunity.  The fundamental underlying principle of an ACO is that you will get a bonus in exchange for lower utilization.  If that bonus is bigger than what you’d get from the utilization, then why would Medicare pay it?  If that bonus is LESS than what you are getting now, why would you do it?
  3. I have met newly elected Republican lawmakers of late and few of them are thinking that money will be saved with this approach.  As with other aspects of health reform law, they appear to be eager to… well, let’s just say…scrutinize the mechanics closely.

None of this is certain and there will be exceptions to all the rules anyone tries to write.

This leaves one thing certain.

Do NOT make multi-year investments that depend upon ACO actually happening.

So as far as ACO goes, pay as you go.

With me?

Jonathan Bush co-founded athenahealth, a leading provider of internet-based business services to physicians since 1997.  He blogs regularly at THCB and at the athena blog where this post first appeared. Prior to joining athenahealth, he served as an EMT for the City of New Orleans, was trained as a medic in the U.S. Army, and worked as a management consultant with Booz Allen & Hamilton. He obtained a Bachelor of Arts in the College of Social Studies from Wesleyan University and an M.B.A. from Harvard Business School. He blogs regulary at the athena blog, where this post first appeared.

Failure is Not an Option

2010 is drawing to an end amongst a flurry of activities in the Health IT field. In a few short days 2011, the year of the Meaningful Use, will be upon us and the stimulus clocks will start ticking furiously. In addition to the yearlong visionary activities from ONC, December 2010 brought us two landmark opinions on the future of medical informatics. The first report, from the President’s Council of Advisors on Science and Technology (PCAST), recommended the creation of a brand new extensible universal health language, along with accelerated and increased government spending on Health IT. Exact dollar amounts were not specified.

The second report from the Institute of Medicine (IOM) is a preliminary summary of a three-part workshop conducted by the Roundtable on Value & Science-Driven Health Care with support from ONC, and titled “Digital Infrastructure for the Learning Health System: The Foundation for Continuous Improvement in Health and Health Care”. The IOM report, which incorporates the PCAST recommendations by reference, is breath taking in its vision of an Ultra-Large-System (ULS) consisting of a smart health grid spanning the globe, collecting and exchanging clinical (and non-clinical) data in real-time. Similar to PCAST, the IOM report focuses on the massive research opportunities inherent in such global infrastructure, and like the PCAST report, the IOM summary makes no attempt to estimate costs.

Make no mistake, the IOM vision of a Global Health Grid is equal in magnitude to John Kennedy’s quest for“landing a man on the moon and returning him safely to the earth” and may prove to be infinitely more beneficial to humanity than the Apollo missions were. However, right now, Houston, we’ve had a problem here:

  1. The nation spent upwards of $2.5 trillion on medical services this year
  2. Over 58 million Americans are poor enough to qualify for Medicaid
  3. Over 46 million Americans are old enough to qualify for Medicare
  4. Another 50 million residents are without any health insurance
  5. The unemployment rate is at 9.8% with an additional 7.2% underemployed
  6. This year’s federal deficit is over $1.3 trillion and the national debt is at $13.9 trillion

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Will ACO IT Models Be Walled Gardens or Open Platforms?

Will ACO (accountable care organization) IT models be walled gardens or open platforms?  i.e., will ACO IT platforms focus on exchanging information within the provider network of the ACO, or will they also be able to exchange information with providers outside the ACO network? (If the question still isn’t clear, click here for a further explanation.).

One POV: ACO’s Will Need Open IT Platforms

Mike Cummens, M.D., associate chief medical information officer at 750-physician Marshfield Clinic in Wisconsin, is quoted in a recent article in Healthcare Informatics. Dr. Cummens argues for an open ACO IT approach:

There will be an emphasis on transfer-of-care summaries and how to facilitate information sharing across the full continuum of care, he said. “For instance, you will have to work into care management plans the notification of home health agencies,” Cummens added. “In an ACO model, you will have to have methods in place to communicate all this information to providers who are not part of your own organization. People will have an option to see providers outside an ACO, so you will need to be able to transfer care summaries and discharge summaries outside the ACO.”

Also, because patient involvement is a key part of ACOs, the IT infrastructure will have to support patients signing off on their care plans and document their progress toward reaching goals, he noted. That will involve some type of self-management tools and personal health record access to their own data.

Cummens noted that the patient-centered medical home is geared toward an individual practice, and meaningful use metrics are geared toward providers, but ACOs will require managing data across enterprises. “When we visualize this and realize we are dealing with multiple electronic health records, the infrastructure for ACOs really has to ride on top of that,” he said. He sees the need for a new type of system, probably outside the EHR, that can bridge organizations, allow for risk assessment and analytics and reach down into tools for day-to-day management. That’s a tall order.

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HIT Trends Summary for October 2010

This is a summary of the HIT Trends Report for October 2010.  You can get the current issue or subscribe here.

The evolving health information exchange market. The HIE segment was center-stage this month with a game-changing announcement by Surescripts. It will combine its national physician directory and EMR connectivity with apps from its strategic investment in Kryptiq to offer physician-to-physician clinical messaging beginning in December, extending its dominant market position.  As first to market with these functions, it will likely cement its standing as the country’s premiere neutral national network.  It also enables a platform for additional web services from collaborating partners in the future.  We are also reminded this month in Healthcare IT News of the relative dominance of Epic in the IDN and large practice market with the startling statistic that 75% of Wisconsin residents are in the databases of its state user group.  Using Epic tools and with patient consent physicians in the state can see patient information across institutions.  And there’s a story this month that Verizon is expanding its vision as an HIE by adding clinical lab and imaging results to its networking services with leading transcription companies.  These three lenses:  (1) Surescripts as the leading national network; (2) Epic as the leading national EMR; and (3) Verizon as the leading national telecom, exemplify the rapidly changing dynamics in this segment.

EHRs and HIT have become central to transformation of clinical practice. One large driver is the announcement by the insurance commission of the inclusion of HIT as well as wellness and care management as medical expenses for insurers under PPACA.  In the past these areas were generally allocated to the administrative budget of health plans which limited participation.  This will increase payer investment.  A CMS exec, Anthony Rogers, reported to Healthcare IT News on early results of CMS accountable care organization (ACO) pilots.  He noted that practices with EMRs were getting most of the $36M in incentives and said, “If that’s not a business case [for EHRs], I don’t know what is.”   The Patient-Centered Primary Care Collaborative, the organization driving medical homes released two reports this month also highlighting HIT’s role in transformation.  One report looks at best practices to engage patients in a medical home project using HIT.  It’s a compendium of 15 essays by a diverse set of experts on different perspectives about using health IT to engage patients, plus snapshots of two dozen case examples.  The other report focuses on five ways to implement HIT effectively to enable clinical decision support.  And CSC released a roadmap for HIT in ACOs with an elegant six factor model:  member engagement; medical management; clinical information exchange; quality reporting; business intelligence; and  risk and revenue management.

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What’s Your Platform?

We’ve done some heavy dipping into the world of policy recently. In mid-September, I spent a day in Washington, D.C., with friend and advisor Tom Scully meeting researchers, senators, and a congressman.  We heard from “ONCHIT” that “CCHIT”—which, as you know is an “ATCB”—granted us Stage 1 MU!  This is great news for me, mostly because some competitors didn’t get it!  (How’s that for starting a policy blog with some serious ABCs?!)

I met with some amazingly smart and engaged reporters who now (I think, get called “researchers,” since their newspapers can no longer afford them) work for the Henry J. Kaiser Family Foundation or NPR.  They’re the real deal.  They needed much less initial grounding in the problems we try to solve than most of the journalists we meet.  They had taken on board the assumption that the move toward ACOs means less waste (which it could for some) and can get everybody in the clinical supply chain on one system (which has been seen to work at times).

But none of them appears to have considered the idea that there is a relationship between a healthy integrated health information ecosystem and a health information exchange marketplace.  It’s still surprising to me, but precious few people correlate sustainability of any social good with the existence of a healthy marketplace with enough room for flexibility to allow innovation over time.  It’s like the single economic condition responsible for ALMOST ALL of the social progress of this nation since inception, but in health care it’s still kind of a new idea.

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Update on Modular EHR Technology: Harvard’s SMArt Research

ONC awarded four Strategic Health IT Advanced Research Project (SHARP) grants earlier this year to

”…address well-documented problems that have impeded adoption of health IT and to accelerate progress towards achieving nationwide meaningful use of health IT in support of a high-performing, learning health care system.”

One of  these grants was awarded to a Harvard group led by Drs. Ken Mandl and Isaac Kohane, based in Children’s Hospital Boston and Harvard Medical School. This research team is tackling the problems associated with developing an ecosystem of  modular, plug-and-play medical applications, what we have referred to as Clinical Groupware.  (Disclosure: DCK is on the Harvard SHARP grant’s advisory board.)

The research is aimed at creating a “medical apps store” based on the iPhone/iPad model of substitutable applications running on a device or platform. The name of the project, SMArt, stands for “Substitutable Medical Applications, re-useable technology.” The approach could impact both the EHR industry and the federal regulatory and standards process, possibly within a relatively short period, i.e., 1-3 years, so we think it merits your attention.

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Reckless REC Wrecking

The Health Information Technology Extension Program, created and funded by ONC, has completed funding for all 62 Regional Extension Centers (REC), with a grand total of well over half a billion dollars and, predictably, criticism of the program was immediately forthcoming. The RECs are supposedly an impediment to free EHR markets and doomed to failure from the start, which may seem a bit contradictory if you think about it. Anyway, before making further statements and assertions regarding the “recklessness” of the RECs, or the impeding “train wreck” they represent, it may be beneficiary to take a closer look at the program.

Overview

The HIT Extension Program consists of 62 RECs, at least one for each State and territory, and one national Research Center (RC). The stated goal of the program is “to provide outreach and support services to at least 100,000 priority primary care providers within two years”. The individual RECs are supposed to conduct outreach and education campaigns in their respective States and inform physicians on the latest HIT developments and available programs and incentives. The RECs are also chartered to offer support and guidance to physicians selecting and implementing EHRs, particularly Primary Care docs in small practices and in underserved areas. These are the doctors that were left out by the regular market process because they were hard to reach, too expensive to implement and too poor to bother with. While the individual RECs are locally oriented, with feet on the ground in each State and each County, the RC is basically a National forum for RECs to share information and exchange lessons learned.

Funding

Other than a small amount of seed money, RECs are not handed out all those hundreds of millions of dollars of grant funds. RECs are paid for performance. For each physician they touch and manage to recruit, the RECs are paid about $1500. If and when the provider implements an EHR, the RECs receive another equal payment. The last third of the money is handed to the REC if, and only if, the provider achieves Meaningful Use. This arrangement is only in effect for two years. All those who believe that RECs are bound to fail should be reassured by the fact that in that dire case most of the allocated funds will remain with ONC. The RECs are expected to use the ONC seed money and find a way to become sustainable businesses after ONC ceases to support them financially.

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