2014 will see wide-scale production and exchange of Consolidated CDA documents among healthcare providers. Indeed, live production of C-CDAs is already underway for anyone using a Meaningful Use 2014 certified EHR.
C-CDA documents fuel several aspects of meaningful use, including transitions of care and patient-facing download and transmission.
This impending deluge of documents represents a huge potential for interoperability, but it also presents substantial technical challenges.
We forecast these challenges with unusual confidence because of what we learned during the SMART C-CDA Collaborative, an eight-month project conducted with 22 EHR and HIT vendors.
Our effort included analyzing vendor C-CDA documents, scoring them with a C-CDA scorecard tool we developed, and reviewing our results through customized one-on-one sessions with 11 of the vendors.
The problems we uncovered arose for a number of reasons, including:
material ambiguities in the C-CDA specification
accidental misinterpretations of the C-CDA specification
lack of authoritative “best practice” examples for C-CDA generation
The Obama administration announced significant adoption for the Blue Button in the private sector on Friday.
In a post at the White House Office of Science and Technology blog, Nick Sinai, U.S. deputy chief technology officer and Adam Dole, a Presidential Innovation Fellow at the U.S. Department of Health and Human Services, listed major pharmacies and retailers joining the Blue Button initiative, which enables people to download a personal health record in an open, machine-readable electronic format:
“These commitments from some of the Nation’s largest retail pharmacy chains and associations promise to provide a growing number of patients with easy and secure access to their own personal pharmacy prescription history and allow them to check their medication history for accuracy, access prescription lists from multiple doctors, and securely share this information with their healthcare providers,” they wrote.
“As companies move towards standard formats and the ability to securely transmit this information electronically, Americans will be able to use their pharmacy records with new innovative software applications and services that can improve medication adherence, reduce dosing errors, prevent adverse drug interactions, and save lives.”
While I referred to the Blue Button obliquely at ReadWrite almost two years ago and in many other stories, I can’t help but wish that I’d finished my feature for Radar a year ago and written up a full analytical report.
Extending access to a downloadable personal health record to millions of Americans has been an important, steady shift that has largely gone unappreciated, despite reporting like Ina Fried’s regarding veterans getting downloadable health information.
Today, academic medicine and health policy research resemble the automobile industry of the early 20th century — a large number of small shops developing unique products at high cost with no one achieving significant economies of scale or scope.
Academics, medical centers, and innovators often work independently or in small groups, with unconnected health datasets that provide incomplete pictures of the health statuses and health care practices of Americans.
Health care data needs a “Henry Ford” moment to move from a realm of unconnected and unwieldy data to a world of connected and matched data with a common support for licensing, legal, and computing infrastructure. Physicians, researchers, and policymakers should be able to access linked databases of medical records, claims, vital statistics, surveys, and other demographic data.
To do this, the health care community must bring disparate health data together, maintaining the highest standards of security to protect confidential and sensitive data, and deal with the myriad legal issues associated with data acquisition, licensing, record matching, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Just as the Model-T revolutionized car production and, by extension, transit, the creation of smart health data enclaves will revolutionize care delivery, health policy, and health care research. We propose to facilitate these enclaves through a governance structure know as a digital rights manager (DRM).
The concept of a DRM is common in the entertainment (The American Society of Composers, Authors and Publishers or ASCAP would be an example) and legal industries. If successful, DRMs would be a vital component of a data-enhanced health care industry.
Giving birth to change. The data enhanced health care industry is coming, but it needs a midwife.There has been explosive growth in the use of electronic medical records, electronic prescribing, and digital imaging by health care providers. Outside the physician’s office, disease registries, medical associations, insurers, government agencies, and laboratories have also been gathering digital pieces of information on the health status, care regimes, and health care costs of Americans.
However, little to none of these data have been integrated, and most remain siloed within provider groups, health plans, or government offices.
Karen DeSalvo started as the new National Coordinator for Healthcare Information Technology on January 13, 2014. After my brief discussion with her last week, I can already tell she’s a good listener, aware of the issues, and is passionate about using healthcare IT as a tool to improve population health.
She is a cheerleader for IT, not an informatics expert. She’ll rely on others to help with the IT details, and that’s appropriate.
What advice would I give her, given the current state of healthcare IT stakeholders?
1. Rethink the Certification Program – With a new National Coordinator, we have an opportunity to redesign certification. As I’ve written about previously some of the 2014 Certification test procedures have negatively impacted the healthcare IT industry by being overly prescriptive and by requiring functionality/workflows that are unlikely to be used in the real world.
One of the most negative aspects of 2014 certification is the concept of “certification only”. No actual clinical use or attestation is required but software must be engineered to incorporate standards/processes which are not yet mature. An example is the “transmit” portion of the view/download/transmit patient/family engagement requirements.
There is not yet an ecosystem for patients to ‘transmit’ using CCDA and Direct, yet vendors are required to implement complex functionality that few will use. Another example is the use of QRDA I and QRDA III for quality reporting.
We continue to see progress in improving the nation’s health care system, and a key tool to helping achieve that goal is the increased use of electronic health records by the nation’s doctors, hospitals, and other health care providers. These electronic tools serve as the infrastructure to implementing reforms that improve care – many of which are part of the Affordable Care Act.
Doctors and hospitals are using these tools to reduce mistakes and hospital readmissions, provide patients with more information that enable them to stay healthy, and allow for rewarding health care providers for delivering quality, not quantity, of care.
The adoption of those tools is reflected today in a release from the Centers for Disease Control and Prevention’s National Center for Health Statistics which provides a view of the Medicare and Medicaid EHR Incentive Program and indicates the program is healthy and growing steadily.
Nearly 80% of office-based physicians used some type of electronic health record system, an increase of 60 percentage points since 2001 and nearly double the percent in 2008 (42%), the year before the Health Information Technology and Economic and Clinical Health Act passed as part of the Recovery Act in 2009.
About half of office-based physicians surveyed said they use a system that qualifies as a “basic system,” up from just 11% in 2006.
Almost 70% of office-based physicians noted their intent to participate in the EHR incentive program.
Figure 1. Percentage of office-based physicians with EHR systems: United States, 2001-2013
The report also noted that 13% of physicians who responded said they both intended to participate in the incentive program and had a system that could support 14 of the Meaningful Use Stage 2 “core set of objectives,” ahead of target dates. This survey was performed in early 2013 – before 2014 certified products were even available.
Let me concede from the outset that, in this blog post, I lean toward the negative—dire predictions, worst-case scenarios, a bit of doom and gloom, etc.
But I ask you, oh gentle, patient reader, how could I not?
Let’s go to the satellite. You can see warm air from a low-pressure system (Meaningful Use Stage 2, not changed dramatically by the one-year extension) collide with cool, dry air from a high-pressure area (the turmoil of Obamacare) and tropical hurricane moisture (ICD-10). Tell me you don’t see the Perfect Storm yourself.
And here we sit in our little fishing boat, waiting for the mighty ocean to consume us.
Overly dramatic? Certainly, but still not wholly inappropriate, I will argue.
Consider a recent report on the HIMSS/WEDI ICD-10 National Pilot Program collaborative that was created to, “…minimize the guess work related to ICD-10 testing and to learn best practices from early adopter organizations.”
Designed to ascertain the realities of the entire healthcare system adopting and using ICD-10, this pilot included an education and adoption program for all participants, followed by a set of “waves” in which diagnoses for the 100-200 most common medical conditions were actually coded and submitted using ICD-10.
The end-to-end testing approach …
…would encompass a number of medical test cases that mirror actual processing, including situations with multiple “hops” or “steps” between providers, clearinghouses, and health plans; the identification of high-risk medical test cases to help prioritize testing; the identification of available testing partners; and key reporting and sharing of test results. The test environment must mirror production.
And how did this pilot testing go? (Cue dark, foreboding music here …)
The average accuracy was in the 60 percent range with low scores around 30 percent. Yes, some medical scenarios had nearly 100 percent accuracy, which is great. But very low accuracy accompanied a number of very common conditions. Not so great.
Back in the mid-1990s, I did a lot of web work for traditional media. That often meant figuring out what the client was already doing on the web, and how it was going, so I’d find the techies in the company, and ask them what they were doing, and how it was going. Then I’d tell management what I’d learned. This always struck me as a waste of my time and their money; I was like an overpaid bike messenger, moving information from one part of the firm to another. I didn’t understand the job I was doing until one meeting at a magazine company.
The thing that made this meeting unusual was that one of their programmers had been invited to attend, so management could outline their web strategy to him. After the executives thanked me for explaining what I’d learned from log files given me by their own employees just days before, the programmer leaned forward and said “You know, we have all that information downstairs, but nobody’s ever asked us for it.”
I remember thinking “Oh, finally!” I figured the executives would be relieved this information was in-house, delighted that their own people were on it, maybe even mad at me for charging an exorbitant markup on local knowledge. Then I saw the look on their faces as they considered the programmer’s offer. The look wasn’t delight, or even relief, but contempt. The situation suddenly came clear: I was getting paid to save management from the distasteful act of listening to their own employees.
Recently, the President of the United States, the most powerful person on earth, the man whose finger rests on the nuclear button, struck a bold blow for . . . procurement reform?
“There are a whole range of things that we’re going to need to do once we get [the Affordable Care Act (ACA) rollout] fixed—to talk about federal procurement when it comes to IT and how that’s organized,” the president said on November 4, speaking to a group of donors and supporters.
People are clamoring for heads to roll, and the president is talking about what just could be the geekiest, most obscure topic ever to clog a federal bureaucrat’s inbox. Procurement reform? Has he gone off the deep end?
Well, not really. Among the causes of healthcare.gov’s difficulties, the federal process for purchasing goods and services could rank right up there with toxic politics, lack of funding for ACA implementation, and management goofs. Let me explain why, from personal experience.
From 2009 to 2011, I served as National Coordinator for Health Information Technology. My job was to implement the HITECH ACT, which aims to create a nationwide, interoperable, private, and secure electronic health information system. As national coordinator I had to lead a lot of federal contracts.
While there has been much focus lately on the ways in which ObamaCare is chilling the growth of private business, we should not overlook the continuing deleterious effects of the one surviving relic of HillaryCare, the Health Insurance Portability and Accountability Act (HIPAA). Quietly, September 23 came and went as the compliance effective date for a new rule, expanding the reach of HIPAA, and likely driving many smaller players out of the health care industry.
Spearheaded by then First Lady Clinton, HIPAA was established in 1996 to improve privacy of personal health information, referred to as protected health information, or PHI. It requires health care providers, known as “covered entities,” and their vendors, contractors, and agents with access to PHI, known as “business associates,” to comply with certain privacy standards under its “Privacy Rule,” and with certain security standards under its “Security Rule,” in order to protect sensitive health information that is held or transferred in electronic form.
Over the past decade, equipped with the noble aim of protecting our privacy, HIPAA has successfully demonstrated the power of the law of unintended consequences. Improved protection of PHI has been marginal. However, HIPAA has impeded communication among physicians, reduced physician time devoted to patient care, and deterred medical research. And all at an enormous cost of compliance. While estimates vary widely, the cost of compliance for many providers has been in the millions.
Now, rather than take heed, the government has decided to double down through expansion. Under the Health Information and Technology for Economic and Clinical Health Act (HITECH), a corollary of HIPAA, promulgated to create incentives to facilitate the development of healthcare information technology, the government has sought to update the requirements of HIPAA in light of the changing dynamics of technology and health practices, increasing the safeguards and obligations of health care providers and their business associates.
I’ve recently written about healthcare.gov and the lesson that going live too soon creates a very unpleasant memory.
As I work with healthcare leaders in Boston, in New England, and throughout the country, I’m seeing signs that well resourced medical centers will struggle with Meaningful Use stage 2 attestation, ICD-10 go live, HIPAA Omnibus Rule readiness, and Accountable Care Act implementation, all of which have 2013-2014 deadlines.
People are working hard. Priority setting is appropriate. Funding is available.
The problem is that the scope is too big and the timeline is too short.