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Tag: HITECH

The Long Tail of the EMR

HomepageIn the fall of 2008 I had the opportunity to do some research on the, then dormant, EMR marketplace. The results came as no surprise. Most physicians did not have an EMR and were not interested in adopting an EMR due to cost and usability barriers.

Much has changed in one short year. Spurred by ARRA and its HITECH portion, there is a renewed interest for technology in the physician community. Some of it came from the promise of stimulus funds and some stems from the perceived inevitability of the need to have technology in one’s office. There is no feverish anticipation of the great things an EMR will bring to a medical practice. Instead, there seems to be a somber resignation to the upcoming demise of a trusted friend: the paper chart.Continue reading…

Advice For State REC Planners

By DAVID C. KIBBE & BRIAN KLEPPERKathleen-sebelius

On August 20th, HHS Secretary Kathleen Sebelius and ONC head David Blumenthal announced $598 million in grants to set up about 70 “regional extension centers” (RECs) that will help physicians select and implement EHR technologies. Another $564 million will be dedicated to developing a nationwide system of health information networks.

The RECs are based on the example of agricultural extension offices, established over 100 years ago by Congress, which offered rural outreach and educational services across the country. These extension services made America’s agricultural revolution possible, dramatically increasing farm productivity. By analogy, the Administration hopes that on-the-ground health IT trainers and implementation experts can facilitate small medical practices’ adoption of EHR technologies, especially in rural and under-served areas, enhancing care quality and efficiency around the US.

The comparison between RECs and agricultural extension offices is probably a good one, and we applaud this effort. But there are some striking differences between agriculture and health IT. For one thing, many best farming practices were well known by the early days of agricultural extension services. The road map under ARRA/HITECH for successful small medical practice health IT acquisition and use is still under development, and remains full of tough questions and unknowns.

In fact, under Dr. Blumenthal’s leadership, the government is now crafting specifications for Meaningful Use, HHS Certification, security, and interoperability. It’s not yet clear what “meaningful use of certified EHR technology” means. So we could be in a cart-before-the-horse situation. It might be a little premature to set up technical assistance programs if we can’t provide specific guidance on how to assist. Even fully CCHIT-certified comprehensive EHRs can’t meet the Meaningful Use criteria today, so the REC’s geek squads will have their work cut out for them.

However, a body of knowledge and experience already exists about successful health IT system implementation in small primary care and specialty practices. For several years, one of us (DCK) worked under the auspices of the American Academy of Family Physicians (AAFP), helping family physicians’ practices prepare, select, implement, and maintain information technology offered by EMR and EHR vendors. The AAFP’s current Center for HIT staff has expanded this effort, assembling an impressive body of resources and tools. It was augmented as well by the work of the Quality Improvement Organizations (QIOs) that participated in the Doctors Office Quality-Information Technology (DOQ-IT) programs between 2006-2008.

Some of this knowledge is anecdotal, and should certainly be revised in light of the definitions and specifications that the ONC will issue later this year and likely finalize by spring of 2010, according to Dr. Blumenthal. But the AAFP’s and QIO’s hard-won lessons may be useful to those who are planning the new effort.

Here’s some broad guidance for state planners who are applying for these grants and who hope to set up their RECs by early 2010.

  1. Keep your advisory services simple and targeted on solving actual problems. Hire people with hands-on medical practice experience, who will carefully listen to what physicians and practice managers want the EHR technology to do for them and their patients. Physicians in small practices generally will use EHRs in caring for patients and for managing office accounts. Overwhelming change won’t be welcomed. Instead, focus on incremental implementations that try to solve information management problems without interrupting work flows.Start with one system or workflow area, gaining success and then moving on to another. For example, some practices may be ready to implement ePrescribing, but are not ready to replace paper records with an electronic documentation system. Many practices have found that  Web portals facilitating patient communications are a good EHR starting point, because they let doctors and patients exchange information online and asynchronously, easing telephone line congestion.
  1. One size does not fit all. General IT skills are useful. New rules will soon specify how physicians and hospitals can qualify for the HITECH incentive payments and which products will be certified. Even so, there may be many different routes to successful EHR use. A flexible perspective is paramount. Favor advisers with generalized health IT system knowledge, rather than expertise with a particular vendor’s product.Some medical practices will choose a single-vendor EHR with all the added features, but others will mix and match modular applications that together create can minimum system capability needed for HITECH meaningful user status and incentive payments.

    Similarly, some practices will prefer to locate data servers inside their practices or at the community hospital. Others will opt for Clinical Groupware, web-based and remote services EHR technologies that offer less hassle and expense for maintenance and security. Recognizing and differentiating between EHR technology offerings is going to be a major challenge for REC personnel in the near future.

  1. Skate to where the puck will be. The old paradigm of health data management tried to collect a patient’s complete data in a single database application, owned, maintained and controlled by a particular organization. However, throughout other disciplines, information management has become Web-centric and based on meta-data searches augmented by real-time communications and shared group activities.  Think Wikipedia, Google docs, Microsoft Sharepoint, the Apple iPhone, and, yes, even Facebook, as representative of where health IT is migrating over the next few years.Eric Schmidt, CEO of Google, and a member of the President’s Council on Science and Technology, PCAST, recently urged President Obama and David Blumenthal to consider Web-based technologies as the basis of the national health information network.  He warned that “the current national health IT system planned by the administration will result in hospitals and doctors using an outdated system of databases in what is becoming an increasingly Web-focused world. The approach will stifle innovation.” Mr. Schmidt’s advice, and similar advice from Craig Mundie of Microsoft, is coming from within the Administration, not from outside it. In other words, it’s much more likely to be heeded than if were it coming from the opposition.

    We hope that ONC’s specifications, issued as guidance to the RECs by mid-2010, reflect market-driven innovations that can reduce the cost and complexity of EHR technology acquisition and use. Otherwise we’re in for a national exercise in chaos.

  1. Don’t waste time re-inventing the wheel. Every REC should network with every other REC, regardless of location or stage of development, to share lessons and experience, and to avoid wasted effort. In the past, for example, regional helper organizations – some QIOs and medical societies – independently formed exclusive contracts with one or two EHRs vendors, hoping these arrangements would simplify choices and implementation. These proprietary relationships were invariably unsuccessful for the helper organization and for the practices.Physicians and their organizations want to make health IT selections based on their own situations and needs. But almost always, they will seek the same kinds of IT support during implementation: e.g. networking, set up, Internet connectivity, security, and basic computer skills training for staff and physicians alike.

    RECs should collaborate on tools and instruction kits where ever possible: each REC doesn’t need to develop its own HIPAA privacy and security guide book, for instance. Remember that peripheral devices, such as printers, fax machines, and modems, are part of every office’s set up, and that these items can be troublesome to set up and use.

  1. Come to the task understanding that successful HIT implementation requires fundamental process re-design. We’ve learned this the hard way. Unless health IT helps re-design practice work and information flow processes so they can be more efficient and quality-promoting, then the IT is simply an expensive appliance. Process re-design also can determine whether the EHR technology deployment produces a return on investment (ROI). For example, re-designing the documentation process to reduce or eliminate dictation transcription services, relying instead on EHR data entry by office staff and the physicians themselves, can save money and lead to an ROI within 12-24 months. We have seen this occur frequently. On the other hand, practices that continue dictation at the old levels are simply adding new data capture expense, making it harder to justify the investment.

States are hurrying to get access to this stimulus money. Many organizations aspiring to be RECs are focused on the rapid grant/award cycles. But its critical for planners to focus on what it will take to get the job done, and setting the groundwork for effective regional centers that can offer thousands of practices the help they need.

David C. Kibbe MD MBA is a Family Physician and Senior Advisor to the American Academy of Family Physicians who consults on healthcare professional and consumer technologies. Brian Klepper PhD is a health care market analyst.

THCB Classified: HIPAA Webinars-on-demand

The passing of the HITECH Act of 2009 mandated additional guidelines for the Health Insurance Portability and Accountability Act (HIPAA). On August 24, 2009 the Department of Health and Human Services (HHS) issued interim Security Breach Notification rules mandating compliance by September 23, 2009. All Covered Entities (CEs) and Business Associates (BAs) as defined by HIPAA are required to comply.

HITECH Answers provides to its subscribers a two-part Webinar series that deals directly with the HITECH Act’s impact on HIPAA and what CEs and BAs must do now to stay compliant. Presented by Jeff Rickman, Attorney-at-law and HIPAA specialist.

For more information visit www.hitechanswers.net/hipaa

“Meaningful Use” Criteria as a Unifying Force

Over the past several years, many diverse initiatives have arisen offering partial solutions to systemic problems in the U.S. health care non-system.

We see Meaningful Use Criteria recommended by the HIT Policy Committee as a unifying force for these previously disparate initiatives. These initiatives have included:

  • Patient Centered Medical Homes (PCMHs)
  • Regional Health Information Organizations (RHIOs)/Health Information Exchanges (HIEs)
  • Payer Disease/Care Management Programs
  • Personal Health Record Platforms — Google Health, Microsoft HealthVault, Dossia, health banks, more to come
  • State/Regional Chronic Care Programs (e.g., Colorado, Pennsylvania, Improving Performance in Practice)
  • Accountable Care Organizations — the newest model being proposed as part of national reform efforts

Today

While there are some commonalities and overlap, to-date these initiatives have mostly arisen in isolation and are highly fragmented — they’re all over the map. Here’s a graphic representation of the fragmentation that exists today:

Continue reading…

“Meaningful Use” Criteria as a Unifying Force

Vince-20kuraitis09-small

Over the past several years, many diverse initiatives have arisen offering partial solutions to systemic problems in the U.S. health care non-system.

We see Meaningful Use Criteria recommended by the HIT Policy Committee as a unifying force for these previously disparate initiatives. These initiatives have included:

  • Patient Centered Medical Homes (PCMHs)
  • Regional Health Information Organizations (RHIOs)/Health Information Exchanges (HIEs)
  • Payer Disease/Care Management Programs
  • Personal Health Record Platforms — Google Health, Microsoft HealthVault, Dossia, health banks, more to come
  • State/Regional Chronic Care Programs (e.g., Colorado, Pennsylvania, Improving Performance in Practice)
  • Accountable Care Organizations — the newest model being proposed as part of national reform efforts

Today

While there are some commonalities and overlap, to-date these initiatives have mostly arisen in isolation and are highly fragmented — they’re all over the map. Here’s a graphic representation of the fragmentation that exists today:

MU1

Tomorrow

The HIT Policy Committee recently recommended highly detailed Meaningful Use criteria for certified EHRs.  Doctors and hospitals who hope to receive HITECH Act stimulus funds will have to demonstrate that they are meeting these criteria; the criteria are not yet finalized.

The Committee website describes the central role of the Meaningful Use criteria:

The focus on meaningful use is a recognition that better health care does not come solely from the adoption of technology itself, but through the exchange and use of health information to best inform clinical decisions at the point of care.

The HIT Policy Committee also is recognizing that there are multiple routes to achieving Meaningful Use beyond the traditional EMR 1.0, e.g., modular Clinical Groupware software.

While some might view the Meaningful Use criteria as limited to the world of health IT — something happening “over there” — we see much more going on. We believe the Meaningful Use criteria are becoming a powerful unifying force across the health system, with potential to converge previously disparate initiatives.  Here’s our conceptual representation:

MU2

Let’s consider a couple examples to demonstrate how convergence is occurring.

RHIOs were formed primarily with a mission of developing health IT infrastructure for local data exchange; they had little need to think about how care providers, health plans and others would actually use the data.

Patient Centered Medical Homes have been built around seven principles (e.g., physician directed medical practice, care coordination) — none of which directly relate to a need to develop health IT infrastructure; the fact that IT infrastructure is necessary to implement these principles has been assumed but not defined.

RHIOs focused on health IT with little thought about objectives, while PCMHs had grand objectives with little thought about needs for health IT.

All this is changing.

RHIOs are recognizing that achieving meaningful use of data is essential; PCMH initiatives are recognizing the need for a robust IT infrastructure and the need to match their efforts to Meaningful Use criteria.

Here are some broader implications about Meaningful Use criteria becoming a unifying force:

  • These diverse initiatives will have more commonalities and will look more and more alike
  • Expect previously disconnected regional initiatives to start talking to one another about collaboration.
  • A common phrase we are hearing is “We need to do a crosswalk of Meaningful Use criteria with our initiative/organization/application functionality.”
  • Vendors must ask: “What are we doing to contribute to Meaningful Use of EHRs”
  • Care providers (doctors and hospitals) must ask: “How are vendor offerings helping us to achieve Meaningful Use of EHRs?”

These are positive developments.  Meaningful Use criteria are becoming a powerful unifying force toward integrating our fragmented health system.

Vince Kuraitis JD, MBA is a health care consultant and primary author of the e-CareManagement blog where this post first appeared. David C. Kibbe MD MBA is a Family Physician and Senior Advisor to the American Academy of Family Physicians who consults on healthcare professional and consumer technologies.  Steve Adams is Founder and CEO of RMD Networks, a Denver, Colorado based company.

Is “Cloud Computing” Right for Health IT?

Robert.rowley

The announcement of Salesforce.com investing and coordinating development efforts with Practice Fusion has brought talk of “cloud computing” to the fore. Salesforce has been known as a leader in cloud computing, and moving healthcare IT to that “cloud” has raised questions by a number of observers. What, exactly, is “cloud computing?” Is it appropriate for health IT? What are the security issues and risks?

“Cloud computing” is a term described as a style of computing in which on-demand resources are provided as a service over the Internet. Software-as-a-service (SaaS) is a type of cloud computing, where users do not need to install or maintain any software themselves – simple Internet access and a browser are all that is needed.  Users do not need to have knowledge of, expertise in, or control over the technology infrastructure in the “cloud” that supports them – the Internet site (e.g. Practice Fusion) provides a unified dashboard to the user, and works out the technical issues of presenting that data in the background.Continue reading…

On Clinical Groupware, Interoperability and the HITECH Bill

Was it not Aristotle who once remarked “Nature abhors a front end that is not connected to its backend?”

In his recent, insightful blog here on Clinical Groupware as an alternative “meaningful use” of IT under the Health Information Technology and Economic and Clinical Health Act (HITECH),  contained in the American Recovery and Reinvestment Act of 2009, David Kibbe commented that the primary purpose for using these IT systems is to “improve clinical care through communications and coordination involving a team of people, the patient included…in a manner that fosters accountability in terms of quality and cost.”

Yet it takes a “connected” health care ecosystem to make this kind of communication possible, and thus HITECH is replete with references to “interoperability” and “data exchange.”  Indeed, the concepts of “meaningful use” and “interoperability” are inextricably linked in HITECH.  For example, Section 4102 states that hospital incentive payments are dependent on demonstrating, “that during such period such EHR technology is connected in a manner that provides, in accordance with standards applicable to the exchange of information, for the electronic exchange of information to improve the quality of health care, such as promoting coordination of care.”

Continue reading…

For whom the HITECH Bill Tolls?

As part of a sweeping effort to address the woes of the current US economy, the government has placed $19 billion on the table for HIT, aimed at containing healthcare costs and creating new jobs. The ultimate instruments for implementing this HITECH bill are America’s physicians and there is much confusion and apprehension in the physician community regarding the net effects of this bill on doctors in particular and healthcare in general. The HIT stimulus effort will not reach its stated objectives without voluntary adoption by our doctors. The government and the HIT community must find a way to draw physicians all over this country into the process of defining and implementing the stimulus package.

In very broad terms, interoperability standards will be defined, Electronic Health Records (EHR) technologies will certify compliance with the standards and physicians will be provided financial incentives to acquire, and meaningfully use, those EHR technologies. The assumptions are that use of these standardized EHRs will reduce costs by reducing medical errors, reducing duplication of tests, improving quality of care and encouraging evidence based clinical decisions. Jobs will be created as the EHRs are deployed across the nation. Experts are already at work “on the Hill”, in the White House, in the boardrooms of HITSP, NIST, CCHIT and other acronym organizations. Technology vendors are feverishly doing their part, from creating websites devoted to the HITECH bill, to making products available at Wal-Mart, to sudden revelations that HIT is really their main business. Everybody is actively involved in making this bill a success.  Well, maybe not everybody.

Continue reading…