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Health Information Exchange: 101

2010-10-18T14:42:00.000-07:00

What is HIE

There are many definitions of HIE – Health Information Exchange. Health information exchange (HIE) may be defined as the mobilization of healthcare information electronically across organizations within a region, community or hospital system. Or, it can be described as infrastructure that enables the exchange of health information. Simply put, HIE is the secure, electronic exchange of health information among authorized stakeholders in the healthcare community – that include care providers, patients and public health agencies to provide more timely, efficient, effective, equitable, patient-centered care. The final goal of course is to have EHR for every American by 2014 along with better health care at lower costs.

Why Is It Important and Why Now?

Of course, the easy answer is there is never been a perfect time to reform or improve healthcare in America! There is enough data out there that shows healthcare can be delivered much more efficiently in the United States. The debate has always been on how to do it. And, everyone(physicians, patients and the government) is convinced about the benefits modern IT technologies can bring to healthcare system. Therefore all this talk about stimulus and EH R adoption and so on. The HIE program (with E HR adoption) will ensure:

Significant reduction in duplicate testing. Studies indicate the same drug or a radiology exam is ordered 11% of the time and patients comply with the duplicate 50% of the time.
Less Uncertainty: One in seven admissions and one in five lab tests and radiology exams gets ordered due to retrieval barriers. Also, a typical physician receives test results from five or more locations

HIE will change all that. It will break down barriers and will make information available to all authorized providers (users) in a secure manner. The result is better care and lower costs. HIE will transform the country’s healthcare system with new delivery models, reimbursement regulations and holds a myriad of benefits for Physicians, Hospitals and patients.

Our government has committed over $500 million to various States to create regional HIEs or organizations. There are several HIE (platform) vendors, notably Medicity and Axolotl (recently acquired by Ingenix) and technology behemoths like Microsoft, Google and IBM who are trying to make inroads into this fairly new market. Simplistically speaking, there are essentially two models for any information exchange, and, HIE is no different.

Centralized Model: This approach involves all information creators (or content producers) pushing their content to a centralized repository – in real time. Users can pull the information from this repository on demand in real time. (think Cloud computing). The key feature of this approach is big government involvement. Government investing monies in hardware and software, building clusters of databases, assigning national identifiers for Physicians, publish specifications for data that can be sent or pulled, etc. EH R vendors will build web services and will integrate them in their technology and processes.

Federated Model (or Call it the Distributed Model): Health information is maintained where it is created. It may be a clinic or physician office, hospital, therapy center or any other patient care facility. In this approach, contributors will push content to users if they want to and users will pull content from contributors when they need to. This is somewhat of a traditional telephony model. You make a contact or send or receive any information – i.e. when you want to. In this kind of communication between so many disparate entities, knowing the same language and know each other’s phone number is important- euphemistically speaking! The biggest barrier to success of this model is lack of open standards. As we are all aware, healthcare systems across the country use proprietary system and it is fairly common to find E HRs not talking or communicating with each other using open transmission protocols. No one knows for sure how the final HIE will look like. Initial deployments and trends indicate that it will be somewhat of a hybrid of the two models though.

Few Implementations

1. HealtheLink, the eight-county western New York State HIE whose service area includes Buffalo and Niagara Falls, got its start in 2004. Several state and federal grants helped pave the way over last six years and now HealtheLink has more than 700 providers and 3,000 users (including physician staff) sharing health information.

2. The Utah Health Information Network (UHIN) had a different start from most HIEs. It began in 1993 as an electronic administrative exchange, sharing claims, remittances, eligibility orders and other HIPAA-compliant data exchanges, and now covers 90 percent of the medical providers in Utah.

3. The Michiana Health Information Network (MHIN) serves more than 3,200 community healthcare professionals in northern Indiana and southwest Michigan. From 1999 to 2005, the basis of the exchange was jumpstarted with the participation of the South Bend Medical Foundation, an organization that provides cost-effective laboratory and blood banking services to communities in Indiana, Michigan, Kentucky, Ohio, and Illinois, and the six-facility Saint Joseph Regional Medical Centre in north central Indiana. Now the exchange includes more than 1,000 physicians, seven hospitals, more than 15 extended care facilities, radiology practices and more.

As we write, State HIEs are busy selecting and deploying various HIE platforms, using a wide range of privacy and security policies and standards for communication technologies. There will definitely be a lot of distributed or federated structure in the overreaching NHIN – Nationwide Health Information Network – which is under construction. To be sure, specification work on NHIN is far from complete. There are other private smaller, HIE networks being built. Large EHR vendors are building to run their own proprietary peer-to-peer networks across organizations, and, everyone (platform & organization) promises “seamless” integration of all these conflicting initiatives.

Where do we go from here? No one knows for sure. What we know for sure is exchange and sharing of healthcare information among stakeholders will look vastly different in 2014!

Health IT Standards & Committees

2010-09-27T15:13:00.000-07:00

In the last two blogs we talked about Meaningful Use and benefits of EHR adoption in these changing times. In the coming years we will see lot more debate and discussion as IT becomes more integrated in terms of how medical care is delivered in the US. That is where the role of Federal government comes in. Let us take a closer look at how Federal government is trying to shape the IT standards and protocols when it comes to practicing medicines at clinics and hospitals at facilities across the country. The caveat for the reader is that it will be a high level view. And, hopefully, the take away for the reader will be to a somewhat better understanding in terms of keeping track of federal and government initiatives in the months to come!

Understanding Health IT Policies & Committees

The American Recovery and Reinvestment Act of 2009 (ARRA) provided for the creation of an HIT Policy Committee under the auspices of the Federal Advisory Committee Act (FACA). The HIT Policy Committee is charged with making recommendations to the National Coordinator for Health IT on a policy framework for the development and adoption of a nationwide health information infrastructure, including standards for the exchange of patient medical information.

The HIT Policy Committee has several workgroups to further the work of the FACA Committee. The HIT Policy Committee’s workgroups are:

Meaningful Use Workgroup
Certification/Adoption Workgroup
Information Exchange Workgroup
NHIN Workgroup, Strategic Planning Workgroup
Privacy & Security Policy Workgroup
Enrollment Workgroup

Details: http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__health_it_policy_committee

Health IT Standards Committee: The American Recovery and Reinvestment Act of 2009 (ARRA) also provided for the creation of an HIT Standards Committee under the auspices of the FACA. The HIT Standards Committee is charged with making recommendations to the National Coordinator on standards, implementation specifications, and certification criteria for the electronic exchange and use of health information. The HIT Standards Committee will focus on the policies developed by the Health IT Policy Committee. The HIT Standards Committee also includes several workgroups to further the work of the FACA. These workgroups are: Clinical Operations Workgroup, Clinical Quality Workgroup, Privacy & Security Workgroup, and Implementation Workgroup.

Details:http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__health_it_standards_committee.

The Office of the National Coordinator for Health Information Technology (ONC) also supports the efforts of several related initiatives to facilitate nationwide adoption of health IT. Such initiatives include:

State-Level Health Initiatives: Initiatives designed to ensure that states and regional efforts to achieve health information exchange (HIE) are aligned with the national agenda.
Nationwide Health Information Network: A collection of standards, protocols, legal agreements, specifications, and services to enable secure HIE.
Federal Health Architecture: An e-government line of business initiative to increase efficiency and effectiveness in all government operations.
Adoption: An initiative supporting two national health IT adoption surveys: one of physician offices and one of hospitals.
Clinical Decision Support & the CDS Collaboratory: An initiative to provide clinicians, staff, patients or other individuals with knowledge and person-specific information, intelligently filtered or presented at appropriate times, to enhance health and health care.

Needless to say, these organizations are meet regularly, organize events, forums, trade shows, etc., where lot of information is shared and disseminated. To track changing healthcare IT environment, it is perhaps critical for a technology vendor to be a part of such discussions and announcements.

We suggest at least visiting the URL http://healthit.hhs.gov/portal on a regular basis (if attending and participating in related formus and events is not an option) to stay abreast as HITECH unfolds for the physician community!

EHR Debate: Meaningful Use and CCHIT Certification

2010-09-21T14:44:00.000-07:00

Is the confusion finally over?

“Our recovery plan will invest in electronic health records and new technologies that will reduce errors, bring down costs, ensure privacy and save lives.” President Obama, Address to Joint Session of Congress, February 2009

Yes, it is true that is when it all started. After lot of discussions and just about a year and a half later, on July 13^th, U.S. Department of Health and Human Services Secretary Kathleen Sebelius made key announcements regarding Meaningful Use (MU) and Stimulus money. Though I will cover various aspects of MU in many subsequent posts, it is best to visit the URL http://www.cms.gov for a comprehensive understanding. (Warning: It is quite a read! So plan on spending few hours for few days to get most out of it!)

We may not completely agree on how the stimulus, E HR adoption and MU will all play out in the long term, but it is true that there is a new excitement (I may add, much needed!) in the EHR marketplace and physician community is busy trying to select an E HR vendor, put together an implementation plan and trying to be ready when time comes to collect Federal Stimulus dollars- all over the country. Let us look at few facts:

-     As much as $27 billion has been committed in incentive payments over ten years. Eligible Professionals (EP) may receive as much as $44,000 under Medicare and $63,750 under Medicaid.
-     Hospitals may receive millions of dollars for implementation and meaningful use of certified EHRs underm both Medicare and Medicaid as well.
-     The final rules divides the requirements into a “Core” group of requirements that must be met, plus an additional “Menu” of procedures from which providers may choose.
-   Eligible professionals and hospitals must successfully demonstrate meaningful use of certified electronic health record technology every year they participate in the program(Medicare). Eligible professionals and hospitals may qualify for incentive payments for the adoption, implementation, upgrade or the demonstration of meaningful use in their first year of participation. They must successfully demonstrate meaningful use for the remaining years they participate in the program(Medicaid).
-     Proposed rules expect eligible professionals to meet 25 requirements in their use of EHRs. 20 of the objectives must be completed to qualify for an incentive payment. 15 are core objectives that are required, and the remaining 5 objectives may be chosen from the list of 10 menu set objectives.
-    For Hospitals, there are a total of 24 meaningful use objectives. 14 are core objectives that are required, and the remaining 5 objectives may be chosen from the list of 10 menu set objectives.

The criteria for meaningful use will be staged in three steps over the course of the next five years. Stage 1 sets the baseline for electronic data capture and information sharing. Stage 2 (est. 2013) and Stage 3 (est. 2015) will continue to expand on this baseline and be developed through future rule making.

There are detailed regulations with regards to penalties for not adopting EHRs. For instance, Medicare payments may be reduced to 99% in 2015, and reduced further to 97% by 2017 for practices that have not implemented a certified EHR. Also, after 2015, incentive payments will end.

There will be many new bodies certifying E HRs in the months and years to come. And, it is certain that CCHIT will be one of the certifying bodies. It is important to understand that CCHIT is not the same thing as Meaningful Use (MU). MU can be understood best as a subset of CCHIT certification.

Isn’t that a lot of information to digest? Though fair amount of regulations have been announced and finalized in the last few months, this will continue to be a dynamic environment. For one thing, E HR penetration in the clinical segment (especially smaller practices and solo practioners) remains quite low, and a higher adoption will breed new ideas and ways to practice medicine that no one has thought before. More to follow..

More reads. .
http://www.ofr.gov/OFRUpload/OFRData/2010-17207_PI.pdf
http://www.ofr.gov/OFRUpload/OFRData/2010-17210_PI.pdf

EHR Debate: Meaningful Use and CCHIT Certification

2010-09-21T14:32:00.000-07:00

Taking a Deeper Dive. . .

This is the second post in our series of EHR and meaningful use. First, few notable announcements and then some more powwow!

Two EHR Certifiers

The Office of the National Coordinator for Health Information Technology has named the Certification Commission for Health Information Technology (CCHIT) and the Drummond Group Inc. as the initial Authorized Testing and Certification bodies for the temporary electronic health records certification program.

- Chicago-based CCHIT has long been associated with certification process. And, Driummond Group (TX) is a new company that has always wanted to be in this space. EHRs currently certified under previous CCHIT programs must now be recertified as supporting electronic health records meaningful use criteria under the temporary certification program that lasts until at least Jan. 1, 2012. Now, vendors need to apply to CCHIT and Drummond Group to go through the testing and certification. For more information visit cchit.org and drummondgroup.com.

Let us talk about Stage 1 Objectives in this post as these will be critical to understand and implement EHR till 2013. Stage 2 kicks in 2013 and Stage 3 in 2015 - at least this is how the Final Rule stands today!

What is Stage 1 Criteria?

· 15 Core Objectives – For benefits to kick in, Eligible User (EU) has to satisfy all 15 objectives

· Menu set of 10 Objectives, i.e., EU to satisfy 5 of 10 from the menu set

15 Core Objectives

1. CPOE – Computerized Physician Order Entry: At least one medication ordered via CPOE for >30 percent of unique patients seen with at least one medication on current medication list

2. Drug-drug, Drug-Allergy Checking: CPOE drug-drug and drug-allergy checking features should be enabled

3. Generate and Transmit Electronic Prescriptions: >40 percent of all permissible medication orders (excluding controlled substance orders) are electronically prescribed

4. Maintain up-to-date Problem/Diagnosis List: For >80 percent of unique patients seen (at least one structured entry, ICD-9-CM or SNOMED CT)

5. Maintain Active Medication List: For >80 percent of unique patients seen (at least one structured entry)

6. Maintain Active Medication Allergy List: For >80 percent of unique patients seen(at least one structured entry)

7. Record Vital Signs: For >50 percent of unique patients ≥ 2 years old seen, record and chart changes in vital signs (as structured data): i. Height, weight, blood pressure; ii. Calculate & display BM, Plot and display growth chart, including BMI (patients 2-20 years old)

8. Record Demographics: For >50 percent of unique patients seen, record demographics (as structured data):

i. Gender; ii. Ethnicity, race (federal guidelines), preferred language; iii. Date of birth

9. Record Smoking Status: For >50 percent of unique patients seen ≥ 13 years

10. Report Quality Measures to CMS and the States: Report ambulatory quality measures — per data captured and calculated by the EHR — to CMS or the states for specified core and specialty measures

–      For 2011: attest to accuracy and completeness of aggregate numerator and denominator
–   For 2012 (and beyond): submit (at least one measure) electronically
11. Implement Clinical Decision Support: Implement one rule (with high clinical priority for or relevant to the specialty of the EP) and track compliance
12. Provide Patients with Clinical Summary of Office Visits: Satisfy more than 50 percent of requests for a clinical summary of an office visit (via Personal Health Record (PHR), portal, other electronic media, or printed output) within 3 business days
13. Provide Patient with Electronic Copies of Health Information: Provide >50 percent of patients who request copies with electronic copies of their health information (lab test results, problem, medication, allergy lists) within 3 business days
14. Implement Capability to Exchange Key Clinical Information: Perform at least one test of the capability of the certified EHR system used by the EP to electronically exchange key clinical information (for example, problem list, med list, allergies, test results) with another EHR (not shared)
15. Implement Systems to Protect Patient Data: Conduct or update a security risk assessment per 45 CFR

Functional Requirements
1. Incorporate Test Results into EHR: Incorporate clinical laboratory test results into EHR as structured data
for >40 percent of all clinical lab tests ordered with positive/negative or numeric results
2. Medication Reconciliation: Performed at >50 percent of relevant encounters and transitions of care
3. Drug Formulary Checking: Drug-formulary check functionality is enabled (with access to at least one internal or external formulary for entire period)
4. Generate Patient Lists: Generate at least one list of the EP’s patients with a specific condition to use for quality improvement, reduction of disparities, and/or outreach Health Information Exchange (HIE) Requirements
5. HIE: Patients: Provide >10 percent of unique patients seen with electronic access (available on-demand at any time) to their health information (lab test results, problem, medication, allergy lists) within 4 business days of the

information’s availability to the EP
6. Patient Follow-up/Preventive Care Reminders: Send reminders for preventive/follow-up care (per patient preference) to >20 percent of patients who are ≥65 or <5 years old
7. HIE: External Providers: Provide summary care record (via electronic exchange, secure portal, secure e-mail, CD, USB drive or printed copy) for >50 percent of patient transitions of care and referrals
8. HIE: Immunization Registries: Perform at least one test of the capability to submit electronic data to
immunization registries; Actual submission where required and accepted
9. HIE: Syndromic Surveillance Data; Perform at least one test of the capability to provide electronic surveillance data to public health agencies. Actual transmission according to applicable law and practice
10. Identify Patient-Specific Educational Resources: Use EHR technology to identify and provide >10 percent of unique patients seen with patient-specific educational resources

And now, the final caveat.   Incentive payments for becoming a “meaningful user of certified EHR technology” are only a small portion of the savings in the overall healthcare costs if changing policy works as expected over the next 5 years. The EHR incentive programs are putting approximately $25 billion (give or take a few billion), into the hands of physicians and hospitals who adopt EHR technology during 2011 and 2016. During the same time, experts claim we could see savings of $100 billion to Medicare alone,( depending on whose estimate you believe) by reducing waste, duplication, and unnecessary procedures. It might be a lot more.   Some studies indicate that about 25%- 30% of our total national health care expenditure of $2.5 trillion (about $800 million), is unnecessary and could be eliminated through healthcare reforms as proposed by President Obama administration. Now, that is definitely an amount the country can benefit from!

HITECH Act: Privacy Requirements

2010-04-12T22:02:00.001-07:00

HITECH Act: Privacy Requirements

Subtitle D of the Health Information Technology for Economic and Clinical Health Act (HITECH Act), enacted as part of the American Recovery and Reinvestment Act of 2009, and addresses the privacy and security concerns associated with the electronic transmission of health information.
This subtitle extends the complete Privacy and Security Provisions of HIPAA to business associates of covered entities. This includes the extension of newly updated civil and criminal penalties to business associates. These changes are also required to be included in any business associate agreements with covered entities. On November 30, 2009, the regulations associated with the new enhancements to HIPAA enforcement took effect.
Another significant change brought about in Subtitle D of the HITECH Act, is the new breach notification requirements. This imposes new notification requirements on covered entities, business associates, vendors of personal health records (PHR) and related entities if a breach of unsecured protected health information (PHI) occurs. On April 27, 2009, the Department of Health and Human Services (HHS) issued guidance on how to secure protected health information appropriately. Both HHS and the Federal Trade Commission (FTC) were required under the HITECH Act to issue regulations associated with the new breach notification requirements. The HHS rule was published in the Federal Register on August 24, 2009, and the FTC rule was published on August 25, 2009.
The final significant change made in Subtitle D of the HITECH Act, implements new rules for the accounting of disclosures of a patient's health information. It extends the current accounting for disclosure requirements to information that is used to carry out treatment, payment and health care operations when an organization is using an electronic health record (EHR). This new requirement also limits the timeframe for the accounting to three years instead of six as it currently stands. These changes won't take effect until January 1, 2011, for organizations implementing EHRs between January 1, 2009 and January 1, 2011, and January 1, 2013, for organizations who had implemented an EHR prior to January 1, 2009.

Effects on research and clinical care

The enactment of the Privacy and Security Rules has caused major changes in the way physicians and medical centers operate. The complex legalities and potentially stiff penalties associated with HIPAA, as well as the increase in paperwork and the cost of its implementation, were causes for concern among physicians and medical centers. An August 2006 article in the journal Annals of Internal Medicine detailed some such concerns over the implementation and effects of HIPAA.

Effects on research

HIPAA restrictions on researchers have affected their ability to perform retrospective, chart-based research as well as their ability to prospectively evaluate patients by contacting them for follow-up. A study from the University of Michigan demonstrated that implementation of the HIPAA Privacy rule resulted in a drop from 96% to 34% in the proportion of follow-up surveys completed by study patients being followed after a heart attack. Another study, detailing the effects of HIPAA on recruitment for a study on cancer prevention, demonstrated that HIPAA-mandated changes led to a 73% decrease in patient accrual, a tripling of time spent recruiting patients, and a tripling of mean recruitment costs.
In addition, informed consent forms for research studies now are required to include extensive detail on how the participant's protected health information will be kept private. While such information is important, the addition of a lengthy, legalistic section on privacy may make these already complex documents even less user-friendly for patients who are asked to read and sign them.
These data suggest that the HIPAA privacy rule, as currently implemented, may be having negative impacts on the cost and quality of medical research. Dr. Kim Eagle, professor of internal medicine at the University of Michigan, was quoted in the Annals article as saying, "Privacy is important, but research is also important for improving care. We hope that we will figure this out and do it right."

Effects on clinical care

The complexity of HIPAA, combined with potentially stiff penalties for violators, can lead physicians and medical centers to withhold information from those who may have a right to it. A review of the implementation of the HIPAA Privacy Rule by the U.S. Government Accountability Office found that health care providers were "uncertain about their [legal] privacy responsibilities and often responded with an overly guarded approach to disclosing information...than necessary to ensure compliance with the Privacy rule". Reports of this uncertainty continue.

Costs of implementation

In the period immediately prior to the enactment of the HIPAA Privacy and Security Acts, medical centers and medical practices were charged with getting "into compliance". With an early emphasis on the potentially severe penalties associated with violation, many practices and centers turned to private, for-profit "HIPAA consultants" who were intimately familiar with the details of the legislation and offered their services to ensure that physicians and medical centers were fully "in compliance". In addition to the costs of developing and revamping systems and practices, the increase in paperwork and staff time necessary to meet the legal requirements of HIPAA may impact the finances of medical centers and practices at a time when insurance company and Medicare reimbursement is also declining.