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Lou Agosta

Greetings and welcome to my blog focusing on reengineering healthcare using information technology. The commitment is to provide an engaging mixture of brainstorming, blue sky speculation and business intelligence vision with real world experiences – including those reported by you, the reader-participant – about what works and what doesn't in using healthcare information technology (HIT) to optimize consumer, provider and payer processes in healthcare. Keeping in mind that sometimes a scalpel, not a hammer, is the tool of choice, the approach is to be a stand for new possibilities in the face of entrenched mediocrity, to do so without tilting windmills and to follow the line of least resistance to getting the job done – a healthcare system that works for us all. So let me invite you to HIT me with your best shot at LAgosta@acm.org.

About the author >

Lou Agosta is an independent industry analyst, specializing in data warehousing, data mining and data quality. A former industry analyst at Giga Information Group, Agosta has published extensively on industry trends in data warehousing, business and information technology. He is currently focusing on the challenge of transforming America’s healthcare system using information technology (HIT). He can be reached at LAgosta@acm.org.

Editor's Note: More articles, resources, and events are available in Lou's BeyeNETWORK Expert Channel. Be sure to visit today!

January 2010 Archives

The following are reasons in favor of (required) certification of EHRs. Future comments (posts) will consider the other side of the debate - the case against (required) certification of electronic healthcare record (EHR) technology. If you (dear reader) can think of addition reasons, please let me know - comment below. Thanks!

 

  1. Market dynamics are enhanced by certification: A market filter (or gate-keeper) is useful to separate the wheat from the chafe. Market discipline has its uses in providing prospective buyers with a short list of contenders. If a vendor is so small and marginal to be unable to get over the bar to afford certification, then just maybe it needs to stay on the sidelines and not try to play with the tried-and-true vendors in the market. This will reduce the likelihood of orphan software, rip-and-replace projects, and surprises that damage the reputation of the software (system development) industry as a whole. Along the same lines, even if critics argue that CCHIT is an organizational bottle-neck (or becomes one at any point), certification as such is a positive requirement and additional resources should be marshaled to make it work.

 

  1. HIT is a complex artifact. Healthcare providers (EPs and hospitals) are in the business of fighting disease, not debugging software. It makes good sense to perform the work of identifying, distinguishing, and testing IT functionality up front. This eases the acquisition process and speeds time to implementation. Although it is shocking to think that such things occur, sales people from would-be EHR/EMR systems are already telling small physician practices and community hospitals that 'EMR is mandated - you have to buy one - let me give you a deal on mine'. Of course, nothing could be further from the truth. Discipline is required.

 

  1. Certification reduces information asymmetries: Instead of relying on the vendor's marketing brochure, prospective buyers of complex HIT are able to consult the results of a disinterested third party, for example, downloading detailed testing scripts off the CCHIT.org web site and doing their homework up front. Without certification, the floodgates will be opened to reimbursements as providers address the issue willy-nilly by buying a standard relational database, a data model, and a frontend query and reporting tool. In addition, the transparency and accountability in required system functionality serves a useful educational role.

 

  1. System software quality is promoted, standards are implemented by required certification. There is an argument that the testing that occurs as part of certification has value, especially as part of a conversation about standards and benchmarks. Even given that some controversy about the details is seemingly inevitable, the amount of information surfaced by the assembly and application of the certification-oriented test scripts is substantial.  The certification process can (and will) drive standards promoting interoperability - content exchange, transport, security standards - into the market.[1] Interoperability' and that lack of it is one of the major challenges facing HIT. Lack of interoperability creates substantial friction and inefficiencies. The incremental implementation of interoperability will go a long way to reducing costs, improving care, and modernizing HIT in the USA.


[1] For example, for the purpose of submitting lab results to public health agencies, certified EHR Technology must be capable of using HL7 2.5.1. Certified EHR Technology is supposed to be capable of receiving a message with Logical Observation Identifiers Names and Codes (LOINC®) codes from a laboratory, retaining those LOINC® codes, and using LOINC® codes to populate a patient summary record. Certified EHR Technology is only supposed to be capable of using LOINC® codes that are received and retained to populate a patient summary record. For the purposes of performing a drug formulary check, certified EHR Technology must be capable of using NCPDP Formulary & Benefits Standard 1.0 adopted by HHS (73 FR 18918) in order to ensure in circumstances where an eligible professional or eligible hospital electronically prescribes a Part D drug for a Medicare Part D eligible individual, he/she can maintain compliance with applicable law. This list of standards is not complete, but will serve to make the point.


Posted January 28, 2010 8:03 PM
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The game is afoot. On Wednesday December 20, 2009, the Department of Health and Human Services (HHS), Centers for Medicare & Medicaid Services, Electronic Health Record Incentive Program, issued its proposed criteria for the meaningful use of certified electronic healthcare records (EHRs).

      In every case, the healthcare provider (physician, professional, hospital, and so on) is the entity that is eligible for reimbursement and which must demonstrate meaningful use. The mere purchase of a software/hardware package or system integration project - regardless of its status as certified or not - is not sufficient. The technology is required to be used in a way that, in effect, adds value in transforming the delivery of healthcare services. In this case, 'value' consists in capturing clinical data - for example, vital signs - in electronic form, using it for clinical decision support, and gradually enabling interoperability, usability, affordability (cost reduction), and applying that information to the solution of individual and communal healthcare challenges. As currently stated, the criteria focus on a result and a measure rather than a "how to" or method of demonstrating the result. For example, entry level criteria mandate the collection and recording of  patient demographics, record vital signs, and maintaining a list of active medications for at least 80% of unique (individual) patients admitted. The later is basic data processing, though other criteria are more complex and demanding. The message? For those lagging adopters, it's time to throw away paper charts and advance to the twentieth century.

      The proposed rules implement the provisions of the American Recovery and Reinvestment Act of 2009 (ARRA). At this point, the status of the rules are 'a proposal' and a request for public comment from healthcare professionals, healthcare consumers, and everyone - the public at large. However, the expectation is that something substantially similar to this 556-page proposal (Pub. L. 111-5) is what will actually be implemented, even if extensive minor changes are incorporated and the date slips a tad.

     It is this proposal that provides the definition of 'meaningful use' and incentive payments to eligible professionals (EPs) and eligible hospitals participating in Medicare and Medicaid programs for adopting certified electronic health record (EHR) technology. The proposed rule defines the criteria an EP and eligible hospital must meet in order to qualify for the incentive payment and the calculation of the incentive payment amounts. The proposed rule also defines payment adjustments - here 'adjustment' means 'penalty, fee, fine, or deduction' under Medicare for failing to implement meaningfully use certified EHR technology.

            This proposal offers both a carrot - substantial reimbursements - as well as a stick. The stick? Those EPs and hospitals that do not meaningfully use an EHR by 2015 will find their reimbursements cut significantly by Medicare.

     The proposal furnishes answers - in detail and in draft - to answer the question, 'So what are the rules anyway?' As usual, the devil is in the details.

Congress specified three types of requirements for meaningful use: (1) use of certified EHR technology in a meaningful manner (for example, capturing data about who smokes cigarette, vital signs, electronic prescribing); (2) that the certified EHR technology is connected in a manner that provides for the electronic exchange of health information to improve the quality of care; and (3) that, in using certified EHR technology, the provider submits to the Office of Secretary (HHS) information on clinical quality measures.

The goal is to make meaningful use of certified EHR technology a foundation for healthcare that is patient-centered, evidence-based, prevention-oriented, efficient, and fair. The matter of who or what gets to certify what entity is already a contentious one, and will be addressed in forthcoming posts in this blog. Meanwhile...

Starting in 2011 - which basically means 'get ready now' - the first stage of meaningful use focuses on the electronic healthcare record (EHR) and electronically capturing health information in a coded format; using that information to track clinical conditions and communicating that information for coordination of care, implementing clinical decision support software and processes, enabling disease and medication management; and reporting clinical quality measures and public health information.

Beginning in 2013, stage 2 raises the bar on the use of health IT for continuous quality improvement at the point of care. The exchange of information in the most structured format possible is required, for example, the electronic transmission of orders entered using computerized provider order entry (CPOE) and the electronic transmission of diagnostic test results (such as blood tests, microbiology, urinalysis, pathology tests, and other diagnostic data). In addition, the criteria will be applied broadly to inpatient and outpatient settings.

Beginning in 2015, stage 3 criteria focuses on improvements in quality, safety and efficiency, enabling decision support for national high priority conditions, patient access to self management tools, access to comprehensive patient data and improving population health.

  Do not be scared off by the size of the report. There is an amazing amount of redundancy and repetitions as befits a government report. However, there still is a couple hundred pages of meaty material under any interpretation. What are your plans for the weekend? You can download the full document at

http://www.federalregister.gov/articles/2010/07/28/2010-17207/medicare-and-medicaid-programs-electronic-health-record-incentive-program



Posted January 6, 2010 9:12 PM
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