Time again for our weekend EHR Twitter round up. Let the fun begin.

@ahier – Brian Ahier
#EHR’s need encryption says @HealthPrivacy to Senate panel bitly.com/rTnx6s

Is there an EHR software that doesn’t use encryption? Is there a doctor’s office that’s paying for an EHR that doesn’t use encryption? Certainly not all EHR encryption implementations are created equal. In fact, I wish that things like encrypting data were part of an EHR certification. Why? Cause that’s something you can actually certify in a meaningful manner.

@drmikesevilla – Mike Sevilla, MD
RT @SeattleMamaDoc Computers all down in the exam rooms today. One major limitation of an EMR/EHR (dependence on a computer)

Definitely is one challenge with an EMR/EHR. I wonder how many patients were seen without the chart, because it couldn’t be found quickly. There are always pros and cons to IT. It does highlight the need to have a well thought out plan for how you’re going to care for patients when your EHR is down.

@iWatch – iWatch News
State health exchanges might not be sustainable after $548M in stimulus money runs out: bit.ly/t9QfSl #HIE #EHR

Wait, so changing the name of them from RHIO to HIE didn’t solve any of the problems with these exchanges? Oh yes, I forgot to mention the extra $548 million to help solve the problems. I think this best illustrates that money isn’t the issue or at least there are more issues with HIE than just the money.

Jeremy Bikman from KATALUS Advisors wrote this interesting comment on a LinkedIn discussion I was participating in:

Perhaps there is a place for MUMPS but only if healthcare continues to thumb its nose at the prevailing technology trends. It’s hard for me to envision healthcare to continue to embrace a technology that doesn’t like to play nicely with other non-MUMPS systems. If there were real advantages to it you would see a fair number of high tech firms utilizing it (Facebook, salesforce.com, Twitter, Spotify, etc).

If your goal is to have an enterprise system with a database that has some scale to it and certainly has good speed, and you don’t really care about interoperability with other systems, then MUMPS is certainly a good viable option. But IMO, the days of healthcare IT being insular, and moving out of phase with the rest of the tech world, are numbered.

I found this comment incredibly interesting. Mostly because I’ve never personally believed that the fact that many of the larger healthcare IT and EMR systems are built on MUMPS was any part of the reason why healthcare entities aren’t interoperable. I’m a tech guy by background, but I’ve never worked on a MUMPS software system myself so I don’t have first hand knowledge of MUMPS in particular. However, it seems wrong to “blame” MUMPS on the lack of healthcare data interoperability.

I guess the way I look at it is that no matter which database back end you have, you’re always going to need some front end interface to take care of the transport of the healthcare data to another system. Is this any harder with MUMPS than another SQL or even NOSQL database? From my experience it shouldn’t matter. I’d love to hear if there are reasons why it is harder.

I also don’t want to give the impression that Jeremy is trying to say that MUMPS is the only reason that healthcare IT has been so insular and closed. I’m pretty sure he agrees with me that a lot of other factors that have stopped healthcare from sharing data. I just don’t believe that MUMPS is one of those reasons.

Of course, the question of whether MUMPS should continue in healthcare is a different question. In fact, I wrote about MUMPS in healthcare IT and EMR here.

What are your thoughts? Is MUMPS the problem with healthcare interoperability? What are the other reasons stopping healthcare interoperability?

Update: Jeremy Bikman provided the following clarifying comment in the comments of this post:
Good points John. I really should have clarified. MUMPS is not really the issue (although I still stand by my assertion that if it was such a superior technology you’d see it all over Silicon Valley, RTP, etc). The main issue is really with the walled garden (w/ razor wire and machine guns along the top) approach of the major EMR/HIS vendors that have it as their foundation.

The more control you exert over your clients and the harder you make it to connect with other systems, the more money you can make…at least in the short-term.

John’s thought: I still look forward to the discussion around MUMPS and interoperability and healthcare interoperability in general.

The following is part of an email interaction I had with an EHR vendor about the future of CCD. Of course, I can never let strong opinions go unpublished. So I asked if I could put this on my site. I have a feeling there will be many people who have a different view of CCD and how these standards will play out. I’d certainly be happy to publish an opposing view as well. My contact page is here. I’m interested to hear other view points on the subject.

Stage 1 MU allowed either CCR or CCD. Stage 2, and the short term efforts will require CCD. The jury is still out on what Stage 3 of MU will focus upon. Many at the ONC can see that the CCD will never have the flexibility to deliver. These are largely the same people that facilitated the Direct Project initiatives.

I still predict that it is inevitable that the data will become uncoupled from unwieldy, anachronistic document structures. That will be the only means to get to true information portability that can deliver patient-centric use of the information. The CCD will still be around for a while to come, just as CD’s are still around for music sharing. For now, we have to have the CCD to preserve legacy, industry-centric control of the information.

John Halamka has a couple of recent posts that do a good job of explaining what is evolving…. http://geekdoctor.blogspot.com/2011/09/september-hit-standards-committee.html and http://geekdoctor.blogspot.com/2011/10/cool-technology-of-week.html . Both of these contain links to some very interesting information. When the ONC proceeded to issue an advanced notice of rulemaking, the industry power elites became enraged. http://www.ihealthbeat.org/articles/2011/9/22/groups-urge-onc-not-to-include-metadata-standards-in-stage-2.aspx

Technology delivering to patients will eventually win out just as the open-platform WWW won out over proprietary CompuServe. http://www.healthdatamanagement.com/news/onc-metadata-ehr-meaningful-use-43021-1.html Once we have a means to truly exchange the content without the overhead associated with the CCD/RIM crap, we will see a revolution in healthcare similar to the social networking phenomenon.

Again, the whole CCD/CDA will stick around to support legacy information needs, but it will eventually be largely eclipsed by more straight-forward solutions that don’t require a team of consultants and IT engineers to implement.

Today at MGMA, Fujitsu together with Osmosyz announced a new scanner that supports the relatively new CDA “Unstructured Document” HL7 standard at MGMA 2011. I must admit that the press release is a little intense. However, I find what they’re doing with a hardware product to support HIE is quite interesting.

I don’t want the title of this post to be misleading. While certainly HIE has generally become synonymous with some large health information exchange entity, in this case I’m describing a hardware device (a smart scanner if you will) that acts as a small health information exchange. Basically, it’s more along the lines of Direct Project as opposed to NHIN. Although, I imagine that it could send the documents to some larger health information exchange if someone wanted to do so.

The larger application I see of this technology is as a replacement for the fax machine. In some ways, it’s like a second generation fax machine. The major differentiation I see between a document sent using the CDA “Unstructured Document” HL7 standard and a fax is all the meta data that comes with the CDA document.

The fax or scanning workflow for most EHR software consists of receiving faxed documents or scanning documents into what amounts to basically a bucket of all the scanned documents. Then, it’s up to the user to go in and sort through all the various faxes that have been received or documents that have been scanned. At this point, the user can assign the document to a patient in the EHR. You can imagine the challenges that this can pose. I wonder how many documents scanned or faxed into an EHR have been assigned to the wrong patient accidentally.

That’s what makes this new Fujitsu scanner quite interesting. If it’s receiving the document from an outside source, it will come with the meta information for the document as part of the CDA standard. That can then be leveraged to more quickly assign that document to the patient. Not to mention, then all of that CDA information is available for other uses within the EHR.

For inside documents that are scanned in through the Fujitsu device you can actually assign the document to a patient on the scanner itself. That’s right, you can identify which patient a scanned document belongs to while you’re holding the document in your hand. A much better way to ensure that the document you scanned gets attached to the right patient in your EHR.

I’m just touching on a few of the features of what’s possible with this new Smart Scanner from Fujitsu and smart documents. You can do other things on the scanner like dividing document scans between multiple patients.

Meaningful Use Monday Angle
Of course, as most of you know, on Monday we usually do our regular Meaningful Use Monday series. Turns out that the CDA Clinical Document standard that I discuss above is being adopted by ONC as part of meaningful use. I’ll be interested to see how this plays out over time, but don’t be surprised if EHR software has to support this standard in the future.

What I find more intriguing is that the above scanner could be used by someone who doesn’t have an EHR, but wants to exchange patient information. I still think that the long term solution to interoperability of patient information has got to come from connections with EHR software. However, this does illustrate that technology solutions can and will be created to exchange health information. In fact, some combination of these solutions could be a way to meet some of the meaningful use requirements around exchange of health information. You still can’t get the EHR stimulus money without an EHR, but technologies like this could help you achieve meaningful use.

I’ll keep an eye on how this technology progresses. I wonder how many EHR vendors will integrate with this type of technology. Whether we like it or not, documents are going to be a major part of healthcare for the foreseeable future. We’ll see if smart documents and smart scanners are an intermediate step to the health information exchange nirvana (whatever that might be).

I must admit that I’m not much of a book guy. Especially since there’s so much free information available on the internet about just about any subject you could want. However, I’ve been quite intrigued by the number of healthcare IT related books that I’ve seen coming out of late. Here’s a quick roundup of some of the ones I’ve seen.

Getting to Meaningful Use and Beyond: A Guide for IT Staff in Health Care by Fred Trotter and David Uhlman – I’ve been a big fan of Fred Trotter for a while. So, I’m glad he’s working on this book. Turns out the book isn’t even published, but in Fred Trotter open source style fashion, the book is available for free online right now. Of course, they’re hoping you’ll provide feedback.

The HITECH Act Made Easy: A Simple Guide to the Federal EHR Incentive Programs – I had this book sent to me. It’s a short book which I think is good. It tries to tackle not only the details of the Medicaid and Medicare stimulus program, but also has a number of sections on EHR selection and implementation as well. I love it’s question format where many of the chapters are a question and the chapter offers the answer.

Health Information Exchange Formation Guide: The Authoritative Guide for Planning and Forming an HIE in Your State, Region or Community – I haven’t really had a chance to dig into this book yet. It’s brought to you by HIMSS. It’s a pretty thick book which I think describes well the challenge that is forming an HIE. Without reading the book, I’m a little torn just by the subtitle of the book, “The Authoritative Guide for Planning and Forming an HIE in your State, Region or Community.” I guess it’s hard for me to imagine it being the “authoritative guide” when I think we’re still trying to figure out the right HIE business model. I don’t think we’ve found it yet. I guess I should read the book to find out.

Jim Tate’s EHR Incentive Roadmap – Ok, this is an e-Book, but I think it’s as good a value as any hard cover book. So, it’s worth mentioning. I wrote a whole post on Jim Tate’s EHR Incentive book before.

Any other books about EMR, Meaningful Use, and/or healthcare IT that are out that we should know about?

UPDATE: User EHR and Meaningful Use Recommendations from the comments below:
Electronic Health Records For Dummies – Recommended by Nate Osit

Electronic Health Records: Transforming Your Medical Practice, second edition – “This is a book from MGMA and was recommended to me by a coordinator from the REC (Ohio) that I have been shadowing.” – Mary Ellen Weber

Healthcare and health IT are plagued by conundrums. Providers long have been the ones asked to make hefty investments in EMRs and other IT systems to help remove costs from the healthcare system, but payers and plan sponsors tend to enjoy most of the financial benefits. Clinicians wish their organizations would share data with others, but those in the executive suite have been reluctant to cooperate with competitors for fear of losing revenue. And, let’s face it, medical errors can be profitable if a routine procedure turns into an expensive inpatient admission.

Portions of the American Recovery and Reinvestment Act and the Patient Protection and Affordable Care Act are intended to address these problems by providing financial incentives for “meaningful use” of EMRs (including health information exchange) and by encouraging the creation of Accountable Care Organizations

I’m just back from the Institute for Health Technology Transformation health IT summit in Fort Lauderdale, Fla., where I moderated panels on how health IT underpins ACOs and how business intelligence can create a framework for health information exchange.

The panelists did great job of articulating some of these conundrums and strategies to overcome them, but none better than Kevin Maher, director of clinical innovations for Horizon Healthcare Innovations, a new affiliate of Horizon Blue Cross Blue Shield of New Jersey tasked with testing new care models, and Victor Freeman, M.D., quality director in the Health Resources and Services Administration‘s Office of Health IT and Quality.

The patient-centered medical home is a great idea for managing care, promoting prevention and, ultimately reducing costs. “We view the base of the ACO as the patient-centered medical home,” Maher said. But what exactly does an ACO look like? “An ACO is like a unicorn,” Maher said. “We can all describe it, but we’ve never seen one.”

He noted that Horizon has started paying some physicians a care coordination fee to manage populations that potentially could add $60,000 or more to a doctor’s annual income. But there are plenty of factors outside a physicians’ control.

“Potentially the No. 1 focal point of a patient-centered medical home or an ACO is patient behavior,” Maher said. A doctor can’t force a patient to exercise more, quit smoking or get a mammogram or PSA test. There’s pay-for-performance for doctors, but what about paying for patient performance?

In January 2012, Horizon will launch a pilot to offer incentives to members who get recommended tests and choose providers that meet the health plan’s quality standards. That’s right, the Blues plan in New Jersey will pay people to go to the doctor and to make informed choices about which doctors they see. (“Everyone says she’s a great doctor” won’t cut it as an informed choice anymore.)

Freeman called the Horizon experiment “P4P that makes sense.”

Let’s just hope the technology can support making the right choices. “People in government get more involved in quality measurement, not necessarily quality,” Freeman said. Incentive programs these days still tend to be more pay-for-reporting than pay-for-quality, and the technology hasn’t fully matured in that area.

“EMRs were designed for billing, not quality reporting,” noted Freeman, who has a background in public and population health. Information often isn’t stored in discrete form, such as with images generated by specialists flagged as being abnormal, so even with HIE, it’s hard for primary care physicians to identify patients who might be candidates for early interventions before they actually exhibit symptoms of a disease.

“My biggest interest in HIE is how clinicians communicate with each other,” Freeman said.

But is the technology ready to help them do so? “HIE now reminds me of what EMRs were five years ago,” said another panelist, Bruce Metz, Ph.D., newly hired senior VP and CIO at the Lahey Clinic in Massachusetts. It’s viewed as an IT project that’s not necessarily linked to a business or clinical strategy. “You can’t force the technology to mature that fast,” he added.

And so the ride continues on what Metz called “a fast-moving train.” Have we even had time to see if the right people are on board?

I live in Chicago, a highly competitive healthcare market with some world-class medical schools (Northwestern, University of Chicago, Loyola, Rush) and a pretty decent record of EMR adoption. At least four major institutions/health systems run similar Epic EMRs: University of Chicago Medical Center, Northwestern Memorial Hospital, Rush University Medical Center and, in the northern suburbs, NorthShore University HealthSystem (formerly Evanston-Northwestern Healthcare).

Three NorthShore hospitals–Evanston Hospital, Glenbrook Hospital and Highland Park Hospital–were among the first in the country to reach Stage 7 on the HIMSS Analytics EMR Adoption Model.(NorthShore’s Skokie Hospital since has reached Stage 7). Several others, notably Rush, Advocate Lutheran General Hospital in northwest suburban Park Ridge, Mercy Hospital & Medical Center and  Swedish Covenant Hospital, have gotten to Stage 6.

But there’s been very little effort to interconnect these institutions and affiliated physician practices. Even during the RHIO heyday of 2004-07, I don’t recall much interoperability talk in the Chicago area. (In fact, one family physician, Dr. Stasia Kahn, in far west suburban St. Charles, got so frustrated that she formed her own group to promote EMR adoption and health information exchange, Northern Illinois Physicians for Connectivity. I had heard talk for a while of some south suburban hospitals joining in an HIE with counterparts across the state line in Northwest Indiana since Illinois was moving too slowly.)

All of that non-action at the state and regional levels happened under the not-so-watchful eye of one Gov. Rod Blagojevich, who apparently was more preoccupied with his own vanity and “giving healthcare to kids” (while also allegedly trying to blackmail the CEO of Children’s Memorial Hospital into donating to his campaign fund and also slowing Medicaid payments to pay for his All Kids program) than in, you know, actually improving healthcare for everyone by promoting HIE.

In February 2009, shortly after Blagojevich was removed from office and a couple weeks before the federal American Recovery and Reinvestment Act became law, new Gov. Pat Quinn signed a law allocating $3 million to the state’s Department of Healthcare and Family Services for HIE planning. That laid the groundwork for this week’s widely publicized announcement that the not-for-profit Metropolitan Chicago Healthcare Council had chosen technology from Microsoft, Computer Sciences Corp. and HealthUnity to build what could be the largest big-city HIE in the country, potentially serving 9.4 million people in nine Illinois counties and small parts of Indiana and Wisconsin.

I bring all of this up because I met yesterday with executives from the Metropolitan Chicago Healthcare Council, a 76-year-old coalition of healthcare organizations in and around the city. It just so happened that the 2011 Microsoft Connected Health Conference was in town this week, so it was the perfect time and location for Microsoft to drop the news. According to MCHC Vice President Mary Ann Kelly, more than 70 percent of the council’s 150-some members have made a commitment to participate, and they seem to have a plan to make the HIE effort sustainable.

The exchange will operate on a subscription model, with the vendors taking on some of the risk, Kelly said. “The subscription fee will be based on the benefit each member derives,” Kelly explained.

Initially, the exchange will involve 22 hospitals in nine organizations, said Teresa Jacobsen, the council’s HIE director. “We want to get one or two use cases running first,” she said. They will start by linking emergency departments to exchange clinical summaries and for syndromic surveillance, according to Jacobsen. Once that’s going, the HIE plans on adding medication and allergy lists, diagnostic testing results and Continuity of Care Document reports, as well as additional elements for public health, including immunization records.

It all sounds great, and it’s a good idea for them to start slowly, but I wonder when and if smaller physician practices will get involved. My own physician has had an EMR for a while, but not every doctor in the practice uses it. (The four-physician practice recently upgraded to the Meaningful Use Edition of Sage Intergy and has started the 90-day clock for qualifying for Stage 1 Medicare incentives this year, but there’s essentially zero interoperability with other healthcare entities, unless you consider faxing records to others straight from a computer interoperability. I sure don’t.)

My guess is that scenarios like this are playing out all over the country. I wish them luck, but I’m not counting on nationwide interoperability for many years. For one thing, the federally funded, state-chartered Illinois HIE Authority held its very first organizational meeting Wednesday afternoon. “That’s the biggest wild card we don’t know,” MCHC CFO Dan Yunker said.

It’s key to getting payers—particularly Illinois Medicaid—on board with HIE and linking metropolitan exchange networks across the state and beyond. “Our hospitals in Chicago are responsible for the snowbirds who are in Naples (Florida),” Yunker noted. They’re also responsible for patients who come from places like Rockford, Springfield, Champaign, Carbondale and the Quad Cities for certain specialized services only available in the big city.

Yeah, this interoperability thing isn’t so easy.

John’s Note: The following is a guest post by Mark Segal talking about the recently announced ACO program and it’s relationship to EHR, meaningful use, and healthcare IT. I also love the insider look at rule making.

The long-awaited proposed rule on Medicare’s Shared Savings Program (SSP)/Accountable Care Organization (ACO) program is out. These 429 pages outline how the Administration plans to transform U.S. health care delivery from fee-for-service to a value-based emphasis on accountability for quality and efficiency of care provided for populations. Following a final rule later this year, the program is to start January 1, 2012, with additional January 1 annual starts by ACOs, and a special optional start possible for July 1, 2012 given the tight timing this year.

CMS solicits comments on program design areas. The final rule will certainly track the proposed rule in key aspects, but there could be important changes based on comments – although revisions must be within the scope of proposed rule options because CMS cannot add new concepts in the final rule.

Care coordination, patient centeredness and evidence-based medicine are major priorities. As expected, therefore, health information technology (HIT) and electronic health records (EHRs) will be central to ACO success.  In some cases, HIT is cited explicitly; for example at least 50 percent of ACO primary care physicians must be meaningful users of EHRs in an ACO’s second year.

In other cases, CMS, focusing on patient engagement, care coordination, and care transitions, highlights HIT capabilities an ACO should address in its SSP application. For example, CMS calls out using EHRs and health information exchange (HIE) to send care summaries at care transitions.  In addition, CMS flags HIT areas like telehealth and remote monitoring, evidence-based medicine, and measuring physician performance across practices and using measurements to improve care and service. Also, HIT will be central to the need to report on and achieve desired levels (after year one) of many of the 65 quality measures.  For example, HIT could help reduce levels of healthcare-acquired conditions.

CMS’s HIT approach is non-prescriptive.  An ACO must address, in its application, how it would address such requirements as care coordination (including use of HIT) but CMS does not dictate technology tools or specific features.   Fundamentally, CMS is outcomes-focused, looking at up-front plans and then focusing on ACO ability to meet quality metrics and overall efficiency goals.  Such flexibility contrasts with meaningful use, which is highly prescriptive.  ACOs will have flexibility to design and deploy their HIT strategies.  Overall, such flexibility should also be considered as the HIT Policy Committee, ONC and CMS consider requirements for Stage 2 of meaningful use, especially for newer areas of HIT use.

Finally, of concern, and relevant also to the need for multi-year meaningful use roadmaps, CMS reserves the right to annually change the SSP during three-year ACO agreements.  Although CMS excludes some areas from such annual changes, this uncertainty is worrisome given the substantial investments and organizational changes that must be made by ACOs.  Three years is a blink of the eye in care transformation; ACOs need regulatory stability and predictability to plan and invest with confidence and to succeed at the change management that will underlie ACO success.

So read carefully and submit timely comments!

Mark Segal is the vice president of government and industry affairs at GE Healthcare IT.

There’s a pretty fierce battle going on right now between all the various stakeholders interested in exchanging patient data. The stakeholders range from very large companies to government initiatives to startup companies. One of the major problems that I see is that it’s not completely clear which model of patient data exchange will win out. In fact, let’s not be surprised if a number of different options take hold.

With this said, I found it interesting that my favorite open source healthcare IT advocate, Fred Trotter, has chosen to get behind the Direct Project. In Fred’s post describing the challenges with the IHE-protocol HIE model approach is flawed and that the direct exchange of healthcare information is the way to go. In fact, he provides the following two illustrations in his post to show the difference:

HIE Model (click on the image to see it full size)

Direct Model (click on the image to see it full size)

Fred then offers this incredibly interesting conclusion:

At every level, organizations are deciding whether to invest in Direct or IHE-based exchange. At this point, I believe the only viable option is for a local exchange to either support Direct only, or both Direct and IHE. IHE is simply going to be too heavy weight for early adoption. Eventually, IHE may become dominate but for now Direct is much simpler, and puts the patient right in the center of everything. If you are a policy maker, you should be asking anyone involved with an HIE process to detail what their Direct-strategy is. If any effort is ignoring Direct and going with IHE-only I would lay odds that they will be broke and defunct before the decade is out.

Moreover, an IHE-only strategy is going to exclude direct participation from patients at this stage. If you care about patient empowerment, I recommend that you advocate for the Direct project at every level, including in your local HIE and REC.

Lots to consider with this complex challenge.

I guess you could say that the direct model is the patient centric model. Although, one could easily argue that the direct model doesn’t have the patient as the center of the model, but instead is a PHR centric model. So, the direct model will be a patient centered model only as much as the PHR software allows the patient to be involved.

Thus, it makes since why Microsoft HealthVault and Google Health are heavily involved in the Direct Project. Of course, they want to be involved in a project that puts them at the center of the communication.

The real question even with the direct model is what incentive do the various PHR vendors have to make this interaction happen? What will be the “cost” that PHR vendors pass on to consumers and/or doctors that use the PHR centric model? Basically, what’s the business model of the PHR vendors?

Unless we can find a PHR centric business model that works for the PHR vendor while still empowering the patient, even the direct model will fail or have adverse outcomes.

I recently heard Arien Malec from ONC summarize the biggest challenge of Healthcare Information Exchange (HIE) in one simple phrase:

There’s no @ sign for healthcare

It’s a really basic idea, but sadly cuts straight to one of the core reasons HIE isn’t happening. We don’t have a great way to authenticate, verify and address health information to another provider.

Twitter has created this interesting concept of using @ to specify people. For example, you can find me @techguy and @ehrandhit. It’s amazing how quickly Twitter has created a whole new set of addresses where we can communicate with other people. Certainly it’s not designed for healthcare, but it’s amazing that they could create this whole new address system for people and organizations. And trust me when I say that Twitter is a great communication and collaboration mechanism.

One of the main reasons the fax machine is so successful in healthcare is that each clinic has a unique identifier, their fax phone number. I’ll be writing more about the fax machine in the future, but HIE needs to solve the problem of a verifiable address that’s unique to each healthcare provider if we want to move beyond the fax machine.

It seems like the people behind NHIN are trying to address this challenge, but they still have a ways to go. Does anyone else know of other ways people are trying to address the missing @ sign in healthcare?