Blumenthal gave a recent speech at the HIT Symposium at MIT. I must admit that as I’ve heard Blumenthal speak I’ve grown pretty fond of what he’s trying to do within the bounds of what’s available to him. Here’s a quick look at some things he said with my thoughts.

“I found that (information technology) changed me as a physician. I thought it was going to change practice. That was 10 years ago,” Blumenthal said. “I think that reality will be realized within a few years.”

I’ve heard Blumenthal say this before. I guess given the number of speeches he gives it’s ok for him to repeat on occasion. That said, this is something that physicians hate to hear, but need to hear it. An EMR will change the way you practice. It won’t change the fact that you are going to give quality care to your patient. It won’t remove the need for all your training and intellect. However, information technology does become the heart of a practice when you implement an EMR. It’s nice that Blumenthal is willing to just state the facts.

More Blumenthal…

“If you look at the calendar and think about the institutions we need to create by 2011, it is a truly daunting prospect,” Blumenthal said. “And in some ways, if we started a year ago, we’d still be late.”

I’ve been talking about a delay in EMR stimulus money for a while. No doubt it is a daunting task. Luckily, I’m one that believes in the BHAG (Big Hairy Audacious Goal) and it seems like Blumenthal does too. Considering the government’s spending billions of dollars, you better think that way. Let’s just hope we don’t spend all that money and actually regress.

Blumenthal acknowledged other challenges facing the ONC, such as addressing the needs of small providers, privacy and security concerns and the lack of attention the current legislation pays to providers of long-term care, home care and hospices. ONC hopes to include those providers later, he said.

“We need that connection, but very frankly we don’t have the resources or the authority in this legislation to do what we need to do in that sector,” he said.

Nice to see Blumenthal acknowledge some of their weaknesses. I’ve been an advocate for the small providers for a long time. I don’t think the EMR stimulus money is right for small practices for the most part. However, I do think an EMR is right for small practices. They can still provide benefits without the EMR stimulus money.

As I first looked over the meaningful use matrix (PDF) that was created by the HIT policy committee I thought that the requirements listed were reasonable and doable. Then, I realized that I was only looking at the first page of a seven page document.

For now, I’ve focused on looking at the 2011 objectives. I wanted to really focus on it since that’s the bar with the most stringent timeline for those wanting to get the EHR stimulus money from ARRA.

I’ll talk in more detail about the various items in a future post. However, as I look through the list of objectives to show meaningful use for 2011, I don’t think any of them sound unreasonable. On their own, each objective listed seems to be something that is completely doable. I might question why some are on the list, but I don’t see any of them individually as too much to accomplish in that time frame.

The problem is that the 22 meaningful use 2011 objectives as a collective whole would be daunting for any practice. I previously wrote about the challenge hospitals face implementing an EHR quickly, but I think this list of objectives would be hard for a practice of any size. I guess some of the reporting could be centralized for a hospital system and save them some time. For a small office, they’d have to do all the reporting themselves and that could be time consuming. No wonder David Blumenthal, ONC head, sent the meaningful use matrix back to the HIT Policy Committee.

I see two other major problems I see with the meaningful use matrix. First, some of the requirements don’t even have established standards yet. Sure, it’s a nice concept to say that doctors should have to “exchange key clinical information.” That’s kind of one of the points of the legislation. Unfortunately, we don’t have any real established standard for sharing key clinical information between providers. CCR seems to have some merit, but is far from becoming THE standard for sharing clinical information. Seems like we’re getting cart before the horse when we ask people to do something for which there is no established and recognized standard.

Second, how is HHS/ONC going to measure accomplishment of these objectives? There not going to go around to each clinic to verify that they actually have an “active medication list” or that they “incorporate lab results in the EHR.” Maybe it’s just the practical side of me. It’s nice to have these objectives, but if we don’t have a way to meaningfully measure that the objectives are being accomplished then it will be abused. I think ONC and HHS might be responsible for deciding how to do this, but I think it would be naive of the HIT policy committee to make these recommendations without good ways to measure them.

We’re all still sitting here waiting for the government to finally decide two key terms in regards to gaining access to the $18 billion in stimulus money in the HITECH act (ARRA). I’ve been interested in the subject myself since before it was even settled that we’d call it meaningful use as opposed to meaningful EMR user. From the looks of that post back in February, there was still a lot of confusion about “meaningful use” and “certified EHR.”

Turns out that a few months later, we still have very little clarification about what these two terms mean. Certified EHR discussion has really revolved around CCHIT certification or some other alternative. We’ll try to leave that discussion for other posts. What has been interesting is in just the past week or two there has been a literal flood of people offering their perspective on meaningful use. Sometimes I like to be on the cutting edge of these definitions (like I was in the link above) and other times I like to sit back and let them play out. This time I’ve been letting it play out and it’s really interesting to see the multitude of perspectives.

I’m not planning on writing my own plan for how they should do meaningful use. I may do that at a later time if so inclined. For now, I’ll just focus on highlighting points from what other people have suggested and provide commentary that will hopefully enhance people’s understanding of this complicated mandate (yes, that means this post will be quite long).

I think it’s reasonable to first point you to the NCVHS hearing on “Meaningful Use” of Health Information Technology. This matters, because at the end of the days hearings like these are where most of the information are going to come. Then, with the information from these hearing decisions will be made. The other sources like blogs won’t carry nearly as much weight (although it’s unfortunate that more politicians aren’t listening).

John Chilmark on Meaningful Use
Next, I’ll go to one of my newly found favorite bloggers named John Chilmark (any coincidence we’re both named John). John from Chilmark Research commented that HHS is bringing together the “usual suspects” to discuss “meaningful use. Chilmark also states that the following criteria are what’s required for meaningful use:

1. Electronic Prescribing
2. Quality Metrics Reporting
3. Care Coordination

I’m not sure where he got this list, but this list feels kind of weak if you ask me. In fact, John suggests that these requirements will be simple and straightforward and first and then ratcheted-up in future years. Interesting idea to consider. I hope that they do draft the requirements for meaningful use in a way that it can be changed in the future if it turns out to not be producing the results it should be producing.

John Halamka on Meaningful Use
Next up, the famous John (another John) Halamka, Chief of every Health IT thing (at least in Boston), calls defining “meaningful use” “the most critical decision points of the new administration’s healthcare IT efforts.” He’s dead on here. In fact, it might not be the most critical decision for healthcare IT, but for healthcare in general as well. Here’s John Halamka’s prediction for how “meaningful use” will be defined:

My prediction of meaningful use is that it will focus on quality and efficiency. It will require electronic exchange of quality measures including process and outcome metrics. It will require coordination of care through the transmission of clinical summaries. It will require decision support driven medication management with comprehensive eRx implementation (eligibility, formulary, history, drug/drug interaction, routing, refills).

Basically, he’s predicting inter operable EMR software and ePrescribing with a little decision support sprinkled on top. I won’t be surprised if this is close to the final definition. The only thing missing is the reporting that will be required to the government. The government needs this data to fix Medicare and Medicaid (more on that in another post).

Blumenthal Comment to Government Health IT
Government Health IT has a nice quote from David Blumenthal that says: “The forthcoming definition of the “meaningful use” of health information technology will set the direction of the Obama administration’s strategy for health IT adoption, said David Blumenthal, the new national coordinator for health IT.”

I think there’s little doubt that David Blumenthal has a good idea of the importance of the decisions ahead. What should be interesting is to see how involved Obama is in these very important decisions. I’m guessing Obama won’t do much more than sign a paper to make it happen. I just hope I’m wrong.

HIMSS Definition of Meaningful Use
Here’s a short summary of the HIMSS definition of “meaningful use”

According to HIMSS officials, EHR technology is “meaningful” when it has capabilities including e-prescribing, exchanging electronic health information to improve the quality of care, having the capacity to provide clinical decision support to support practitioner order entry and submitting clinical quality measures – and other measures – as selected by the Secretary of Health and Human Services.

Basically, e-prescribing, interoperability and clinical decision support. Turns out a BNET Healthcare article suggested the same conclusion “The consensus of physician and industry representatives was that meaningful use should include interoperability, the ability to report standard quality measures, and advanced clinical decision-making.”

I think we’re starting to see a bit of a pattern here. I should say that these are all very good things, but the challenge I see is that any requirement needs to be easily and consistently measured. Interoperability and clinical decision support are both very difficult to measure. Just wait until they see the variety of software that tries to do those two things. It’s very difficult to measure it consistently across so many EHR software.

Wow!! I barely even got started on this subject. Instead of belaboring the point, let me just point you to some other interesting readings about the HITECH Act, ARRA, and “meaningful use.”

• Fred Trotter’s Open Source Perspective
• Blackford Middleton’s Comments on “Meaningful Use”
• Steve Beller’s Definition of “Meaningful Use”
• Human Factors and “Meaningful Use”
• AHIMA Comments on “Meaningful Use” (pdf)
• Markle Foundation Framework (PDF)

Please let me know if there are other good sources for perspectives on defining “meaningful use.” This really is a landmark decision for healthcare IT.

About a month ago I read an interesting post by Will Weider, CIO of Ministry Health Care and Affinity Health System, where Will is the first to announce delays in the HITECH Act (ARRA) EHR stimulus money. To make his case he gives two reasons for his belief:

1. In my experience, government mandates delays are the rule
2. This EHR deadlines are completely unreasonable

HHS finally has Kathleen Sebelius in as secretary and so that should help move things along. However, I have to agree with Will that the EHR stimulus money will be delayed.

I’m not really blaming HHS or ONC or any other government organization for this. The HITECH Act (ARRA) guidelines are so vague that they should take their time and make sure the $18 billion is spent wisely. Luckily, I feel like David Blumenthal seems to understand the importance of the decisions they make as far as what’s defined as a “certified EHR” and meaningful use. That’s a good thing and it’s better to do things slowly than to do things poorly.

This will be bad news for all those EHR vendors who aren’t selling products. More delays on the definitions of these two things could put a number of EHR vendors in trouble (as I’ve spoken about a few times before).

I think we’re in for a really interesting year for those interested in selecting an EHR and the EHR space. I wonder if the first person to get a stimulus check from the government will take a picture and post it on Twitter or some blog. That will be a momentous occasion indeed.

I’m sure that most of you in healthcare saw that Kathleen Sebelius was finally sworn in as the new HHS secretary. You can read the reuters report on the confirmation and swearing in of Kathleen Sebelius.

From the report, there’s no doubt that a lot of Kathleen Sebelius’s first job will be to work on this swine flu. No doubt a very important thing for her to keep an eye on and do what she can to protect us from having a major outbreak.

However, I must admit that I get the feeling that were going to hear very little from this new HHS secretary about EMR and EHR. I could be wrong, but I just don’t see her getting really involved in all the discussions of EHR implementation and the $18 billion of EHR stimulus money as part of the HITECH Act (ARRA).

Certainly she’ll be around for major announcements, but I get the strong impression that it’s actually David Blumenthal that’s going to be in the trenches doing the work of defining “certified EHR” and “meaningful use.”

Anyone know more about the situation that can help clarify what might happen, who will be responsible and whether Kathleen Sebelius will do much for EMR as HHS secretary?

Many people know that I’m quite fascinated by Twitter. I love it and I love connecting with people on Twitter. However, today I came across a clearly fake twitter account. At least to me it was easy to see it was fake. It was a twitter account supposedly for Dr. David Blumenthal. Yes, the name might be familiar to many people here. How did I know it was fake? It linked to some awful news site. Plus, the tweets were just odd and so you could tell it wasn’t really Blumenthal at all.

What scares me is that many people in IT and healthcare won’t know that it’s not him. In fact, that’s why I’m not going to add a link to the fake account. I guess there’s no harm in someone following a fake account. Some of the fake accounts on twitter are really funny. In this case it was someone just promoting their waste of a website. That’s not something I like.

I’ve posted my personal twitter account on here before, but I recently just started a general EMR, EHR and HIT twitter account. It’s currently aggregating some of my favorite HIT and EMR bloggers. We’ll see how it evolves over time. I know I’ve used it to keep track of a bunch of great content that’s being created.

Also, thanks for those who have signed up for the EMR and HIPAA email subscription. It’s been growing like crazy. Nice to think that people enjoy the content I’ve created.

John over at Chilmark Research has a really good find on his blog. He quotes the new head of ONC, David Blumenthal, from an article in the New England Journal of Medicine (NEJM) where Blumenthal talks about the certified EHR requirement in the HITECH act. Here’s the quote:

ONCHIT currently contracts with a private organization, the Certification Commission for Health Information Technology, to certify EHRs as having the basic capabilities the federal government believes they need. But many certified EHRs are neither user-friendly nor designed to meet HITECH’s ambitious goal of improving quality and efficiency in the health care system. Tightening the certification process is a critical early challenge for ONCHIT.

I find it really interesting how two people can take the same quote different directions. Chilmark Research gives a nice little rant about how you can’t certify usability, quality and efficiency in an EHR. I agree with him on most points and I definitely agree that the market is much better at these three items than some government certification body.

However, I don’t feel like this was what Blumenthal meant in the above quote. I don’t think Blumenthal was trying to say that the certification would need to certify user-friendly, quality and efficient EHR software. Instead, I see the above quote meaning that the current CCHIT certification isn’t good enough, because it has certified a bunch of unusable EHR (a topic we’ve talked about many times before). Sounds to me that Blumenthal is making a case for why the government shouldn’t use the CCHIT certification. At least not in its current form. Essentially Blumenthal is saying that CCHIT isn’t good enough to meet the goals of HITECH.

This seems like a ray of hope for myself and others who think that selecting CCHIT certification as the certified EHR requirement of the HITECH act is the worst decision the government could make. Albeit still just a ray.

What Blumenthal means about “tightening the certification process” is up for debate. He could mean something like what John from Chilmark research describes. Basically some convoluted method of measuring usability, quality and efficiency of an EHR system. Or it could mean that the certification process will need to be tightened so that unneeded requirements are removed and it gets cut down to what will help an EHR achieve the ambitious goals of the HITECH act.

Of course, in the end the certified EHR criteria will probably land somewhere in between. However, this quote did give me some hope that Blumenthal realizes the impact that it will have on EHR adoption if many of the currently unusable certified EHR gain wide adoption thanks to the $18 billion in EHR stimulus money.

I do think John from Chilmark Research does make a nice conclusion to his post:

Suggesting that we tighten the certification process is heading in the wrong direction. Instead, we need to actually relax the certification process to encourage innovation in the HIT market allowing developers to create solutions that will truly provide value to their users while concurrently meeting the broader objectives of delivering better care and better outcomes. Creating light certification criteria and focusing more on what outcomes we wish to see occur as a result of broad HIT adoption is where Blumenthal and his staff need to focus their energies.