I recently read a Healthcare IT article that talks about some of the challenges with the EMR stimulus money. Here’s a couple of the challenges discussed with my commentary.

Albert L. Strunk, MD, representing the American College of Obstetricians and Gynecologists, said ACOG is concerned that the measures, while clinical in nature, are not related to adoption of electronic medical records. “The meaningful use measures for ARRA should determine whether a physician has met the objectives shown in the meaningful use matrix, not whether the EMR is being used to report clinical quality measures that rarely apply to that physician’s patients,” he said.

I think this is an interesting analysis. Clinical quality measures are one of the main goals of having an EMR. However, very few doctors look at it that way. I think they will get the incentives wrong if they focus on the clinical quality measures and not on the features of an EMR that benefit the doctor. I’m still sticking with my original analysis that the government really wants doctors to have an EMR so they can improve the Medicare reimbursement rates (in their favor of course).

Another section about interoperable EMR software:

Experts at the hearing testified that providers are willing to wait to purchase a HIT system until they know it will be interoperable. They said physicians from small practices often interact with more than five community hospitals and several labs, each with a different system. Doctors need to know that whatever electronic health record they buy will work with the systems the labs and hospitals have.

I don’t personally get the feeling that most doctors care about interoperability when making their EMR selection. Ok, let me clarify. They want it to connect with their lab and hospital. However, most don’t worry about it interacting with other doctors offices in a true interoperable fashion. The problem is that interoperability between a doctors office and hospitals/labs is not the same as what most people consider an interoperable EMR. I’m talking about EMR software talking to other EMR software (or an RHIO or HIE). Most doctors don’t care about this. At least not more than all the other financial issues related to EMR.

Healthcare data sharing is one of the hottest topics when talking about the importance of EMR software. Some people call it healthcare data portability. One of the problems I have with these discussions is that everyone has different goals for why they want to share the information. Here’s a partial list of reasons people may want to share healthcare data between various EMR respositories (in no particular order):

• Clinical data sharing for reimbursement purposes
• Quality data sharing for broader research goals
• Quality data sharing to meet ARRA requirements/reimbursement
• Data shared for continuity of care between providers

There are probably other reasons to have EMR software be able to share clinical data. However, you get the basic point. There are a lot of reasons why people want the ability to share healthcare related data from an EMR. One problem in the discussion of EMR data portability is that the conversation often gets convoluted when clear lines aren’t drawn for why the EMR data is being shared. Kind of reminds me of what it’s like to discuss EMR and not differentiate between a hospital EMR and ambulatory EMR. There are important similarities, but there are also important differences which always seem to confuse the discussion.

One of my readers pointed out that NaviNet was offering their Health Information Exchange (HIE) solution to state governments for free. Here’s a short part of the press release:

NaviNet (formerly NaviMedix), America’s largest real-time healthcare communications network, today announced the NaviNet Health Information Exchange (HIE), a solution that combines the NaviNet Provider Network of more than 770,000 providers nationwide, and NaviNet technology and services. The NaviNet HIE is now available to all state governments and U.S. territories at no cost, enabling more efficient implementation and expansion of local health data exchange. Adoption of NaviNet HIE minimizes technology investment requirements, providing states and territories a rapid and cost-effective way to offer their own branded health information exchange to electronically connect physicians, hospitals, insurers and existing HIEs in their regions. NaviNet is already used by two out of every three U.S. healthcare providers, and leading national, commercial and Blues health plans, resulting in significant costs savings to the industry.

I always find it interesting when someone starts offering something for free. I always have to ask myself the question of why they would offer it for free. I don’t know NaviNet that well, but it seems like this free offering is 2 fold. First, it seems like they probably want to sell the HIE to people other than government. Second, I think that they probably want participants in the HIE to also use NaviNet’s billing services.

What’s really interesting to me also is that it seems like NaviNet is basically a billing company (although, I don’t know them that well). I find this really interesting since I’ve often seen the argument that we’ve been exchanging billing information electronically in healthcare for a while. Since this is the case, many people have wondered why we couldn’t also exchange other healthcare information. Is this offering from NaviNet, the realization of this principle?

Free EMR has been going well for a while. We’ll see how Free HIE goes.

A few years ago there was this really funny thread over on the EMR Update forum that asked if doctors would one day display a sign that said “Got EMR?” (this was before the term EHR became in vogue) The concept was asking the question about whether patients would ever demand that their doctor us an EMR or they’d go to another doctor for care. The comparison was made to online banking. I remember online banking being on my list of requirements for a bank. Why couldn’t EMR be on your list of requirements for a doctor?

However, I don’t think most patients really know enough about EMR to want their doctor to ask for it. Maybe if EMR companies and independent studies of EMR really showed a stark improvement in patient care by those using an EMR this would change. Until then, don’t expect patients to start requesting doctors that use an EMR.

With that said, patients may start demanding other things which would tangentially require a doctor to use an EMR. For example, a patient may want their doctor to be interoperable. Patients may want to be able to easily schedule an appointment with their doctor online. Patients may want to start getting script refills done online. Of course, we could talk for hours about patients eventually wanting to actually have the patient visits done online, but we won’t start down that path in this post.

Each of the above patient requirements really needs to have an EMR. We’re definitely not at the point now that patients are demanding these types of features. I wonder if we’ll ever reach this point or if there are just so many patients and so few doctors that even if the patients start asking for these features doctors can continue to do business as usual.

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.

I’ve had a number of people ask me my thoughts on this Wall Street Journal article which talks about open source EHR and in particular the open source EHR developed by the VA hospitals called Vista.

I must admit that I’ve been enamored by the concept of free EMR. One of my most popular blog posts was this guest post about Free EMR by Medicare. Turns out that Vista is one of those open source (free) emr software that keeps popping up. I imagine it will continue to pop up for a long time to come.

Let me offer three points that I keep hearing over and over when I hear people talk about open source Vista.

1. (We’ll start with the good) Those that go to the VA are quite happy that no matter what VA hospital they go to, they have their information available. I’ve heard this on multiple occasions. I’m not sure if people are saying this because they’ve actually experienced it (which is likely considering the transient nature of veterans) or because they’ve had the concept drilled into their head. Either way, this is the major perception and considering it’s all one nice package I’m inclined to think it’s a huge advantage of Vista in the VA hospitals. I’d love to hear someone address how this “EHR interoperability” using Vista would work in commercial hospitals.

2. The users of Vista really don’t like using the program. It’s clunky, unwieldy and not the friend of the user. I’ve heard this multiple places and not just from doctors, but also from nurses and the IT people supporting the software.

3. The “database” that Vista uses, MUMPS, is a piece of junk and a major anchor on what could be an otherwise interesting open source project. I’m sure there’s some really interesting history behind the VA’s decision to use this MUMPS “database” system instead of one of the current SQL based database systems. Unfortunately, I’ve seen numerous people talking about the pains of MUMPS and the problem it creates for the future of open source EHR Vista.

I’ll admit that I’m not an expert on Vista, but I’m just telling you about the common themes I’ve read over and over again. Any other ones we should know about or other perspectives on Vista EHR?

A reader recently commented about something called openEHR. Maybe I was a little swayed by anything that says open since open source has used the term open so much. The idea of an open EHR sounded really interesting to me. I’m still not sure I completely understand the plan of openEHR, but I was put in contact with a fine lady named Heather Leslie who is working with openEHR on a product called Clinical Knowledge Manager (CKM).

I must admit that when I read the various information on clinical knowledge manager’s attempt to create clinical archetypes I was pretty lost. Maybe I’m just dumb or maybe across the pond (the project started in the UK) they are just using different terminology. Possibly it’s a little of both.

When I got this email about clinical knowledge manager the concept of creating clinical archetypes was new to me. I could be wrong, but reading it now they should have just said their creating standards for clinical data. That’s a concept I can understand and appreciate.

From what I can tell, it seems like CKM is essentially a wiki-like platform for displaying and improving these clinical standards (or archetypes if you prefer). I really think that the power of the crowd is the only way clinical standards are going to be defined, so the idea of a wiki-like website where people can collaborate around clinical standards sounds exciting. My only fear with it all is that if I’m having trouble cutting through much of the technical jargon, I wonder how many doctors will want to participate in this discussion. This seems like a really noble goal, but I can help but question if CKM and openEHR are not keeping EHR interoperability simple.

Time will tell how many EHR choose to adopt the clinical archetypes that openEHR creates. That will be the true measure of how valuable CKM will be to healthcare. I will be interested to see how this rolls out and if they can garner enough EHR interest and participation to make it a viable standard.

The following is an email about participating in clinical knowledge manager and more information on how it works:
Read more…

I think that anyone that is in this industry had to be struck by the story of ePatientDave pulling his medical history into Google Health (see my previous ePatientDave post). It’s not that we didn’t already know that it was a problem. I think that most in the medical industry know the problems associated with our data right now. However, I feel like we’re all (including myself) in a little bit of denial about this fact. The story of ePatientDave just painted a picture of how bad the data really is going to be.

The takeaway I have from ePatientDave’s experience is that we’re still a long way from having interoperable patient records. In fact, it makes my previous post about ICD-10 and EHR interoperability even more significant. Not to mention the need to simplify Health Information Exchanges.

Honestly, if we don’t simplify I’m not sure we’re going to get any of this healthcare data exchanged in my lifetime.

There are a bunch of myths being perpetuated right now around ARRA and the HITECH act. I’ve been on a number of conference calls and read a number of people perpetuating these myths. Some might call it poor communication and others might call it downright unethical talk. I’ll leave any judgment to someone else, but I believe these myths could lead to major problems in HIT.

Here’s the first myth I’d like to debunk here and now:
Myth: The EHR Stimulus bill (often referred to as ARRA or the HITECH Act) REQUIRES doctors to use EHR and be interoperable.

Reality: The government has no ability to actually require the use on an EHR. ARRA and the HITECH act do require you to use a certified EHR and show “meaningful use” IF (that’s a big IF) you want to receive the potential $44k in stimulus money avoid the 1-5% medicare/medicaid penalties that will go in force a few years down the road.

That means that if you’re not interested in the government stimulus money then you’ll need an EHR. However, I have a feeling that a large number of people are going to sit back and take the penalties and forget about the stimulus money. In fact, don’t be surprised if many just stop taking medicare/medicaid in response. The point being that it’s a requirement to get money, but not a legal requirement that a doctor use an EHR. I have a feeling those not using an EHR will still have lots of company for the forseeable future.

The interoperability falls under the same story. However, you may not even have to have an interoperable EHR at all if interoperability isn’t part of the EHR certification and “meaningful use” requirements. That part we’ll just have to wait and see.

Moral of the Story: Select an EHR because it makes sense for you and your practice. Don’t focus on the stimulus money and you’ll be much happier in the end.

I’ve been hearing a bit of discussion about ICD-10 really helping to solve some of the problems of interoperability. Their contention is basically that ICD-10 is more precise in its description of the diagnosis and so therefore the information that is coded using ICD-10 will then provide more specific codified information that can then be rather easily shared. If you haven’t read about the transition from ICD-9 to ICD-10, here’s a good article about the transition.

In theory, this is completely accurate. If everything went as outlined, we could really get a lot of interesting information for studies and for interoperability of health data out of our ICD-10 codes.

The problem is that in reality ICD-10 is just going to cause even more problems for sharing quality data. Not because we can’t share the data. That’s a topic for a different discussion. The problem is that we’re never going to achieve quality input of diagnosis codes.

I’m not a doctor and so I’m not going to give a specific example here. However, I think all we have to do is look at the current ICD-9 diagnosing patterns. I’ve seen from first hand experience that often a doctor gets stuck searching for the right ICD-9 code. Right or wrong, they end up picking a code that may not be exactly the right code for what they’ve seen. Maybe they choose NOW (Not Otherwise Specified) instead of the specific diagnosis that would be more appropriate. Add in the complexity of diagnosis requirements for getting the most out of your insurance billing and I don’t think anyone would disagree with the assertion that ICD-9 code entry is far from accurate.

I’m not trying to place blame. I believe this is a chronic problem in our health system that those in the trenches have known about for years. My point here is that if we can’t get the rather “simple” set of ICD-9 codes right, then how can we ever expect the much more complex set of ICD-10 codes right?

Everyone knows the common phrase of garbage data in produces garbage data out. When we’re talking about interoperability of EHR software, doctors really have to think if they want other people’s garbage in their system.

ICD-10 really could produce some awesome information if used properly. The challenge we face is producing systems that codify the data properly so we have meaningful interoperability of healthcare data.