I’m currently on the long flight from Las Vegas to New York City. The early flight time and long flight remind me why I prefer to just stay in Las Vegas with the occasional west coast trip, but I digress. In order to not lose an entire day of work on the airplane, I spent far too much for the overpriced internet service on my flight. As I’m traveling at 30,000 feet, it’s amazing to me that I’m connected nearly as good as when I’m sitting at home. Sure, in flight internet has been around for quite a while, but it still amazes me. What will amaze me even more is when the internet is free on every flight. Maybe pharma ads could pay for this too.

While experiencing this amazing connectivity, I can’t help but think of how poor so much of the connectivity in healthcare is. That’s right. We can find a way to offer internet connectivity at 30,000 feet in an aircraft moving hundreds of miles per hour and yet we can’t get connectivity to rural hospitals and other healthcare locations?

Plus, even speaking more broadly, I can access all of my normal services from an airplane, but for some reason I have no way to connect all of my healthcare data together.

Those in the industry realize the problems. The challenge of connecting all of our healthcare data from the various EHR (or maybe in this case EMR is appropriate) data silos is an academic exercise that’s easily accomplished. Hit any of the interoperability showcases at HIMSS or other healthcare IT events and you’ll see EHR software vendors communicating with each other and sharing data. Why then can’t we make this a reality?

The challenges are still the same they’ve been for a long time now: funding and politics.

I still cringe to think of the missed opportunity that ARRA and the HITECH Act could have provided in this regard. Instead of incentivizing use of an EMR, they should have and could have incentivized interoperability of healthcare data. The great part is that you’re not going to start exchanging data in healthcare without an EHR so you’d be getting more EHR software adopted and interoperability. Water under a bridge now I guess, but it keeps eating at me.

My biggest hope now is that a grass roots movement will form that will drive what we should be doing anyway. Everyone knows and understands the benefits to healthcare and the patient of exchanging healthcare data. It’s easy to make the case for how patient care improves and how duplicate costs are avoided. We need more people that are willing to hop on board interoperability of healthcare data cause it’s the right thing to do. Sure, we need to do it in a smart and reasonable way, but the ROI of healthcare data exchange goes well beyond dollars and cents. This ROI can’t be put on a spreadsheet, but instead will help us all sleep better at night.

Are there any movements like this out there? I can’t say I’ve seen any, but I’d love to see one. Then, we’d have a real beacon community that’s set on a hill because it earned and deserved the recognition as opposed to beacon communities paid for by tax payers.

Side Note: I’ll be in NYC this week at the Digital Health Conference and at the mHealth Summit in DC next week. I’m already planning to meet a number of my readers at these events, but I’d love to meet more.

There’s a really interesting article on Nextgov that talks about a CSC report that looks at the role of health IT and EHR software in Accountable Care Organizations (ACOs). The most valuable part of the article is this list of items that an EHR must enable or allow to support an ACO:

• Clinical information and point-of-care automation, with integrated ambulatory and inpatient records and a central repository for clinical data.
• Enterprise master data management and integration, with a population management repository, a master person index and a master provider index.
• Tools to enable participation in a health information exchange.
• Patient engagement tools, including secure messaging, e-visits and tele-visits, social media, patient portals and mobile health applications.
• Care management and coordination tools, including referral and request tracking, provider-to-provider communication, medication reconciliation and case- and disease-management applications.
• Performance management tools, including integrated business and clinical intelligence and analytics.

To be honest, as I look through this list of EHR items, I can’t say that any of them really stick out to me as impossible for any EHR to achieve. In fact, I’d say that they’re quite achievable by almost all EHR software vendors.

The only partial fear I have reading through the list is that some of the points depend on an EHR vendor working with other EHR software vendors. In most of the cases, these are large hospital EHR vendors that have often worked in very closed environments.

The reason this is a cause for concern is that even the best EHR software in the world won’t be an effective ACO and won’t meet the above requirements if the large EHR software vendors don’t work with them to connect their system.

Maybe this isn’t something we should be too concerned about since the hospital client will be motivated to get their EHR vendor to work with the other even small EHR vendors in order to make the ACO happen and get access to the extra reimbursement. However, my gut tells me that this won’t be the case and there will be stories where EHR software is basically shut out of the ACO based on the large EHR vendors decision to not work with them.

While attending the EHR Summit by HBMA, I got the chance to learn more about the AZ REC and HIE. Here are some tweets about the things they said that worth noting with my own comments:

Arizona REC

AZ REC had trouble getting vendors to take their free EHR interns. #EHRSummit11

This was pretty interesting since they said that doctors were more than willing to take on their student interns, but vendors were reticent to take them on. I do love the education program that the AZ REC put together. Internships like this are valuable.

Biggest complaint the HIT students had was access to actual EHR software. AZ REC created a EHR software lab to solve it. #EHRSummit11

This is a really common complaint by the RECs. In fact, I just helped a REC get access to some EHR software to solve this problem. It’s amazing to me that more EHR vendors aren’t happy to provide their software for these education programs.

AZ REC has a list serv of 2500 doctors and a list for vendors. See: http://www.arizonarec.org/? #EHRSummit11

I found it interesting that they had a doctor list and a vendor list. Makes sense.

AZ REC looking at optimizing health IT for ACO’s to be sustainable. I think this will be a common strategy. #EHRSummit11

The idea of REC sustainability is an important one. I think many are looking towards the ACO requirements as one pathway to sustainability. Of course, how stable are ACO’s? One thing seems certain, the relationships the RECs create with doctors could be leveraged for good if done right.

Arizona HIE

The case for the benefits of good information from something like a HIE is easy. The problem is making it actually happen. #EHRSummit11

This was my gut response when the AZ HIE was talking about the benefits of having the information an HIE provides. I don’t think I’ve heard anyone say that exchanging information would be a bad thing and produce worse clinical outcomes. Sure, they want to ensure privacy of the data when it’s done, but the benefits of having the best information are completely apparent.

HINAz (AZ HIE) didn’t depend on grants to create the HIE. They focused on the benefits of the HIE to users. #EHRSummit11

This seems like something that’s a bit unique to AZ. Most HIE’s are so focused on the grant funding. In this sense, I think that this might give the AZ HIE a chance to be successful. Plus, I loved that they did actual research into which users benefited from the HIE.

AZ HIE, Hospitals pay 50% of costs, Plans pay 50% of costs. Physicians pay nominal fee to participate (cause nominal benefit). #EHRSummit11

This is where the real fun begins. The hospitals and plans are paying for the HIE since the AZ HIE found that they’re the ones that would benefit from it. They found that doctors received nominal benefits from using the HIE and so they shouldn’t be charged to use it. Of course, the other beneficiaries not mentioned here is the benefit to the patients. I’m sure hospitals and plans will pass the cost on to patients, so I guess that works out in the end.

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.

Dan Neuwirth is the CEO of MedCPU, provider of the innovative MedCPUAdvisor™ platform: with applications for decision support for clinical guidelines, Meaningful Use, and care pathways, that captures the complete clinical picture in real time, including narrative text and structured data to deliver the most accurate clinical and compliance guidance.

There’s no question that healthcare needs to adopt new technology that makes us more effective and efficient and curbs costs, like Electronic Medical Records (EMR) solutions and Clinical Decision Support (CDS) systems. In today’s world, providers of all sizes continue to find it challenging to integrate existing HIT systems with EMRs for a variety of reasons. As our industry evolves, technology solutions need to be smarter and empower seamless integration.

EMR and HIPAA guest author Susan White covers in depth how a lack of connectivity standards affects EMR integration. There are no mandated standards for EMR vendors to follow, making it hard to coordinate data sharing between medical devices and other systems (including from one EMR to another), even at the same facility. As those systems operate in disparate fashions, critical clinical information is often lost or stuck in silos. Most importantly, the information is not where clinicians need it most–at their fingertips, in an exam room, with a patient.

This lack of data sharing is a pervasive concern. One Markle report finds that roughly 80 percent of both consumers and physicians demand that hospitals and doctors be required to share information that improves coordination of care, cuts unnecessary costs, and reduces medical errors.

In 2010, more than $88 Billion were spent on developing and implementing EHRs, health information exchanges (HIEs) and other health IT initiatives. When you consider that the average 10-physician practice spends more than $137,000 per year on prior authorizations and pharmacy callbacks alone, you’ll have to agree that the lack of data integration and sharing get very costly. And although I agree with John Halamka, who recently wrote these challenges exist because healthcare is inherently more complicated than other industries, I am a strong believer that a lot of them can be overcome by the use of smart technology.

We need smart, flexible solutions, which capitalize on existing technologies and require minimal integration. Technologies that employ advanced screen extraction, for example, empower several important improvements in the clinical decision support space such as the capturing and analysis of both free and structured text. A lot of time such solutions are rendered ineffective as they either lack compatibility with leading EMR systems or are too hard to integrate.

As the industry evolves, developing robust protocols for capturing both structured and unstructured data along with standards for data integration and sharing will become increasingly important. With all the data points created on patients every day, we will need a consistent, secure, and reliable way to capture and share patient data among all systems and healthcare providers. What is your experience? What are top data capturing and integration challenges faced by your organization? Looking forward to continuing the dialog and hearing your feedback.

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

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.

While I admit that I’m much more suited to comment on other people’s prognostications and predictions for EMR and health care IT in 2011, I decided to throw caution to the wind and try and make some predictions for the EMR world in 2011.

Few EMR Vendor Acquisitions – I predict that acquisitions of EMR vendors will actually slow down in 2011. Certainly there needs to be some EMR company consolidation with 300+ EMR companies out there right now (and it seems more coming every day). However, I think 2011 will be a wait and see period where companies want to see how the various EMR companies perform for their clients interested in getting the EMR incentive money. The only thing that might ruin this prediction is that if many of the 300+ EMR companies have issues selling product and then have to basically sell off their assets in a fire sale. We might see some of those, but I believe even those will wait until 2012.

EHR Incentive Numbers Down – We’ve all heard the $36 billion in EHR incentive money. Of course, this is just the projection of how much EHR incentive money they’ll have to give out. I expect that when we get the total amount of EHR incentive money paid out in 2011 that it will be much lower than the projected targeted. Especially if many of them sit out 2011 and wait for 2012.

Health Information Exchange Success Stories – There are so many people working on the health information exchange issue that in 2011 we’re finally going to start seeing some breakthrough stories about the exchange of health information. Although, it won’t likely come from where we expect it. Watch for some unique approaches by companies and communities to finally make the exchange of health information a reality. It won’t be across the US in 2011, but we’ll see the signs of what could be in 2011.

Reimbursement for Online Visits – I’m far from an expert on reimbursement and trends in health insurance so this might be a stretch, but I think we’re going to see the first insurance reimbursement for some sort of online visit. The first draft will be a bit cumbersome and restricted, but it will be the start of the online doctor visit in earnest.

Portable Doctor’s Offices – A few years back I started hearing about some doctors who were going back to the old days. Not the old days of medical care, but the old days of the doctor visiting the patients in their homes. When I think about this, I always think of Little House on the Prairie and them calling for someone to go and get Doc Baker. In 2011, I bet we see a lot more doctors eschewing the traditional doctor’s office and visiting patients in their homes. With a hosted EMR and the portable laptops and iPad like technologies that we have today, it makes running an office out of your car pretty reasonable. Certainly it won’t work for all specialties, but it is a service that I think many patients would pay to have from their doctor.

PHR Adoption Will Continue to Lag – I just see no signs that PHR adoption is going to take off this year.

First EMR Lawsuit – I predict 2011 will bring the first HIPAA lawsuit where EMR is at the center of the lawsuit. It will be an important one to watch since it will likely set precedent for future EMR related lawsuits.

There you go. A few little 2011 predictions. I’d love to hear any predictions you’d like to make and which predictions I’ve made that you think are wrong and why.

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?