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?

For those that participated in the CCHIT town hall meetings at HIMSS, it seemed like the writing was on the wall that CCHIT needed to offer some more town hall meetings. There was certainly a lot more to discuss. CCHIT just announced 2 more web “conferences” where the public will have a chance to comment on CCHIT.

The first conference, “New Paths to Certification: Dialog with the Open Source Community,” will take place on June 16 at 1 p.m. EDT and focus on technology. It will address outlying concerns on certification of solutions that are licensed under open source models. Leavitt and Dennis Willson, the commission’s technology director, will be the moderators.

The second conference, “New Paths to Certification,” will take place on June 17 at 11 a.m. EDT and be more geared toward a generalized audience, with dicussion focused on new CCHIT programs.

I think it’s good that they’re having another open source EHR session. I’m just not sure why they would have it before the general session. That means that the open source discussion is going to not be as focused since many people will want to discuss the general issues with CCHIT certification during the open source session.

I’ve made my views on open source and CCHIT certification pretty clear. So, it will be interesting to hear what CCHIT could change to avoid some of the problems I’ve suggested. There’s just not the right motivations for open source EMR to certify. I’ll publish more details on these meetings as they become available.

In a different CCHIT issue, CCHIT has made a comment on the New Jersey bill I’ve written about previously. Here’s the part of their comment that really matters:

First, I do not believe this is an appropriate use of health IT certification. Our goal, stated in almost every presentation I’ve given, and to which I’ve adhered in my leadership of the Commission, has always been to unlock positive incentives for health IT adoption. Bridges to Excellence provides a role model for integrating health IT into outcome-based, pay for performance incentives. Successfully executed, ARRA might too. But the New Jersey bill is nowhere near that. Making software purchases illegal, like dangerous substances? Let’s “just say no” to that idea.

Second, neither I personally, nor CCHIT as an organization, have lobbied, advocated, sponsored, or had anything to do with that bill. We were unaware of it until it started showing up on listserves Friday. The bill has never been mentioned in any of our Trustee, Commission, or staff meetings.

Kudos to Mark Leavitt and CCHIT for making these comments. Underscores my previous feelings that Mike Leavitt and CCHIT really sincere in his desire to help. It’s just that they’re going about it the wrong way.

Hopefully my readers aren’t tired of this NJ CCHIT bill. This will probably be my last post on the subject. Any future comments I’ll just update on my original post about the bill or my post on the Financial ties to NJ Bill Outlawying Non CCHIT EHR. I just had an EMR vendor who is based in New Jersey send me an email with the message they sent to Herb Conaway and their request to meet with Herb. I encourage other people to send in their feelings to Herb Conaway on this bill and I’d be happy to publish other people’s messages on this site if you’re interested.

Here’s the email sent from the New Jersey EHR vendor:

Dear Assemblyman Herb Conaway Jr.

I would like to request a small 15 minutes meeting with you on the ASSEMBLY BILL NO.3934 wherein you have suggested to impose the use of Certified EHR from January 1st, 2011.

As part of the bill, New section suggested is “No person or entity, either directly or indirectly, shall sell, offer for sale, give, furnish, or otherwise distribute to any person or entity in this State a health information technology product that has not been certified by the CCHIT.

As used in this section, “health information technology product” means a system, program, application , or other product that is based upon technology which is used to electronically collect, store, retrieve, and transfer clinical, administrative and financial health information.
Everything is fine with this bill, it is a good initiative except the FINANCIAL PART, CCHIT doesn’t certify any product based on FINANCIAL PARAMETERS, CCHIT strictly certified EHR or EMR based on clinical parameters. That is the reason why half of the CCHIT certified products don’t have PRACTICE MANAGEMENT OR BILLING PROGRAM BUILT INTO THE SYSTEM,

We , Digital Medical Billing Inc (registered under Department of Banking and Finance) are a small billing company using PRACTICE MANAGEMENT program “DigiDMS” to do billing for 32 providers’ offices, in future we shall continue to use the same program, why we would be forced to switch to CCHIT certified product when CCHIT themselves don’t have any criteria for Financial Data Handling as part of certification. On one side President OBAMA is trying to create more jobs, and wrong bill like this can eliminate 50 jobs which our company is offering.

We would like to meet you to discuss this in person with details of CCHIT certified products which don’t have BILLING SYSTEM built into their product.

Vishal
Manager
Digital Medical Billing Inc
www.dmbi.com

Full Disclosure: Digital Medical Billing is an advertiser of DigiDMS on this site.

I previously wrote about a NJ bill to make non CCHIT EHR use illegal. I got an email from one of my readers that I should take a look at the financial ties to this NJ bill to see how that might have influenced its creation.

Turns out that Al Borg was already a few steps ahead of me and did the following research:

Some data on all of this:

• HIMSS NJ capter- http://www.njhimss.org/abouthimss/abouthimss3.html
• information on NJ Rep Pallone- http://himss.capwiz.com/bio/id/387 (click on “PAC” then 2007/2008 to see the likes of Cerner ($1000), GEPAC ($5000), MS ($5000), Siemens ($6000), ACP PAC ($6750), AMA PAC ($7000).

About the main sponsor of the bill-

• The Honorable Herb Conaway, MD tried to be elected governor in 2004 but was soundly defeated by his Republican rival.
• The Honorable Herb Conaway, MD actually started the mandate-EHR quest back 2 years ago, with the first law passed by the NJ Senate 1.5 years ago- http://healthcare.zdnet.com/?p=615&tag=rbxccnbzd1
• In HIMSS 2008 The Honorable Herb Conaway, MD was presented with the HIMSS State Leadership Award.
• In HIMSS 2009 he was also a major speaker on the “State Officials Legislative Forum”- http://www.prolibraries.com/himss/?select=new_speaker&speakerID=25947&conferenceID=7
• On 2/2009 Conaway is featured in HIMSS HIELights webpage- http://www.himss.org/HIMSS_HIElights/HIMSSHIElights.asp?date=200902.
• Conaway is no friend of physicians and hospitals- check out the bills that he sponsored to force medical error reporting, for prohibiting the payment for “preventable medical errors” and now this pro-CCHIT HIT bill. If you look at here (http://www.democracyforamerica.com/press/2004/6) you’ll see that he’s for Obama’s universal health care dreams, using an HIT backbone, of course.
• I couldn’t find any major political contributions here- http://www.campaignmoney.com/political/campaigns/herb_conaway.asp?cycle=08), so I presume his greatest source of income are speaker fees. Thus I looked for his NJ financial disclosure sheets and yup, he got money from HIMSS, from the “State Alliance for e-Health”, from the “Healthcare Information Management Soc” (only in the 2007 and 2008 years, and I suspect amounts are under-reported): 

• in 2008: http://www.njleg.state.nj.us/ethics/FinancialDisclosure/ConawayH2008.pdf
• in 2007: http://www.njleg.state.nj.us/ethics/FinancialDisclosure/ConawayH2007.pdf
• in 2006: http://www.njleg.state.nj.us/ethics/FinancialDisclosure/ConawayH2006.pdf
• in 2005: http://www.njleg.state.nj.us/ethics/FinancialDisclosure/ConawayH2005.pdf

Ok, so once you discount for some of Al’s bravado it’s interesting to see the back history of the sponsor of this bill. Even if you don’t want to make the claim that he doesn’t have financial reasons for creating this bill, you can at least see where he drank the kool-aid.

Al also missed some other sources of campaign contribution for Herb Conaway and the co-sponsor of the bill Chivukula Upendra. I also found this page on the JN legislature site where I think we’ll be able to track the votes for this bill. Looks like it made it through committee (which it looks like Herb Conaway chairs) with a unanimous vote by Herb Conaway Jr., Connie Wagner, Mary Pat Angelini, Anthony Chiappone, Jerry Green, Linda R. Greenstein, Sandra Love, Nancy F. Munoz, Vincent J. Polistina, Joan M. Quigley, and Linda Stender. That’s a lot of people who probably aren’t getting good information on the EHR industry and CCHIT’s effectiveness.

On that note, someone mentioned in the comments of my first post that I should contact the representative from NJ and take a more proactive approach in responding to such a horrible bill. I’m not sure a representative from NJ really cares about what someone from NV might say, but I also think that it’s worth taking a stand on such a bill so that this bill doesn’t cause other states to consider similar bills. So, here’s the page where you can send a message to Herb Conaway, Jr and Upendra J. Chivukula. Should be interesting to see if they reply to a whole bunch of emails on the issue.

What’s even crazier to me is that Herb Conaway is a physician. I guess he hasn’t been practicing with an EHR lately.

Graham over at EMRUpdate found a really crazy bill being proposed in New Jersey that would make the use of non CCHIT certified EHR illegal.

Here’s the sections of the bill that seems to capture the crux of what’s being proposed:

“· On or after January 1, 2011, no person or entity is permitted to sell, offer for sale, give, furnish, or otherwise distribute to any person or entity in this State a health information technology product that has not been certified by CCHIT. A person or entity that violates this provision is liable to a civil penalty of not less than $1,000 for the first violation, not less than $2,500 for the second violation, and $5,000 for the third and each subsequent violation, to be collected pursuant to the “Penalty Enforcement Law of 1999,” P.L.1999, c.274 (C.2A:58-10 et seq.).

· The bill defines “health information technology product” to mean a system, program, application, or other product that is based upon technology which is used to electronically collect, store, retrieve, and transfer clinical, administrative, and financial health information.”
…
” 5. (New section) a. The Director of the Division of Consumer Affairs in the Department of Law and Public Safety, in consultation with the Office for e-HIT in the Department of Banking and Insurance and the Commissioner of Health and Senior Services, shall require that, on or after a date to be determined by the Office for e-HIT and in accordance with requirements established by that office pursuant to and in furtherance of the purposes of subparagraph (a) of paragraph (1) of subsection b. of section 8 of P.L.2007, c.330 (C.17:1D-1), each health care professional who is licensed or otherwise authorized, pursuant to Title 45 or Title 52 of the Revised Statutes, to practice a health care profession that is regulated by a professional and occupational licensing board within the division or by the director, shall purchase, rent, lease, or otherwise acquire for use in that person’s professional practice only those health information technology products that have been certified by the Certification Commission for Healthcare Information Technology.”

I’m really kind of speechless. If you read this blog regularly, you know that’s pretty rare. As Graham points out, why would they want to pre-empt whatever rules ONCHIT puts in place for EHR? I also wonder how they plan on enforcing this act. Plus, what is this senator really thinking? I think that each of these bills should require a full disclosure as to the impacts both good and bad and the reasoning behind even proposing such an idea. Reminds me a lot of the senator who called for an open source EMR, but this is much crazier.

Seriously, what’s the basis for this senator wanting to have it illegal for someone to use any EHR other than a CCHIT certified EHR? I’ve asked many times for some sort of study (independent hopefully) that shows that CCHIT certified EHR have a higher implementation success rate, or improve patient care, or save doctors time or any other benefit over the non CCHIT certified EHR out there. So far no one has produced such a finding. I’d suggest we haven’t found that study since the results of said study would find the opposite.

All I can say is that I’m glad that I don’t live in New Jersey and for their sake I hope this bill fails miserably.