Got a meaningful use stage 2 comment? Here’s some ONC advice

LAS VEGAS – Sometimes on the glorified karaoke exhibition known as American Idol on U.S. television, a fan favorite gets voted off the show because viewers assume that the obviously most-talented contestant will surely get enough votes to remain in the competition during the voting periods – and not enough votes come in.

The same principle works for public comments the Office of the National Coordinator for Health IT and Centers for Medicare and Medicaid Services receive for meaningful use proposed rules, said Steven Posnack, ONC federal policy division director, presenting at a HIMSS 2012 symposium.

Therefore, if something in the proposed meaningful use stage 2 rule really works for you – or seems simple and straightforward to implement because you’re already doing it in a similar fashion – tell them about it. Otherwise, Posnack said, the agencies will only see the negative comments and perhaps unfairly assume that a “fan favorite” idea isn’t feasible.

Policy leaders take each comment seriously, he said, and try to address the concerns of stakeholders. Hearing feedback from health care providers along the lines of “we’ve been doing this for six months, it works well, etc.” gives regulators a signal that a particular criteria or aspect of a proposed rule isn’t unfairly onerous or burdensome, he told SearchHealthIT after his presentation.

It also helps confirm that what ONC is proposing isn’t too far off from what health care providers can achieve, he added. If a particular rule gets a lot of negative comments, ONC begins to think that a rule might be too challenging to the industry. Furthermore, he said, suggestions on alternative ways of accomplishing a particular objective or “partially positive” comments help give regulators and idea of how to potentially reshape rules to ease compliance.

“If it’s a multi-part proposal and parts one and two out of three are really feasible but part three really will cause a significant challenge to folks, splitting those out is important to us in a public comment,” Posnack said. “If you just say ‘this requirement in its entirety is too challenging,’ then it’s hard to know if we’ve reached [too far].”

His main point: Don’t let the easy meaningful use compliance mandates get voted off the show in favor of ones that might be more difficult to achieve because you didn’t speak up for them when you had the chance.

At the time both the CMS and ONC stage 2 rules were about to be issued, regulators had planned to release them in the form of a Microsoft Word documents, enabling stakeholders to make comments in their own copies of it, with revisions in running text if they chose to do so. Regulators also have designed a new means to standardize comments on their end, which they hope will enable deeper analysis and discussion once they collect and concatenate all the public comments.

Twitter co-founder offers health IT innovation insight

It’s no surprise that the health care industry has needed an injection of new ideas for quite some time. At the Health Information and Management Systems Society’s HIMSS 2012 conference in Las Vegas, Twitter co-founder Biz Stone shared some insight from his business and personal experience that many in the crowd seemed ready to apply to health IT innovation and entrepreneurship.

Bloggers Naveen Rao and Joseph Kim, M.D., both offer cogent summaries of Stone’s main points, which can be categorized as either life lessons or assumptions.

Stone’s life lessons, for the most part, may remind readers of a calendar of inspirational sayings — “opportunity can be manufactured,” “creativity is a renewable resource,” “to succeed spectacularly, be ready to fail spectacularly,” etc.

One moral to apply to health IT innovation is to realize that “there is compound interest in altruism.” Align a project with a cause, Stone said, and its impact will, in time, be realized.

Some of Stone’s business assumptions wouldn’t be out of place on the aforementioned calendar, either, including “the only deal worth doing is a win-win deal” and “there is a creative solution to any problem.” Two key points here can apply to health IT innovation.

• “We don’t always know what’s going to happen.” Some of the greatest innovations — penicillin, the sandwich, tea — have been an accident or a spur-of-the-moment decision.
• “There are more smart people outside our company.” This is a point highlighted at the HIMSS 2012 Health Information Exchange Symposium, where speakers detailed how public health departments find value in working with HIEs that can offer everything from health IT infrastructure to data aggregation.

Twitter itself is beginning to play a part in health IT innovation, thanks, for example, to applications that mix mobile health and social fitness. Users have found that community interaction breeds accountability, with friends both congratulating and encouraging. Stone gave a shout-out to the FitBit, a device he (and others at HIMSS 2012) use to track a person’s meals, workouts and weight loss.

In addition, as Emory Healthcare and Matthew Browning have demonstrated, Twitter also has applications in life-critical situations. In short, Browning was faced with a medical emergency, he began to communicate with Emory over Twitter, and the health care provider, as its case study points out, deemed it necessary to “immediately throw out the process flowcharts, remove all barriers, and act.”

Whether other health care providers are as ready as Emory was to accommodate cases such as Browning’s remains to be seen. Many may decide the ramifications of health care social media outweigh the benefits and, as a result, make it a health IT innovation not worth pursuing. Many may eschew the FitBit or other wearable medical devices if patients, physicians or both aren’t taking them seriously enough to impact patient care. Many may find selling mobile health technology to the masses too difficult to be a worthwhile health IT innovation.

Despite the uncertainty, inviting Stone to speak at HIMSS 2012 seems like a good call. It’s hard to discuss health IT innovation without mentioning social media, and it’s impossible to discuss social media without mentioning Twitter. His thoughts, recycled though some may have been, needed to be shared.

Develop best practices for health care applications with end users in mind

Just like the transition from print newspapers to online media, the health care industry is undergoing a transition from paper-based processes to automated and electronic processes. Most of these health care processes rely on applications to facilitate the best care delivery and to decrease adverse events. However, for end users on the frontlines, applications need to work without fail.

That’s why Christus Health, a Texas-based non-profit health care provider, has adopted a best practices checklist for ensuring stability of health care applications with end users in mind. George Conklin, senior vice president and CIO of Christus Health, delved into the checklist in a webinar titled “CIO Insights: How to Optimize User Experience Across 60 Hospitals.”

Here are four best practices from the webinar, which was hosted by Compuware Corp.

Defining acceptable performance is key because clinician expectations are very high, said Conklin, adding that cost certainly comes into play when supporting health care applications. Strike a balance between clinicians using the best applications available, which is what they ultimately want, and the cost to make them function properly. Organizations should develop tools to evaluate service levels, said Conklin, to see if the service matches the price they pay.

What users say about a certain application, or applications, matters. Although that seems straightforward, measuring user experience will help detect any chronic issues. In fact, Conklin said, some organizations are forced to bring in outside IT folks to measure how systems are operating when this process should be done regularly. For Christus, measuring its Meditech Information Technology Inc.-based electronic health record (EHR) is a common procedure, in addition to developing action plans to address chronic issues if they occur.

When end users do operate a system without fail, there are a number of technologies — servers, devices and infrastructure requirements — that need to align. Monitoring the entire delivery chain can ensure successful application deployment, particularly by “isolating fault domains” within the chain. Considering that Christus is tasked with managing close to 1,200 health care applications, isolating faults is a logical solution.

An organization’s leaders should be communicating back to clinicians regarding application performance. Prior to making changes to an EHR system, for example, CIOs should inform clinicians “before they can ask,” said Conklin, suggesting that, if an end user asks before being informed of a problem, addressing the problem could lead to adverse events. Additionally, hospital leaders and clinicians should create “mutually-agreed goals,” said Conklin. Then, an organization can compare system performance compared to those goals. That process, said Conklin, is likely to build trust for better collaboration.

These best practices have helped Christus ensure its health care applications run smoothly for end users, especially given its size — the provider has 24 acute care hospitals, 17 long-term care hospitals and a number of home health and hospice facilities. What’s more, nearly 7,000 physicians work under the Christus umbrella, many in other facilities and holding other positions. “If the applications slip, there is a threat that our providers will leave,” said Conklin. “It is extremely important we align and optimize the needs of physicians.”

The presentation concluded by addressing value-based purchasing, which rewards hospitals and physicians for meeting certain performance measures. However, if health care applications are increasingly faulty due to slow log-in time, chronic system downtime and low patient satisfaction, performance rewards are likely not attainable.

Stage 2 of meaningful use coming this week

When the U.S. Department of Health and Human Services (HHS) announced late last year that stage 2 of meaningful use would be released in February, most of us who follow health IT assumed an announcement would be made in the days before the Health Information and Management Systems Society’s HIMSS 2012 conference, which begins today.

Ah, but we forgot what happens when you assume.

On Friday afternoon, with HHS Secretary Kathleen Sebelius slated to deliver a press conference in Kansas City, we waited. And waited.

Pffft. Nothing.

Admittedly, HHS had a busy day:

• Sebelius did talk about meaningful use, specifically noting that $3.1 billion had been doled out through the Electronic Health Record (EHR) Incentive Programs and that more than 10,000 students to date have completed community college and university courses to train them for careers in health IT.
• The Centers for Medicare and Medicaid Services (CMS) within HHS did appear in the Federal Register thanks to a two-page notice regarding “information collecting activities.”
• Finally, CMS did issue a press release on its proposed Medicare Advantage and Medicare prescription drug plans for 2013.

Still, nothing about stage 2 of meaningful use. It won’t come today, either — it’s Presidents’ Day, a federal holiday. A reveal at the HIMSS 2012 conference, then, makes plenty of sense, though the exact time remains to be seen. The Office of the National Coordinator for Health IT holds a town hall on Tuesday, CMS has its own town hall on Wednesday and ONC Director Farzad Mostashari, M.D., delivers the keynote on Thursday.

Any of those sessions would be a great time to announce the final criteria and deadlines for stage 2 of meaningful use. After all, we will be waiting.

Building the trust fabric for direct exchange of health information

Just over a year ago, the Direct Project launched version 1.0 of its open source software that would allow health care providers to exchange patient information easily and securely. But the direct exchange of protected health information requires more than software — it also requires what David Kibbe, M.D., senior advisor to the American Academy of Family Physicians (AAFP), calls a “trust fabric.”

During this week’s NeHC University webinar, Kibbe introduced DirectTrust.org, an independent organization developed to “help enforce the rules and best practices necessary to maintain trust within the Direct exchange community, and to foster widespread public confidence in the Direct exchange of health information.”

In other words, DirectTrust.org will help sew the trust fabric needed for direct exchange of health information. The organization is neutral, non-profit and not officially linked to the ONC in any way, said Kibbe.

The trust fabric — also known as the trust framework — is complex, said Kibbe. “It’s not about just the technology. The trust framework…[is] about policies, adherence to those policies…there’s a legal component to [it], and of course there are technical components to it as well,” he added.

A significant piece of the trust framework will be the health information service provider, or HISP. “One important thing for everybody to know about Direct exchange,” said Kibbe, “is that ease of use and reliability of use depend very much upon the capabilities of the HISP.”

The HISP, as noted in this diagram from Kibbe’s presentation, has to manage the exchange of digital certificates, which involves sharing public keys, validating the identity of the message sender and receiver and encrypting the message from end to end.

Other duties of the HISP, Kibbe said, would include providing subscribers with account and Direct addresses (similar to email addresses), providing web portal or EHR/PHR integration and staying current with federal policies and regulations.

Kibbe stressed the importance of digital certificates in Direct exchange, because they they literally “stand in” for the individual or organizational identity in cyberspace. These certificates are issued by a certificate authority (CA) or registration authority (RA) only after an identity verification process proves you are who you say you are.

There are still several questions being mulled in the making of this trust fabric for Direct exchange. Who will be acceptable and trustworthy as certificate authorities? What level of identity verification is required for different groups, professionals and patients? What will be decided at a federal policy level and what will be decided at the industry level?

The DirectTrust group will be wrestling with these and other issues as Direct exchange takes off.

ICD-10 implementation deadline will be delayed, HHS says

The U.S. Department of Health & Human Services (HHS) will delay the Oct. 1, 2013 deadline for ICD-10 implementation, the department said this morning in a brief statement. This announcement follows an earlier pledge from HHS to review the ICD-10 implementation timeline.

HHS had been under pressure from the American Medical Association, which had expressed “serious concerns” with the pace of ICD-10 implementation. A 2008 proposed rule set an Oct. 1, 2011 deadline for adopting ICD-10 codes, which were first approved by the World Health Organization (WHO) in the early 1990s, but in 2009 the deadline was pushed back to 2013.

It has been clear for some time now that many providers aren’t ready for ICD-10 implementation, though until recently HHS and the Centers for Medicare and Medicaid Services were adamant about keeping the Oct. 1, 2013 deadline. So was the American Health Information Managers Association, which finds itself in direct conflict with the AMA and views any ICD-10 implementation delay as further diminishing federal efforts to implement health information technology.

It is unclear when HHS will announce the new ICD-10 compliance deadline, nor is it clear how much of — or to whom — an extension will be granted. Some industry experts have suggested that, for federal planning purposes, an extension would have to be at least one year (as opposed to three or six months) and could last two years or more. In such a scenario, the same experts wonder if the United States would be better off skipping ICD-10 altogether and instead make the transition straight to ICD-11, which the WHO expects to finish by 2015.

The U.S. currently uses a clinical modification of ICD-9 called ICD-9-CM to process Medicare and Medicaid claims. The WHO approved ICD-9 in 1979, and it is considered by many in the health care industry to be outdated.

HIMSS 2012: Buckle in for stage 2, ICD-10, and Fitbits

This is nuts. Will the U.S. Department of Health and Human Services get off its collective can and drop that stage 2 meaningful use rule, already? Murphy’s Law says it’s hitting the wires right as this post is being penned, thereby rendering it obsolete before the “publish” button flashes. But rumors flying around say that it will be out on Friday, which has been HHS’s modus operandi.

If it isn’t, we have a lot less to talk about at HIMSS 2012, that’s for sure. However, there is this small matter of ICD-10 compliance that hangs in the balance as acting CMS administrator Marilyn Tavenner said earlier this week that the government health insurer would bend to the American Medical Association’s request to delay ICD-10 implementation.

Another hot topic that many vendors - and a few actual health care providers — are pushing is wireless patient monitoring devices that collect data and publish it to the Web or, better yet, an EHR. As part of that grand experiment, I’m facing off with fellow blogger Brian Ahier in a Twitter-based contest sponsored by PracticeFusion and Fitbit.

While the final details are still being ironed out, the gist is this: Whoever takes the most steps between Brian and me, as measured by our respective Fitbits (these little things also measures other stats like sleep activity, calorie burn and stair climbing), before 5pm on Tuesday wins. The winner gets a charitable donation in his name, and the loser, apparently, will get showered with trash-talking tweets.

Of course, as a health IT reporter, I’m most interested in two aspects of the contest: One is evaluating the Web and smartphone integration the Fitbit offers; as a consumer device that actually has to sell itself to the average patient I’m guessing the Fitbit’s more polished, better designed and intuitive than many of the hardware devices vendors will be showing me in the exhibit floor. But that’s just a guess.

The other? Kicking Ahier’s butt in this contest. Fitbit is even giving a bonus to the first one that hits 30,000 steps. Last year at HIMSS in Orlando, I maxed out at 22,000, and I stayed in a hotel a mile away from the convention center and walked both ways. We’ll see if the bonus is attainable. Considering the number of interviews and other obligations I’ve lined up for Tuesday, there’s a chance.

If you’re going to HIMSS, you can win a Fitbit yourself. Get in on the fun and guess which of us will take more steps on Tuesday. Tweet your response to “Who will win the Fitbit challenge? Don or Brian?” using hashtags #fitbit, #HIMSS12 and @PracticeFusion and they’ll draw a winner among the correct responses on Tuesday. There will be more chances to win a Fitbit on the other days, too; keep up on contest rules here.

Behavioral health off the back burner in Maine

HealthInfoNet — the state of Maine’s health information exchange (HIE) — has a reputation for setting a national example for patient and provider participation. Their reputation is likely to grow with the news that behavioral health has plans to connect to HealthInfoNet.

HealthInfoNet seeks to harmonize primary-care doctors and behavioral health professionals, thanks to a grant from $600,000 grant from the Center for Integrated Health Solutions (CIHS). CHIS received financial backing from Health Resources Services Administration (HRSA) and also the Substance Abuse and Mental Health Services Administration (SAMHSA).

The goal is to facilitate the exchange of electronic health records among 25 behavioral health entities and 200 individual Maine physicians. HealthInfoNet is tasked with creating the infrastructure to leverage data-sharing, which includes linking the behavioral health entities to the HIE.

Patients will have to give their approval to behavioral health providers for the exchange of such information, but this could be a stepping stone to help physicians in treating patients suffering from substance use disorders, psychological disorders and other mental illnesses. The idea of having a patient’s medical record on hand is a novel one, particularly in treating mental illnesses, but it will not be easy to connect primary care with behavioral care.

The biggest hurdles are both an IT and professional issue. The former represents a history of EHR systems designed for primary-care organizations without the incorporation of behavioral health functions. The latter encompasses the space between the primary-care sector of health care and behavioral health professionals, which was echoed by Dennis King, CEO of Spring Harbor Hospital, in a HealthITNews article.

Whether this will lower costs and reduce medical errors is unknown at this point, but bringing different types of medical professionals together through interoperable systems with the goal of better care seems like a positive for all involved.

What the death of GE’s cloud EHR means for the industry

Look at the Health Information and Management Systems Society’s HIMSS 2012 online buyer’s guide for Web-based or cloud electronic health record (EHR) vendors, and many familiar names come up. One does not: General Electric Co.

Last month GE dropped Centricity Advance EHR, the cloud EHR it introduced following its acquisition of MedPlexus Inc. less than two years ago. Citing information from GE Healthcare, HIStalk notes that the cloud EHR will be shut down June 30, with users able to access information in read-only format until Dec. 31.

As John Lynn points out, GE still has three EHR offerings, including the Centricity Practice Solution that users of Centricity Advance will be nudged toward. While HIStalk says GE will cover a practice’s data migration, training, and implementation costs, a physician who emailed Michael S. Barr, M.D. at the American College of Physicians calls the move “the ultimate bait and switch.” (Centricity Practice is GE’s ambulatory EHR software for organizations with up to 100 physicians, while Centricity Advance targeted practices with fewer than 10 docs.)

Lynn suspects that GE is betting that smaller practices, in evaluating the changing health care landscape, will choose to join an accountable care organization over remaining independent — and, in joining an ACO, will be plugged into an EHR system. Whether this bet will pay off remains to be seen.

The news doesn’t just affect GE’s cloud EHR customers. Barr wonders, rightly so, if practices will be hesitant to invest the time and effort in cloud EHR implementation if there’s a decent chance that the vendor will go belly up.

There’s also the issue of meaningful use. Since meaningful use requirements get increasingly complex over time, it’s certainly in a practice’s best interests to work with a vendor that’s in it for the long haul. However, meaningful use — and, for that matter, health information exchange — doesn’t seem to be a huge motivating factor for cloud EHR users, who, at a fundamental level, just want electronic health records. Plus, as Barr points out, incentives for meaningful use and e-prescribing, taken together, still won’t cover the cost of cloud EHR implementation.

Take all this together, and it means any provider speaking with an EHR cloud vendor at HIMSS 2012 should be prepared for a lengthy conversation. With the market in flux, and the future cloudy (sorry), providers can’t afford not to.

Senator drafts bill to remove one of the barriers to telemedicine

One of the major barriers to telemedicine is about to get thrown into the ring by Sen. Tom Udall (D-Utah), who is drafting a bill to streamline medical licensure portability across states. He plans to introduce the bill this spring.

Currently, physicians looking to practice telemedicine must be licensed in the state where the patient receiving services resides. Applying for state medical licensure costs time and money. Fees for medical license applications vary across states, from $110 to more than $1300, said Fern Goodhart, Udall’s legislative assistant, in an interview with Dr.Bicuspid.com. “And the time to obtain these licenses varies from three to 12 months, although the actual state requirements for these licenses varies little, if at all,” she added.

Udall’s proposed bill would streamline licensure with a unified set of standardized data in a comprehensive and interoperable database of primary source verified credentials, Goodhart told GovernmentHealthIT.com at a Capitol Hill briefing in January. Information including claims history, hospital privileges and criminal background check would only have to be entered once, creating a “national practitioner database” of sorts.

The easing of state licensure requirements would certainly be a good thing for telemedicine, but it would only be a baby step toward adoption. If we want telemedicine to become a reality, we need to put our money where our mouth is. The lack of reimbursement for telemedicine services remains one of the biggest barriers to adoption.

Practicing telemedicine across state lines can also be a hassle due to the Centers for Medicare and Medicaid Services’ carrier jurisdiction rule, said Tom Greeson, a partner at law firm Reed Smith, who specializes in radiology-related regulatory matters in an interview with Dr. Bicuspid.com. This rule, he said, requires groups that bill for physician services to enroll and submit claims to the Medicare administrative contractor for the state in which the interpreting physician is located.

“For example,” said Greeson, “the hypothetical group in State A that has a contract with a teleradiology group with radiologists providing services via teleradiology in States B, C, D, and E must enroll and submit claims to each of those Medicare carriers depending on where the interpreting physician happened to be sitting when the service was performed.” Greeson believes this is the barrier that needs to be knocked down, before state licensure.

At least the barriers are getting some attention. Telemedicine technology is coming of age, and advocates are eager to get all the roadblocks removed so physicians can begin using it. During a panel discussion at last year’s Federation of State Medical Boards’ telemedicine symposium, Dale Alverson, M.D., immediate past president of the American Telemedicine Association, said eventually “the borders of states and countries will be blurred by advanced technologies such as live holograms, which will make telemedicine a truly global phenomenon.”

I don’t think he’s talking about the advent of the Emergency Medical Hologram, though that would be pretty cool. Udall’s bill is an example of the borders being blurred to help bridge the gap between policy and telemedicine technology. From there, we are just a hop, skip and a jump away from stating the nature of our medical emergencies to an EMH.