February, 2012

Mostashari at HIMSS 2012: mHealth will deliver patient engagement

LAS VEGAS - In his HIMSS 2012 keynote address, national HIT coordinator Farzad Mostashari, M.D. laid out the case for health IT, and personalized the story down to earlier in his career as assistant commissioner of New York City Department of Health and Mental Hygiene, struggling to connect underserved communities with preventive health information as well as in his role as a patient: Here he is, an M.D., the master of meaningful use, arguing with a pharmacist about whether or not he could take a prescribed medication at night, instead of in the morning as ordered by his physician.

The morning-evening argument could have been answered by researching one fact: The half-life of the medication in his system once he took it. As the pharmacist attempted to look up that question on his computer, Mostashari realized just how far his tiny Office of the National Coordinator for Health IT still has to go.

“Here he goes, I can’t see the screen,” Mostashari said, hand-motioning how the monitor was positioned so he was staring into the back of it. “Clickety-clack, then he uses the mouse. Clickety-clack, the seconds tick by, he in this - I’m sure, very expensive - pharmacy information management system, looking up the half-life. And both of us realize, as the seconds tick by, that we could both pull out our smartphones and Google the damned thing!”

Mostashari got big laughs telling the story to thousands of HIMSS attendees who braved the early-morning Vegas time to hear his keynote. But he told it en route to making a more serious point: While patient engagement is a work in progress for physicians and regulators - who quantified it as a criteria for meaningful use stage 2 - it will get a boost in the next few years as smartphones evolve and their owners figure out how to use them…and patient portals go online.

“That’s changing everything,” Mostashari said. “Patients now have the tools at their fingertips…. [In New York City] we tried to do a texting pilot with patients who hadn’t showed up. My God was that difficult five years ago. It was like, ‘What network are they on?’ ‘We’ve got to collect the information on it!’ And, ‘People don’t use [texting].’”

But all that’s changed in just five years.

“The rate of people using cell phones among individuals over the age of 65 this year was higher than the use of cell phones in age group five years ago. What was so difficult back then to operationalize [is simpler now]…That’s what technology brings. Yes it’s about health, that’s what we’re here for. Yes, it’s about information - it’s better to know, than not know. But it’s also about technology - and what technology is, is the unique knowledge that tomorrow’s going to be better, tomorrow’s going to be cheaper, and tomorrow’s going to be easier.”

Monitoring health via mobile devices remains risky business

National Coordinator for Health IT Farzad Mostashari, M.D., (ONC), said that patients now have tools at their fingertips during his keynote speech at the Health Information and Management System Society’s HIMSS 2012 conference. It was a nod to mobile health, clearly, but patients who use monitoring devices through smartphones and other mobile devices must tread carefully.

Why tread carefully? Smartphones and apps are not always reliable, and often times have flaws. An article in the New York Times helped show inconsistencies in monitoring devices, as did a number of reviews from consumers in the market for devices.

One example is the iStethoscope Pro app, which is intended to monitor heart rate. The app comes with a warning that it is meant for entertainment purposes, but patients could still see it as a reliable monitoring device. While the article says the use of smartphones “must be balanced with the cold reality that all of the experimenters should consult with their physicians,” it does not mean they will.

The $129 Withings blood pressure monitor is designed to plug into an iPhone or iPad. It comes with a cuff that will inflate, deflate and record pulse rate and blood pressure automatically. A review on Gizmodo said it is a “pretty amazing device” if “you’ve been told to monitor your blood pressure, have a family history of hypertension, or are just a quantified-self type into life tracking.” However, the review added that the device does not let the user know when they have explicitly high readings and the colors associated with that are easy to miss. Additionally, the device does not offer wireless connectivity.

Websites designed for patients to enter health information are becoming increasingly popular, too. Glucosebuddy falls into that category, and people can use it to keep track of their blood-sugar level. The information must be entered manually via a computer or iPhone app. If entered on the iPhone, it can be uploaded directly to the website. The Invisible Minority blog posted good and bad comments, ranging from app crashes and small font size to the ability to analyze data in graphs.

While patients may have monitoring devices and their corresponding apps at their fingertips, if those tools do not provide accurate information using them will not result in better care. What’s more, patients who want to continue to monitor their own health might get a long look from their doctor since many in the medical field are not keen on do-it-yourself monitoring, according to Eric Topol, M.D., a cardiologist at the Scripps Medical Institute in La Jolla, Calif., adding that most providers are resistant to change.

Industry reacts to meaningful use stage 2

After a long, sometimes awkward wait, the proposed meaningful use stage 2 criteria have been unveiled. The health care industry was quick to respond to the requirements, with many applauding the progress on patient engagement, data exchange and image sharing. Some suggest, however, that the criteria are too loose on interoperability and too strict on sharing data with patients electronically.

The patient, payer and provider coalition Health IT Now ranks among the skeptics. Under the meaningful use stage 1 criteria, hospitals and eligible providers must test the ability of their electronic health record (EHR) system to participate in health information exchange. Such tests, the coalition notes, are not required in 2012 and 2013 under meaningful use stage 2, and what is proposed for 2014 amounts to what it calls “minimal standards,” particularly when it comes to coordinated care — which, as the group’s name suggests, is something for which the industry simply should not wait.

However, as Brian Ahier points out, stage 2 would require providers either to connect to three or more external providers who do not use the same EHR system or to “establish an ongoing bidirectional connection to at least one health information exchange organization.” Such connections would use Direct Project standards, which has been under development for nearly two years and in use in pilot projects for more than a year.

The data exchange requirements of meaningful use stage 2 also address image exchange, which pleases the American College of Radiology. So do the new menu (optional) criteria for sharing information with cancer registries and other patient registries, as well as the addition of clinical quality measures pertinent to radiologists, both of which the ACR had advocated.

Also ranking among new requirements is an extension of the idea of giving patients access to electronic personal health information (ePHI). Under proposed meaningful use stage 2 criteria, providers can’t just make ePHI available to at least half their patients, as is required in stage 1; they must also show that 10% of patients “view, download or transmit” their ePHI.

This concerns Louis Wenzlow of the Rural Wisconsin Health Cooperative, who fears that rural providers “will have significant challenges meeting a core requirement that is not reasonably within their control,” especially since many such providers serve a large number of elderly patients who lack a broadband Internet connection.

At any rate, the meaningful use stage 2 comment period is open, and it’s safe to say that Wenzlow, Health IT Now and many others will weigh in. Given how stage 1 changed after the comment period — with the 25 requirements pared down to 15 core and 10 menu criteria, and with numerous requirements made less strict — it’s also safe to say that comments will be taken seriously.

How better-performing providers integrate EHR software into practice

By Greg McInerney, Editorial Assistant

The health care industry has shifted toward the use of EHR software at a rapid rate, and by now most users are aware of the perceived benefits of adopting electronic health record systems. More data is now emerging to show how better-performing providers are using EHR software to provide effective health care.

A report from the Medical Group Management Association (MGMA) Healthcare Consulting Group has found that 82.6% of the better-performing providers cite electronic information systems as a key component of their operational success.

Over half of the providers (56%) included in the report had installed EHR software that integrated with their practice billing and claims systems. They concluded that this integration was streamlining the efficiency of their back office logistics and helped reduce error rates and general waste. It also significantly reduces data entry time and helps providers cut the level of missing or omitted information.

The majority (63%) of the providers surveyed were using problem lists as part of their overall EHR strategy. These problem lists are allowing them to more easily compile current and active diagnoses, as well as past diagnoses, that are relevant to the current care of the patient. EHR problem lists are becoming an essential weapon in the arsenal of EHR users looking to fulfill their meaningful use obligations.

MGMA’s report also found a high participation in drug formularies: Over half of the providers have them available as part of their EHR systems. These catalogues of health care plan-specific prescription drugs enable providers to electronically check if certain drugs are in a patient’s plan’s formulary.

As more health care providers implement EHR software, we should get an increasingly complete picture of how they are using it to provide quality health care for patients.

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.