Ready or Not Electronic Health Records are Coming

The games afoot or as they say in England "Game on".....healthcare standards are published (actually the Notice of Proposed Rule Making NPRM - which can be found here) and supplemented by an article posted by David Blumenthal "Launching HITECH" posted by the New England Journal of Medicine.

As before there are multiple stages that include incentives linked to each of the stages but if we focus on Stage 1 that starts in 2011. This includes electronically capturing health information, clinical decision support for disease and medication management, clinical quality measures all tied with protection and securing of the information (don't forget liability for security breaches is now much further reaching). The investment is made (numbers vary but range from $14 - 27 Billion). To receive incentives providers must use their electronic medical records to improve the overall quality of healthcare delivered by demonstrating achievement of a series of objectives. These include (this is not an exhaustive list but captures the main elements):

• Entering orders, medications etc in CPOE
• Maintaining problem lists in ICD9-CM or Snomed-CT coding
• Maintain active medication list and electronic prescribing
• Recording vital signs, smoking status
• Receive and display lab results encoded with LOINC codes
• Generate patient lists based on specific conditions and generate patient reminders
• Provide patients with electronic copy and electronic access to their record and discharge instructions
• Generate a clinical summary for each visit
• Exchange clinical data with other providers
• Protect the information, encrypt it and record disclosures

There are others but these are broad categories and groups and represent a major push to genuine electronic medical records that are digital, contain useful data and are shareable between systems. Certification (as currently provided by CCHIT based on their existing criteria and what we know to date about the requirements for meaningful use) has 11 products certified for 2011 - list here. This is a work in progress and expect to see many more and probably other certification bodies.

The overall tenet of this initiative is summarized by Dr Blumenthal in his article:

...so as to reward the meaningful use of qualified, certified EHRs — an innovative and powerful concept. By focusing on the effective use of EHRs with certain capabilities, the HITECH Act makes clear that the adoption of records is not a sufficient purpose: it is the use of EHRs to achieve health and efficiency goals that matters.

There are other strands/programs that are designed to address the obstacles to adoption - summarized in this chart from the NEJM article:




Behind the scenes the health information exchanges that allow for the easy sharing of clinical data between systems, clinical users and patients will be essential.

This is a broad set of criteria and for many clinical practices a long way from where they are now. The shape of this program is clear - sign up and participate now and receive additional funding/payment or wait and be punished later if you do not implement. There remain many challenges not least of all the products and expertise required to roll these technologies out but to me the message is clear - this train is leaving and failing to get on board will will cost you more in the future.

In the first instance we have an opportunity top provide input to the NPRM - the link for this can be found on the main page of the HHS HealthIT page here or the actual system here. Have you managed to wade through the 600+ pages or found a great summary of the content highlighting key aspects - share the knowledge, leave a comment with your thoughts and/or links and help everyone get up to speed with this material and provide input to the rule by the end of February 2010.

Standards and Interoperability

It has been an interesting week of rhetoric and emotional outbursts for and against healthcare reform. In amongst the many articles I found this post from David Kibbe on the Healthcare Blog: Why Standards Matter - the True Meaning of Interoperability; a word that he believes that the American people are skeptical of.

You only have to take a quick visit to one of the personal health record systems Google Health or Microsoft HealthVault) to understand why when he says:

interoperability is a hugely important word in the context of today's ongoing debate about the use of EHR technology by physicians, hospitals, and patients too

It is not just an important work, it is an essential component of any future innovation in healthcare. At a recent meeting of the HIT committee several of the members acknowledged that

didn't really know" what interoperability means

Yikes! Frightening if the advisers don;'t have a good handle on what this should mean. He is right that there is complexity in a precise meaning of interoperability since there are many levels and the post contains some good descriptions on the various levels and elements of interoperability - for instance data, words, formats, layout etc. But as he rightly points out capturing medical information in PDF format does not make it truly interoperable and in the example h cites of loading his living will into Google Health this is simply an online version of the Amazon Kindle. Interesting and may be useful to have but not really interoperable.For it to be interoperable the information contained in the files should be in a standard format and the example here is XML (the underlying basis of web pages that you are reading this blog on). XML is an open standard and has a lot of flexibility (as we have seen with the advent of even more creative web pages and Web 2.0 type applications)

The essence here is the need for standards that are the industry and users of the information need to agree on the standard. We need to move past the VHS/BetaMax or BluRay/HDDVD debate and to a set of standards that everyone can use.

At this point standards have not been agreed and there are still some competing standards but XML does seem to be an underlying technology format of choice and is in use Healthstory. Based on Clinical Document Architecture (CDA) that uses XML this format allows for the capture of free form narrative linked to encoded content such that the Diabetes in the note can be identified by a computer systems as ICD9 Code of 255.0 - Diabetes Mellitus). Already some systems will import medical information encoded using XML type standards and this is likely to increase. As you think about your health record you should be looking for providers and technology that will export your information in a meaningful format that can be reused in other systems and applications. Start looking for your records in interoperable format - and insist on the full story not just extracts or sub sets of the data.

HIT as a Catalyst to Healthcare Improvement

The Center for American Progress - a think tank group dedicated to improving the US through policy and innovation) published a report: "A Historic Opportunity - Wedding the Health Information Technology to Care Delivery Innovation and Provider Payment Reform". You can download the executive summery here (pdf) or the full report here (pdf)

They make the point tat the American Recovery and Reinvestment Act’s HITECH $19 billion investment is not just about technology. In fact if this is the way the program is actioned:

failure is effectively guaranteed if the HITECH program embraces technology adoption for the sake of adoption. But if this new health IT investment program is wedded to a strong commitment to provider payment reform in forthcoming health care reform legislation and implemented specifically as an accelerator of health care delivery innovation and payment reform, then the investment program can help transform U.S. health care as we know it.

We know technology can contribute significantly to our lives. Everything from basic tools in our homes from cell phones to computer access that replaces the limited access to the Encyclopedia Britannica that we had some years back based on the sale to individual homes. This has been replaced for school children and households with access online to all this information in an instant.

Technology has had similar extended effects in healthcare that have seen revolutions in the diagnosis and treatment that previously were unimagined. But technology alone will not solve the underlying problems of our healthcare system and in the US we must change the payment model that currently incentivises everyone int he system to "do more". The system rewards for volume of service delivered and this is the underlying challenge faced by clinicians and facilities that continue to strive to maintain income when presented with the decreasing reimbursement per unit are forced to increase volume. This leads to the current circumstance where a consultation and patient interaction must be limited to minutes if the number of patients to be seen is to increase and the income stream to be maintained.

But seeing more patients for less time does not help manage chronic conditions, allow for a focus on prevention and chronic condition management that demands time and attention to detail. So as they suggest health care reform should include:

• Proactive improvements in individual and population health status
• Collaboration among health care providers necessary to accomplish these improvements
• Achievement of efficiencies in care, such as the elimination of duplicate services, avoidable hospital readmissions, and unnecessary in-person visits

and should also include a change in the documentation and in particular coding requirements. As they rightly point out the current system of coding

so called evaluation-and-management, or E&M, coding of office visits—which drives extraordinary complexity into clinical documentation and EHR workflow—could be replaced by payment-and-documentation standards that are simpler and more focused on what is actually valuable for patient care.

The much used term "meaningful use" comes up again and the suggestion that this be focused on Health IT that actually helps improve care and accelerate payment reform. IN fact the suggestions include:

• Tracking key patient-level clinical information in order to give health care providers clear visibility into the health status of their patient populations
• Applying clinical decision support designed by health care providers to help improve adherence to evidence-based best practices
• Executing electronic health care transactions (prescriptions, receipt of drug formulary information, eligibility checking, lab results, basic patient summary data exchange) with key stakeholders
• Reporting a focused set of meaningful care outcomes and evidence-based process metrics (for example, the percentage of patients with hypertension whose blood pressure is under control), which will be required by virtually any conceivable new value-based payment regimes.

And in each of these is the implied requirement to capture this information at the point of care which has been a significant challenge to date. I've said it before and I'll say it again - turning our clinicians into data entry clerks does not make sense. Whatever systems are put in place must allow for the capture of this information in way that does not interfere with the patient/clinicians interaction and includes the ability to capture the detail and the data to drive these activities of tracking, clinical decision support and evidence based metrics. There does not seem to be many technologies that can fulfill this at the time of care delivery and one that shines out constantly is that of speech and in particular speech understanding that is able to understand the meaning and generate meaningful clinical documents that can be used in these clinical systems to help deliver this higher quality care.

To this commentator, speech technology and in particular speech understanding must be a fundamental component of the success of healthcare IT as part of the HITECH investment act. What do you think - are we there yet?

David Brailer Weighs in on Health Information Technology

David Brailer writes on the Healthaffairs site with guidance to the incoming President on key reforms to our health care systems. The pledge he refers to of $50 Billion does not appear to jive with the released "American Recovery Reinvestment Act of 2009" (pdf file) draft report that features $20 overall for healthcare + $4.1 billion for preventative health care but relative to the previous investments this is a significant program.

He highlights 4 key areas:

The chasm between the have and have not's - not of health care but of EMR's but rightly he says

We should not incent physicians and hospitals simply to purchase electronic records. We get no benefit when a physician or hospital buys an electronic record. What we should do is reward the use of these tools as part of a patient’s care. “Pay for use” can fund the conversion of the health care system to digital records and ensure that we get the life-saving and money saving benefits they promise

I agree - just buying these expensive systems and funding them seems a flawed strategy and we will just end up with a bunch of unused EMR systems.

Second - the need to build a workforce to enable the digitization of health care - 50,000 people by his reckoning, of people who understand both clinical medicine and information technology. Already in short supply and years in the making. This is right on the money (and I say that with a certain sense of pride since I fall very clearly into this category having made this transition long before this was even a career path or specialization). It is bridging this divide with clear understanding of the issue and challenges faced in practicing day to day clinical medicine that will facilitate acceptance and success.

Third - Information sharing, which is a core fundamental but remains a significant challenge by virtue of the proprietary and protectionist nature to the health care vendors to date. This challenge has thawed and there are many initiatives that will move the industry towards real sharing of data. I certainly want to take my complete "Healthstory" with me wherever I go having just completed the valueless paper based forms for the umpteenth time in my daughters physicians office. There are others but Healthstory represents the complete picture with flexibility to allow participation at a wide range of levels and different detail that makes the adoption more likely. Not forcing or mandating specific data or fields may seem like we loose the data but pragmatic approaches that drive adoption quickly will succeed where highly regimented and overly demanding standards tend to fail in complex environments. So here's my pitch to the incoming Obama administration - mandate the Healthstory standard for capture, exchange and sharing of clinical data. The resistance will be minimal and the standard will allow all stake holders to participate quickly and effectively. Granularity of information will increase over time as the value of this increasingly detailed data is demonstrated with real world use cases - market forces at work.

Fourth - freeing up the clinicians to use the technology and to get paid for digital consultation remotely and facilitating telemedicine. While you are at it I suggest resolving the challenges faced over the practice of medicine in different states as detailed here in the sad case of a Colorado Doctor being prosecuted by California.

Health care reform will happen...it has to happen and there is an explosion of suggestions and ideas, but the above four make a great start and I concur with David Brailer on their importance and value in making these reforms a resounding success but lets make sure that the interoperability is a fundamental part of the equation.