Quality Assurance, Standards, Interoperability

By coincidence Steve Beller, PhD in his recent blog on trusted.md posted some information relevant to health information transparency, and health information exchange. The RHIO monitor has attempted to keep interested readers somewhat current with these developments in the past two years. Readers may go to http://healthtrain.blogspot.com to read more about RHIO attempts in Southern California and elsewhere.
A group of standards for interoperability have been established for electronic medical records by the CCHIT (Commission for Certification of Health Information Technology. These vendors can be found at CCHIT's web site, and also at CALRHIO www.calrhio.org These are standards for electronic interoperability and functionality of an EMR. They however do not standardize nomenclature for diagnosis and procedures, nor pay for performance metrics. There are diagnostic standards, (ICD codes) and procedure codes (CPT codes) that are used by medicare for data mining, however these statistical figures are derived from financial data and not true clinical information.
Due to HIPAA regulations true transparency will never exist, to prevent violation of privacy rules. Statistics will be stripped of patient identifying information.
Organizational strategies are ubiquitous and range from non profit collaboratives, private foundations, community clinics, and now some entrepeneurial asp models for EMR and RHIO portals. One barrier has been a "sustainable business model."
A significant number of RHIOs have failed, the most recent in Santa Barbara after ten years of attempting to overcome barriers of self interest, mistrust and loss of public funding grants for startups.
The situation is highly complex and cannot be oversimplified. While many proponents liken the banking industry and it's information structure to health care IT, they are radically diffferent, and not as simple as inserting an atm card into a terminal...While banks have developed highly secure systems, additon and subtraction of simple numbers is not the same as a medical record system, much of which is analog in nature rather than digital.

More about these efforts in my next post. Steve is on the right track and his comments are all on the mark. Most physicians are so busy with medical care the don't have time to be proponents of HIE, although if given a cost effective system that is non disruptive they would readily accept it. The devil (as always) is in the "details".

Before you buy that EMR

CCHIT, or the Certification Committee for Health Information Technology

This is the latest compilation of electronic medical records that meet the standards regarding functionality, and interoperability

CCHIT’s inspection process is a rigorous test of electronic health record (EHR) products using two methods: jury-observed demonstration and inspection of self-attestation materials.

To complete this testing, CCHIT empanels a team of three clinical jurors, one of whom must be a practicing physician, and an IT security evaluator to assess a product’s conformance to the CCHIT certification criteria. The inspection occurs by observing the performance of the applicant’s product in executing a series of test scripts and reviewing required materials supplied by the applicant.

Provider Jurors
Lee Barnhart, RN, ADN
Clinical Analyst
MD Buyline
Judy Boesen, RN, BGS, MAM
Administrator
Colorado Otolaryngology Associates, PC
Dan Brewer, MD
Associate Professor
University of Tennessee
Teresita Bushey, MA, APRN-BC
Adult Nurse Practitioner, Nursing Faculty
College of St. Scholastica
Bonnie Cassidy, MPA, RHIA, FAHIMA, FHIMSS
Director
Cherry, Bekaert & Holland, LLP
Rose Dunn, RHIA, MBA, CPA, CHPS, FACHE
Chief Operating Officer
First Class Solutions, Inc.
Jennifer Garvin, PhD, MBA
Medical Informatics Postdoctoral Fellow
US Department of Veterans Affairs
Linda Hogan, PhD
VP, Clinical Informatics & Operations
Pittsburgh Mercy Health System
Doris Hubbs, MD
Kingsport Consultants
John Hummel
Clinical Solutions Director
Perot System Healthcare Group
Elisa Kogan, MS, CCS-P
Director, Physician Practice
University of Illinois Medical Center
Kent Maurer, BS, AAS, AAS
Sr. VP, Information Services and CIO
Cook Children's Health Care System
Susan Miller, RN, FACMPE
Administrator
Family Practice Associates of Lexington, KY
Roseanne Moore, BSN, MBA
Director of Clinical Applications and Operations
GWU Medical Faculty Assoicates
Susan Ordway,
HIS Advisor - DOQ-IT Program
MassPRO
Douglas Peterson, MD
CMO; Chief, Correctional HIS,
State of California
Department of Corrections and Rehabilitation
Susan Postal, MBA, RHIA
Vice President
Health Information Management Systems
Hospital Corporation of America
Luis Adrian Rivera Pomales, MD, MBA, MPH,
CCD
Medical Director
PEB Corp.
Iris Spikes, RN, BS, MBA
Senior Systems Analyst
Health First
Angela Tiberio, MD
CMO; Associate Vice President
Rush University Medical Center

Physician Jurors
Kenneth Adler, MD, MMM
Medical Director of Information Technology
Arizona Community Physicians
Kenneth Bernstein, MD
Medical Director/Chief Medical Officer
Darin M. Camarena Health Centers, Inc.
Jennifer Brull, MD
President & CEO
Prairie Star Family Practice
H. Coren, MD
Nitin Damle, MS, MD, FACP
President
South County Internal Medicine, Inc.
Brian Foresman, DO, MS
Associate Professor of Clinical Medicine
Indiana University
Duane Gainsburg, MD
Neurological Surgery
Edward Gold, MD, MBA
Senior Partner
Old Hook Medical Associates, LLC
Patricia Hale, MD, PhD, FACP
CMIO
Glen Falls Hospital
Ronald Hughes, MD
Family Physician
Mark D. Kaufmann, MD
Lawrence Kent, MD
Clinical Professor of Medicine
Case Western Medical School
Douglas Krell, MD
Ardent Health Systems
Andrew Lee, MD
Galion Community Hospital Physician Practice
Stephen Morgan, MD
Pediatric Associates of Greater Salem
Bruce Nelson, MD
Chief, Division of Basic and Clinical Immunology
Mission Internal Medical Group, Inc.
Stephen Newman, MD, MBA
Clinical Instructor
Robert Wood Johnson School
Daniel Shapiro, MD
Adjunct Associate Professor of Medicine,
Boston University School of Medicine
Lahey Clinic
Paul Ullom-Minnich, MD
Partners in Family Care
Robert White, MD, MPH
New Mexico VA Health Care System
Steven Zuckerman, MD
Neurologist
The following list is the current vendors who are compliant with the CCHIT standard.
(note: all links should be "clickable"

Key: Company (Product and version) Date of CCHIT Certified status

· ABELSoft Corporation (ABELMed PM - EMR 7.0) 10/23/2006
· AcerMed, Inc.(AcerMed 1.0) 10/23/2006
· Advanced Data Systems Corporation (MedicsDocAssistant 3.0) 1/29/2007
· AllMeds, Inc. (AllMeds EMR Version 7) 4/30/2007
· Allscripts (HealthMatics Electronic Health Record 2006) 7/18/2006
· Allscripts (TouchWorks Electronic Health Record 10.2.3) 7/18/2006
· athenahealth, Inc. (athenaClinicals 0.15) 4/30/2007
· BizMatics, Inc. (PrognoCIS 1.81) 4/30/2007
· BMD Services (E-Paperless Practice V2.01) 4/30/2007
· BML MedRecords Alert LLC (Physician's Solution 3.0) 4/30/2007
· Bond Technologies (Bond Clinician EHR 2006) 10/23/2006
· Business Computer Applications, Inc. (PEARL EMR 6.0) 4/30/2007
· Catalis (Accelerator Graphical Health Record 4.111) 1/29/2007
· Cerner Corporation (PowerChart 2005.02) 7/18/2006
· Community Computer Service (MEDENT 16) 7/31/2006
· Companion Technologies (Companion EMR v8.5) 7/18/2006
· CPSI (Medical Practice EMR 14) 10/23/2006
· CureMD Corporation (CureMD 9.0) 4/30/2007
· Department of Defense, Military Health System (AHLTA 3.3* **) 4/30/2007
· Document Storage Systems, Inc. (vxVistA V1.0) 4/30/2007
· eClinicalWorks (eClinicalWorks Version 7.0 Release 2) 7/18/2006
· eClinicalWorks (eClinicalWorks Version 7.5) 2/6/2007
· Eclipsys Corporation (Sunrise Ambulatory Care 4.5) 10/23/2006
· EHS (CareRevolution 5.0i) 10/23/2006
· e-MDs (e-MDs Solution Series 6.1) 7/18/2006
· eMedicalFiles, Inc. (MDAware® 2.2) 4/30/2007
· Encite (TouchChart 3.3) 1/29/2007
· Epic Systems (EpicCare Ambulatory EMR Spring 2006) 7/18/2006
· GE Healthcare (Centricity® EMR 2005 Version 6.0) 7/18/2006
· GE Healthcare (Centricity® Practice Solution Version 6.0) 3/28/2007
· Glenwood Systems, LLC (GlaceEMR 2.0**) 4/30/2007
· gloStream, Inc. (gloEMR 3.5) 4/30/2007
· Greenway Medical Technologies (PrimeSuite 2007) 10/23/2006
· Henry Schein Medical Systems (MicroMD EMR 4.5) 1/29/2007
· iMedica Corporation (iMedica Patient Relationship Manager 2005, version 5.1) 7/31/2006
· iMedica Corporation (iMedica Patient Relationship Manager 2006, version 6.0) 11/15/2006
· Infor-Med Corporation (Praxis® Electronic Medical Records, version 3.4) 7/31/2006
· InteGreat Concepts, Inc. (IC-Chart Release 6.0) 1/29/2007
· iSALUS Healthcare (OfficeEMR 2007) 4/30/2007
· JMJ Technologies (EncounterPRO® EHR 5.0) 7/18/2006
· LifeWatch Technologies, Inc. - A LifeWatch Corp Company (LifeT.I.M.E. (7.100)) 1/29/2007
· LSS Data Systems (Medical and Practice Management Suite Client Server Version 5.5 (ServiceRelease 2.1)) 7/31/2006
· LSS Data Systems (Medical and Practice Management (MPM) Suite MAGIC Version 5.5, Service Release 2.1) 1/29/2007
· Marshfield Clinic (CattailsMD Version 5*) 1/29/2007
· McKesson (Horizon Ambulatory Care Version 9.4) 7/18/2006
· MCS-Medical Communication Systems (mMD.Net EHR 9.0.9) 7/18/2006
· MDLAND (MDLAND Electronic Health Record and Practice Management Systems 8.0) 4/30/2007
· MDTablet (MDTABLET 2.6.7) 4/30/2007
· MedAZ.net (MEDAZ 60720.001) 1/29/2007
· MedcomSoft (Record 2006 (V 3.0)) 7/18/2006
· Medical Informatics Engineering (WebChart 4.23) 7/18/2006
· Medical Messenger (Medical Messenger Astral Jet EMR 3.7.1) 4/30/2007
· Medicat (Medicat 8.8) 1/29/2007
· MedicWare (MedicWare EMR 7) 1/29/2007
· MedInformatix (MedInformatix V 6.0) 1/29/2007
· MediNotes Corporation (MediNotes e 5.0) 10/23/2006
· Meditab Software (Intelligent Medical Software (IMS) 2007) 1/29/2007
· MedPlexus, Inc. (MedPlexus EHR 8.5) 10/23/2006
· meridianEMR, Inc. (meridianEMR 3.6.1) 4/30/2007
· Misys Healthcare Systems (Misys EMR 8.0) 7/18/2006
· NCG Medical Systems, Inc. (dChart EMR 4.5) 2/9/2007
· Netsmart Technologies (Avatar PM 2006 Release 02) 10/23/2006
· NextGen Healthcare Information Systems (NextGen EMR 5.3) 7/18/2006
· Nightingale Informatix Corporation (myNightingale Physician Workstation 5.1) 7/18/2006
· Noteworthy Medical Systems, Inc.(Noteworthy EHR 5.4) 10/23/2006
· OmniMD (OmniMD EMR 6.0.5) 4/30/2007
· Partners HealthCare System, Inc. (Longitudinal Medical Record (LMR) 5.1.1*) 4/30/2007
· Point and Click Solutions, Inc. (OpenChart 8.0**) 4/30/2007
· Polaris Management, Inc. (EpiChart 5.2**) 4/30/2007
· PowerMed Corporation (Practice Suite Version 2) 4/30/2007
· Practice Partner (Practice Partner 9) 7/18/2006
· Practice Partner (Practice Partner 9.1) 11/18/2006
· Practice Partner (Practice Partner 9.2) 3/7/2007
· Prime Clinical Systems, Inc. (Patient Chart Manager 5.3) 4/30/2007
· ProPractica Inc.(Streamline MD 9.0.9) 10/23/2006
· Pulse Systems (Pulse Patient Relationship Management 3.1.1) 1/29/2007
· Sage Software(Intergy EHR by Sage v3.00) 7/18/2006
· Sage Software (Intergy EHR by Sage v3.50) 10/20/2006
· Sequel Systems, Inc. (SequelMed EMR V7.50) 4/30/2007
· Spring Medical Systems (SpringCharts EHR 9.0) 1/29/2007
· SSIMED (Emrge 6.0 Release 1.0) 1/29/2007
· SynaMed, LLC (SynaMed EMR 5.487) 4/30/2007
· Universal Software Solutions (VersaSuite 7.5) 1/29/2007
· UNI/CARE Systems, Inc. (Pro-Filer 2007.0.0) 4/30/2007
· Utech Products, Inc. (Endosoft 3.0.3.5) 4/30/2007
· Visionary Medical Systems (Visionary Dream EHR 7.1) 1/29/2007
· Waiting Room Solutions (Waiting Room Solutions Practice Management System 3) 4/30/2007
· Workflow.com, LLC (Workflow EHR 2.1) 4/30/2007
· WorldVistA (WorldVistA EHR VOE/ 1.0) 4/30/2007

Choose CCHIT CertifiedSM Products
CCHIT is the recognized certification authority in the United States for EHR products - an independent, private-sector organization that sets the Gold Standard for EHRs.
A CCHIT CertifiedSM seal assures you that an EHR product meets basic requirements for:
· functionality (ability to carry out specific tasks)
· interoperability (compatibility with other products) and
· security (ability to keep your patients' information safe)
CCHIT works with all its stakeholders to gain consensus on certification criteria and testing processes related to the industry standards produced by healthcare standards development organizations (SDOs). Certification is a mechanism for enhancing the confidence and orderliness of the HIT marketplace. The inspection and testing process performed when certifying HIT products is based on agreed-upon standards, as well as unbiased inspection and/or testing.
Certification for ambulatory EHR products is available in 2006; inpatient EHR products will follow in 2007. CCHIT’s certification criteria and processes are created and piloted with physician input. CCHIT’s product test teams include three clinically experienced jurors, one of which must be a physician.
Get more information: CCHIT exhibits and presents at healthcare and medical meetings, and hosts public Town Halls and Town Calls. CCHIT eNews keeps you up-to-date on all CCHIT announcements and activities. CCHIT shares case studies from its broad stakeholder community.
Find CCHIT CertifiedSM EHRs: Look for certified products or ask vendors when they plan to certify their products.
Email CCHIT. © 2007 Certification Commission for Healthcare Information Technology Privacy Policy Terms of Use
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Information compiled 05/08/2007 Gary M. Levin M.D. Regional Coordinator IERHIO
Ref: http://trusted.md/ (RHIO MONITOR) http://healthtrain.blogspot.com/

in Memoriam--Ron Bassanger M.D.

Prominent doctor dies at 57Redlands Daily Facts - 05/05/2007, 06:41 am: Dr. Ron Bangasser, a physician known locally and nationally for his compassion for patients and his zeal to improve the quality of health care, died of cancer May 2 in Redlands. He was 57... "Ron's death is a tremendous loss to all of us - his family, his patients, his friends and colleagues and all of medicine," said Dr. Anmol S. Mahal, president of the California Medical Association. "Ron was always an example of what a doctor should be, operating his wound care clinic, his practice, treating patients in the hospital, all the while serving his patients and colleagues through his advocacy for the California Medical Association."

Dr Bassanger was on the charter committee of the Inland Empire RHIO. He was a visionary in regard to the importance of HIE and EMRs. We shall all miss his wisdom.

Gary Levin MD

Will Patients select their MD according to Who Has an EMR??

Although I was unable to attend the Consumer Directed Health Care Conference in Las Vegas t his past week (CDHCC) I have been able to follow some important information published on their web site.


Another Reason to Adopt Electronic Medical Recordsby Scott MacStravic
April 30, 2007 at 9:40 pm · Filed under Health IT

A recent Accenture survey found that two-thirds of consumers responding indicated that having an EMR system or not played a role in their selection of a physician. Moreover, a little over half of these consumers said that they would be willing to pay a reasonable extra amount to cover the costs of such a system. Despite this consumer preference, only about 10% of practices and 25% of doctors have EMR systems in place. The cost of implementing and maintaining the system is the overwhelming barrier, with 86% of physicians reporting that as a concern. [“Survey Finds Patients Favor Doctors Using EMRs” E-Health Trend Watch Apr 27, 2007 (www.hcpro.com)]
This consumer attitude adds to the many quality and efficiency reasons for physicians to adopt EMR systems. Fortunately, governments, employer coalitions, and hospitals are indicating a willingness to support physicians’ efforts to digitalize their records systems, and laws against hospitals helping are being relaxed. But another reason emerged in a breakout presentation at the World Healthcare Congress this week.
During the presentation of Regence BlueCross BlueShield and the software firm, Kryptiq Corporation, both in the Northwest, the preference of at least that employer for physician practices with EMR systems was made clear. This makes good business sense for Kryptiq, since it is in the software business, but also because of the advantages the EMRs offer in employee health management.
Almost all the current pressure on physicians to adopt EMR systems focuses on their importance in sickness care. They enable physicians to more quickly access information needed to diagnose and treat patients who are ill, to avoid duplication of tests in making diagnoses, and avoid contraindicated medications in treatment, for example. They also facilitate coding and billing, so help practices in managing cash flow.\
Growing importance is being given to the prospect of sharing EMR information across practices, to improve continuity of care when multiple practices are involved in an episode of care, for example. Regional Health Information Organizations are emerging as ways to enable sharing of data by practices when patients seek care away from their usual sources, perhaps in emergencies such as hurricane Katrina.
But EMRs are also excellent foundations for health management, for preventing and catching early risks and diseases that can be managed in ways that reduce direct sickness care costs, but also worker absences, impaired performance while at work (“presenteeism”), disability wage replacement costs and other labor costs to employers. And employers can influence the physician selection of hundreds, even thousands of employees.
Kryptiq considers the presence of EMRs in deciding which physician practices to include in its provider network, for example, and selected GreenField Health System in Portland, OR as a partner in its effort to manage the health of its employees, not simply deliver sickness care. The founder of GreenField Health serves on the Kryptiq board, while GreenField is also a customer for Kryptiq’s secure online communications system for communicating with patients. Such communications improve the efficiency of practices by eliminating unnecessary office visits, while providing the foundation for ongoing health improvement and maintenance efforts.
In addition to using EMRs as one factor in choosing practices for provider networks, employers can use EMR-enabled performance data on how well practices are doing in managing employee health to inform individual employee choices of personal physicians. When employee performance makes a difference to their compensation and career prospects, and health has a significant impact on their performance, this adds another reason for patients to prefer physicians with EMRs.
My comment

This is obviously a biased survey, since it was performed by businesses that stand to gain from IT adoption.

More on Scott Shreve and HIE from CALRHIO

For those of you who have already read Scott's blog you will realize here is an experienced professional who has laid "the railroad tracks" for Enterprise Health Records. I recommend the article highly to others.

CALRHIO has elaborated a comprehensive plan for the state of California to plan and implement a Health Information Exchange Backbone. This structure will be built out by Medicity and Perot Systems. It will integrate both state, county and private health care providers.

For details I have extracted the information from their posting.
It follows:



HIE Utility Service at-a-Glance

PURPOSE
To build a statewide health information exchange (HIE) utility service that will offer California health care providers and patients secure electronic access to patient medical records, where and when needed.

CalRHIO’s primary goal is to deliver critical health information services securely, reliably, and affordably to clinicians, patients, state, county, and federal health agencies, and communities throughout California.

PROFILE
The CalRHIO HIE Utility Service will provide a suite of services from which individual organizations and regional efforts can select to use some, all, or none. The financing model is designed so that participants are not paying for initial development and implementation of the utility service. Those who benefit pay only for the services they need and use.

The CalRHIO HIE Utility Service will provide health information exchange services that are:
available at a price that no one entity can achieve alone
flexible and adaptable to support a wide variety of legacy systems and technical environments – services adapt to existing technology
designed to permit local users to consume and pay only for those services they find valuable and are not duplicative of services provided locally
ARCHITECTURE
Service Oriented Architecture (SOA): SOA framework and Web services platform facilitates scalable, incremental growth and is capable of quickly deploying new services through the re-use of existing services. Because of the variability in IT system environments, as well as the diversity of business and clinical landscapes within health care communities, no one architectural model will suffice. Given the existing challenges, an architectural style of design for constructing HIE models must be flexible and adaptable to resolve variability and diversity issues. A Web services implementation of SOA can meet these complex, diverse business and technical requirements characteristic of HIE initiatives.

UTILITY SERVICES
Phase I: Establish a state layer or “backbone” of data and services
Phase II: Create regional overlays that leverage and expand on the state layer by adding local data sources and additional services
STATE LAYER - State Network Backbone consists of data and services
· Data: state and multi-regional clinical feeds (claims history from payers, lab/pathology reports from national labs, Meds from RxHub and SureScripts)
· Applications: Master Patient Index (MPI), Record Locator Service (RLS), e-Prescribing
· Options (for regions that are ready):
o Integration Hub: translates patient-centric health information between various Electronic Medical Record (EMR) vendor applications
o EMR Gateway: clinical feeds from lab/path reports from national labs, Meds from RxHub and SureScripts to the physician’s EMR application
REGIONAL LAYER – regional overlay of state network with local data and services
· Data: Local clinical data from hospitals, local labs and imaging facilities (data to include labs, radiology reads, transcription, etc.)
· Application Services: include a MPI; RLS; Electronic Health Record (HER) & Personal Health Record (PHR); medication management (e-Prescribing & medication reconciliation); clinical messaging (referral, lab & imaging orders and results; and data warehouse for reporting and analysis
· Integration Hub Service : translates patient-centric health information between various EMR vendor applications.
· EMR Gateway Service: clinical feeds from lab/path reports from national labs, Meds from RxHub and SureScripts to the physician’s EMR application

State Layer
State of California Clinical Data Services
MPI
RLS
EMR Gateway
Patient
Payor
Provider
Claims
History
RxHub
SureScripts
National
Labs
National Data Feeds
Statewide, Real-time
Clinical Data Access




Region A
State of California Clinical Data Services
MPI
RLS
EMR Gateway
Patient
Payor
Provider
Claims
History
RxHub
SureScripts
National
Labs
National Data Feeds
Region
B
Region
C
Regional Layer
Local Data
(From Labs, Hospitals, EMR)
EMR Gateway
Regional Reporting
BENEFITS FOR ALL USERS
· An information infrastructure that supports optimum care delivery methodologies, transparency, patient empowerment, and integrated health care records
· A utility-like infrastructure that moves health care information efficiently and at a cost that is a small fraction of the money saved for payers, patients, and providers alike
· Affordable utility services that facilitate regional health information exchanges and interconnections among them

PHASE I USERS
· EMERGENCY DEPARTMENTS
· CLINICS
· PHYSICIAN OFFICES

PRIVACY and SECURITY
Users must be authorized and authenticated and have either obtained a patient’s consent or documented an emergency. All data sharing will be carried out pursuant to state and federal laws involving patient consent, privacy, and security. Will require all appropriate parties agree on data sharing scope and methodology.

PARTICIPATION
Participation by individual organizations and communities is completely voluntary. Participation is NOT mandated by any private or public entity.

FAQ
Q: Why is CalRHIO creating a technology platform of its own instead of relying entirely on local organizations to provide a technology platform that satisfies local needs?

A: Time is of the essence. On average, every business day in California more than 50,000 patients are receiving suboptimal clinical care solely because we do not have a comprehensive method for moving patient records where and when they are needed. To rely solely on local organizations to individually engage in the expensive and time consuming effort to select vendors, develop detailed requirements, and supervise a complex HIT project will materially delay the widespread sharing of important patient medical information. CalRHIO is offering an option that organizations and communities can use to meet their individual needs and help advance HIE throughout the state.

CalRHIO and ITS STRATEGIC PARTNERS
Medicity and Perot Systems Corporation were selected to build the CalRHIO utility service through a competitive bidding process. Medicity and Perot Systems were selected because their solution offers a strong, proven, and scalable technology platform that will eliminate limitations on how individual health care organizations and local communities design and implement the health information exchange services they need.

In addition to a suite of solutions that are already integrated and interoperable, Medicity and Perot Systems brought an innovative financial model to the table that will enable CalRHIO to sustain the project long term. Creating a sustainable business model is one of the biggest challenges for health information exchange efforts nationally.

COST AND FINANCING
· The financing model eliminates the front-loaded expenses that penalize the early adopters.
· Cost to the Point of Sustainability: Capital required to finance an implementation that is thereafter sustainable without further capital infusion will require up to $300M with financing coming in two stages: 1) initial private equity funding covering the phase one build of the state HIE backbone and 2) after backbone delivery of basic information and proof of concept, final funding with more traditional debt financing replacing private equity capital. A connected California could save $9B annually.

Stakeholder
HIE Benefits
Physicians
· More “real time” information from outside clinical setting
· Rapid access to test results and ability to track medication history
· Changes the point of clinical aggregation from physician’s desk to having aggregated clinical data accessible electronically – reportable and available anywhere, anytime
· Improves referred patient flow, eligibility determination
· Improve patient experience
· Improves administrative efficiencies and offers administrative savings
· Improves the consistency and completeness of documentation
Health Plans
· Potential to drive down administrative costs
· No capital required; only an expense-related payment, and then only after patient HIE services actually rendered
· Potential to significantly reduce expenditures for unnecessary, redundant, or ineffective services
· Pathway to improved care, quality
· Support for value driven health care and pay-for-performance by helping health care organizations track and document the efficiency and appropriateness of care patients received
· Potential to perform widespread data capture for analysis of utilization rates and quality and performance measurements, which has the potential to reduce costs and improve quality of care
Hospitals
· Reductions in administrative times: (Experience of Indiana HIE is 12 min. reduction in nurse and pharmacist time for each admission as a result of “delivering synthesized useful medication histories to hospitals”)
· Improves care delivery and efficiency through immediate access to information that assists clinicians in diagnosis and treatment
· Support for medication reconciliation in accordance with JCAHO requirements
· Source for patient coverage eligibility for both private and public health plans/insurance
Patients
· Improve care at the point of delivery (including reduced medical errors)
· Improve overall coordination of care
· Improve application of evidence-based medicine
· Facilitate greater patient engagement in their health care through networked personal health records
Employer
· Improve transparency on cost and quality
· Help educate consumers about value and ultimately reduce cost through increased preventive care and lower hospital admissions
· Improve quality of care and reduce preventable admissions
Public Health
· Move toward ability to aggregate surveillance data of disease and critical patient information during disasters or bioterrorist threats

Scott Shreeve, MD: A New Dimension: Introducing the XHR

Scott Shreeve, MD: A New Dimension: Introducing the XHR

NATIONAL HEALTH INFORMATION NEWS-WATCH

Timely and current information regarding RHIOs in the United States is available at NHIN Watch, http://nhinwatch.com/performSearch.cms?channelId=1

The Office of the National Coordinator for Health Information Technology (ONCHIT) offers a listserv mail list which announces what ONCHIT is doing to advance RHIO development.
It can be found at: https://list.nih.gov/archives/health-it.html

Google announces collaboration with Practice Fusion

Practice Fusion and Google, the internet search engine have announced a collaboration whereby the EMR and RHIO solution will be offered to providers free of charge. Income will be derived from advertising banners supplied and linked by Google, which will be accessible from the EMR pages used by the provider online. Privacy issues are one of the main concerns for this business model, which however can be addressed since the advertising would not be linked to particular patient's records.

Featured in RHIO Monitor CALRHIO selects Vendors

Featured in: RHIO MonitorCalRHIO Selects Medicity and Perot Systems Corporation to Build Statewide Health Information Exchange for California
CalRHIO Selects Medicity and Perot Systems Corporation to BuildStatewide Health Information Exchange for California
SAN FRANCISCO, Calif., March13, 2007 – CalRHIO announced today that it has selected Medicity, Inc.,teamed with Perot Systems Corporation (NYSE:PER), to build a statewidehealth information exchange utility service that will offer Californiahealth care providers secure electronic access to patient medicalrecords, where and when they are needed.
“CalRHIO’s primary goal is to deliver critical health informationservices reliably and affordably to clinicians, patients, state,county, and federal health agencies, and local exchange effortsthroughout California,” said CalRHIO CEO and President DonaldHolmquest, MD, JD. “Medicity and Perot Systems were selected becausetheir solution offers a strong, proven, and scalable technologyplatform that will eliminate limitations on how individual health careorganizations and local communities design and implement the healthinformation exchange services they need.”
“In addition to a suite of solutions that are already integrated andinteroperable, Medicity and Perot Systems brought an innovativefinancial model to the table that will enable us to sustain the projectlong term,” said Molly Coye, MD, MPH, one of the founding directors ofCalRHIO’s board and CEO and president of the Health Technology Center.“Creating a sustainable business model is one of the biggest challengesfor health information exchange efforts nationally,” Coye noted, citingfindings of a federal study she chaired last year that assessed ninestatewide HIE initiatives.
Medicity and Perot Systems’ first step will be to assist in theprocurement of private seed money to fund start-up costs for theCalRHIO HIE utility service, including building the statewide backboneinfrastructure and integration, marketing and communication, andCalRHIO’s operating budget. Financing requirements for this phase areestimated at $300 million.
The health information exchange platform will make it possible forphysician offices, hospitals, and health plans that have invested inhealth information technology to use their current technology to accessdata outside their walls. While details of charges are yet to bedetermined, the savings expected as a result of having betterinformation will be many times greater than the cost, according toHolmquest.
Through its partnership with Medicity and Perot Systems, CalRHIOwill offer a suite of secure, privacy-protected services from whichorganizations can select to use all, some, or none. For example, forcommunities that want to enable all their health care providers toexchange information, CalRHIO’s HIE utility service will offer anoptional alternative to building and financing their owninfrastructure. For communities that have already initiated localhealth information exchange efforts, the services offered will becompatible and complementary.
“It is imperative that we get a technology solution up and runningas soon as possible to accommodate the needs of California doctors,hospitals, and patients,” Holmquest said. “Every day in California,50,000 or more patients are experiencing suboptimal care solely becauseimportant medical information is missing from their records. Payers andpatients are paying huge additional costs because of the fragmentedcare that result from lack of timely information.”
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Cerner Statement

I missed last week’s deadline for RHIO MONITOR and Health Train Express due to some interviews and other related projects on EMR. I myself am in the midst of examining and implementing an EMR for my practice. In the process I have had the advantage of my research and study of RHIO as coordinator of a RHIO. In my evaluation it has become apparent that having an EMR which is certified by CCHIT is the ticket of admission, for any serious vendor. All that hard work of the past two years is paying off and demonstrates the process will take time and much patience. Of course I am speaking to the choir, but it emphasizes that we need to do a lot more educating of our fellow physicians. The scope and depth of understanding varies tremendously amongst physicians about EMRs, and RHIOs. There continues to be a divide between vendors and providers. According to my sources they have a difficult time and spend much of it explaining IT to providers. Providers’ eyes glaze over when given a new set of vocabulary and how these systems operate. The differences are also generational. Younger MDs have a set of material from their education which now exposes almost all school children to the basics and more of computers. Microsoft Windows is now the W of the three Rs.
One publication I have access to is a resource is “Functional Matrix” of a number of EMR solutions as prepared by the American Academy of Ophthalmology. While focused on ophthalmology it organizes in a readable manner the items all provider should look at when examining EMRs.
This resource can be found at: http://www.aao.org/aaoesite/promo/business/EMR3.cfm
A profound statement by the CEO of Cerner was quoted in iHealthbeat, published by the California Health Foundation.
“
Cerner CEO: Revamp Health Care Reimbursement SystemMarch 01, 2007
The U.S. health care reimbursement system is "grossly inefficient" and "needs to be changed," Cerner Chair and CEO Neal Patterson said Tuesday at the Healthcare Information and Management Systems Society conference in New Orleans, the Kansas City Star reports.Patterson cited the Healthe Mid-America program, run by Cerner, as an example of how the system could be improved. The independent, not-for-profit program manages the employee health records of Cerner and about 20 other Kansas City-area businesses. Program participants can use an electronic debit and information card to pay for a physician visit and to access computerized personal health records with a PIN, the Star reports. Patterson cited a study that found that 31% of U.S. health care spending is on administrative costs and said that one of Cerner's "goals is to eliminate insurance companies as they exist today." The Healthe Mid-America program is being tested in the Kansas City area, and Cerner hopes eventually to expand the program nationwide, the Star reports (Karash, Kansas City Star, 2/28).

End quote: The Kansas City Star link expands on this brief .

Information from HIMMS Summit Meeting

HIMSS Chair Kicks Off Conference by Touting Necessity of Health ITFebruary 26, 2007
The health IT industry should stop debating the value of electronic health records and accept the technology's importance in the future of health care, Buddy Hickman, chair of the Healthcare Information Management Systems Society board, said on Monday in his opening remarks at the annual HIMSS conference in New Orleans, Healthcare IT News reports."Placing the focus on quality, patient safety and necessary clinical process improvements is consistent with HIMSS' mission and with the reasons why adoption of [health IT] was strongly recommended by the Institute of Medicine's Crossing the Quality Chasm report," Hickman said.Hickman also encouraged the industry to have a unified voice on goals, policies and messages, including a broader view on health IT from the federal and state levels. "In this way, [health IT] becomes part of a necessary solution to critical challenges rather than being viewed as a lesser priority competing for funds," he said."Through smart public policy, alliances and the right incentives, we can create the right kind of national health information network -- one that contributes to quality, safety and better outcomes for all," Hickman said, adding, "If we don't do this now, we only create a greater challenge to fix later" (Enrado, Healthcare IT News, 2/26).


Microsoft last year acquired medical database developer Azyxxi and currently has more than 600 employees focused on health care projects, according to Microsoft Vice President Peter Neupert. Health care "is a huge sector of our economy," yet it still is relatively low tech, he said. As the country's aging baby boomers require more medical attention, the need for health care technology will become clearer, Neupert said. Microsoft CEO Steve Ballmer on Monday will speak at the Healthcare Information Management Systems Society's annual conference in New Orleans. IBM General Manager Dan Pelino said that better computer systems could improve the accuracy of data, prevent duplication and reduce errors. More than 4,000 IBM employees are working on health care products, USA Today reports. IBM also is developing a nationwide patient database with HHS that would store patient information regardless of which hospital or physician a patient visited. Intel and Motion Computing this month unveiled a laptop for physicians and nurses that includes a digital camera to take pictures of patients.

Further Cutbacks Proposed by Bush

Featured in: RHIO MonitorPresident Bush's new proposals for cutbacks to Medicare and Public Health Funding will impact RHIO development
Further Barriers to Implementing RHIOs Submitted by gmlevinmd123 on Mon, 02/19/2007 - 9:41am.
The catch 22 of Pay for Performance. The health insurance industry as represented by IHA is big on P4P and medicare is following suit without waiting for health IT to catch up so that it can be implemented properly.. At the same time it is espousing paying MDs for improving quality the administration defocuses and presents these new proposals. Write your Congressman!!
Physicians not only pay a fair share of taxes, but are now being asked in some states (California-Schwarzzenegger proposal) to pay a 2% surtax at the state level to fund expansion of insurance to the uninsured...??undocumented aliens, as well??
Even large medical groups will not remain immune to these cutbacks, especially hard hit will be MD providers who have a disproportionate amount of seniors, ie, ophthalmologists, urologists, geriatricians, cardiologists, urologists, and more.
EARLY WARNING SIGNS: Reported in AMA news
Washington -- President Bush presented an austere fiscal year 2008 budget to Congress earlier this month, pledging no new money for Medicare physician reimbursements and proposing to slash the rate of public health program growth in other areas.
If no changes are made, doctors could see an across-the-board cut of 10% or more next calendar year.
"Without adequate funding, physicians cannot make needed investments in health information technology and quality improvement, and seniors' access to health care is placed at risk."
Several times in the past, the White House budget has not set aside money to boost doctor pay, but lawmakers have approved such appropriations anyway.
Bush has called on Congress to increase defense spending while eliminating the federal budget deficit by 2012. The plan assumes not only that physicians will undergo yearly Medicare rate reductions for each of the next five years but that lawmakers will approve more than $75 billion in additional Medicare reductions over that time. The proposal would slow the program's projected growth rate from 6.5% to 5.6% over five years.
For those of you who like to watch government budget projections, here is a summary:
Target: Medicare
President Bush has proposed cutting Medicare's projected spending by more than $75 billion over the next five years. Here are some of the biggest ways the White House hopes to save the government money:
Action
5-year savings
Inpatient hospital updates of inflation minus 0.65% each year
$13.8 billion
Home health agency updates of 0% each year
$9.7 billion
Skilled nursing facility updates of 0% in 2008 and inflation minus 0.65% each following year
$9.2 billion
Part B premiums increased for patients with higher incomes
$7.1 billion
Outpatient hospital updates of inflation minus 0.65% each year
$3.4 billion
Part D premiums increased for patients with higher incomes
$3.2 billion
Source: White House budget proposal
BLOGGING is now an important source of information for many people, and as we have seen the internet has played an important an unexpected role in political outcomes. I encourage all those interested, physicians, non physicians, health care pundits, to contribute to trusted.md and other blogs regarding health care.


This post has also been posted on www.trusted.md
Gary Levin MD
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Help

Congress has officially approved of CMS’ decision to implement P4P. I recently read somewhere that CMS would increase physician reimbursements (and hospitals, too I suppose) by 300 million dollars with this incentive (if providers are able to conform to their requirements) I also read that physicians such as myself will not face the 5% annual SGR reduction in CMS payments. This has been massaged into the politically correct phrase as a “raise in reimbursements” (the lord giveth and the lord taketh away). So we are given back that which was taken from us and then told it is a “raise”.
Let’s face it, decision makers in Washington and some state capitols as well as legislators are out of touch with reality. Placing more administrative burdens on an already very dysfunctional barely functioning healthcare system is “insane”, and so are those that make these proposals, and then vote them into effect to placate a worried electorate about whether they will be able to afford another doctor visit or hospitalization.
Many physicians I know have retired in their mid 50s to sell soap or enter MLM businesses, sell real estate or go into other businesses, which tells you a great deal about the stressors on physicians.
I can find hundreds of consulting groups, and health care foundations that study everything to death, make more recommendations which increase further the cost of health care, couching their recommendations in terms such as quality initiatives, pay for performance, etc etc. There is a whole new lingo out there that most physicians do not comprehend, but must learn.
I am not optimistic about our health system in the United States. IT and RHIOs are a small part of what we need. If you are very rich or dead poor in poverty your health care is assured. The large mass of diminishing middle class are at great risk, if they lose employment, and/or their group health policies, have pre-existing illnesses, the quickly join the uninsured. Even those fully employed and insured are soon priced out of full insurance coverage.
HSAs are a joke, I tried one last year and found that it takes quite a while to meet the deductible, and the policies are worded in such a way for a family that the deductible for a family is what counts, not the individual users. You also cannot use it unless you fund the HSA upfront. If you have chronic illness and have high expenses from day one….you may not be able to save . I suspect the IRS will expect accounting through the HSA and not direct payments out of pocket. HSAs are a great deal for the banks and the insurers. It will not save healthcare dollars, nor reduce utilization. When people get sick, they seek medical care.
This year I became unemployed for a time and went onto COBRA, about a month later at the end of the year I finally reached my 4800 dollar HAS deductible. One week later it was January and the deductible started over again. True the premium was lower with the HAS but we had medical drug expenses of about 650 dollars that month….we cancelled our COBRA, went bare and are now forming our own group to obtain group health insurance. Individual coverage is out of the question. Now why is that? Seems to me all the individuals who are not in a group could be put into a group of “the individuals who are not in a group”
And now GWB is proposing tax law changes to “make healthcare more affordable”.
And another thing, when you sign up for insurance you are given an effective date which may be any part of the year, yet your deductible rolls over at each calendar year, whether it’s been six months, four months or eight months since you signed up. The contract is for one year…..so why are you cancelled if you miss one payment? Seems to me it is all weighted toward the insurer, not the patient.
As I write this article I am seeing this from the patient (now known as a consumer) aspect; let alone the physician provider side. The billing and coding aspects of reimbursement have turned into a high stakes poker game with a new industry spun off…..the reimbursement consultant who charges anywhere from 500 dollars to 3000 per year to update the practices on insurance billing practices and codes which change from year to year. It’s a bit like poker. And if you make a mistake you are accused of fraud and a buse, fined, or worse kicked out of a program.
I have been practicing over 30 years since I finished medical school. My the world has changed.
Insurance companies control everything. Recently I moved practice locations back to a community where I first started off as a young ophthalmologist. I discovered that my home hospital had disbanded the ophthalmology department and there were several outpatient centers that did all the eye surgery.
Now, insurance companies usually require the physician to have hospital staff priveleges to be on their provider list…..how does one go about that one? Some doctors already on the hospital staff are now paid to take ER standby call…..they are grandfathered in as staff members, but there is no way for new ASC doctors to be proctored in a hospital setting unless the ASC is part of the hospital. Worse than that some ASCs are privately owned and owners will not allow open access thereby eliminating competition in their geographic area. In my next article I will further details the requirements and administrative bureaucracy that has been generated to “protect” patients (from whom?)