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Tuesday, March 15, 2011

The Ides of our forced REC March

A year ago I was eyeball deep in the Meaningful Use IFR, trying to wrap my head around all of the voluminous detail (much of it explicitly "tentative" at the time), and scrambling from training meeting to training meeting, as we prepared to launch our hyper-ambitious provider recruitment campaign (which continues unabated to this day. I just returned from signing up a primary care doc who is about to upgrade to eClinicalWorks 9.0).

More thoughts to come, in no particular order (this is, after all, just a blog, and pretty much an episodic one-draft evening and weekends when-I-have-the-time effort at that)...


Recall that I've previously cited the PCAST Report at some length. I read this recently on The Health Care Blog.

Realizing Value from Health IT: A BCG Response to the PCAST report

A blended Money Quote:

"...technical policy, standards, and incentives are necessary but not sufficient to drive meaningful use...Ultimately the business structure, not the technical architecture, of the industry will determine which cost, quality, and access objectives are feasible in health care..."

Which, of course, goes to policy reform. And, while policy reform is above my nominal pay grade (my being a mere Meaningful Use technical assistance grunt), well, some things are in fact joined at the hip. If MU is to eventually comprise more than simply "Clicking for Cash," rational policy reform will be at its core. JMHO.

Apropos of all this:

(Click above for the article.)



An example I saw today on our HITRC (Health Information Technology Research Center), a Q & A between two MDs.

Clinical Summary Measure Workflow & Issues

Q: Any advice from folks who have started implementing clinical summaries with EHR’s? We’re running into some concerns about the logistics of clinics getting clinical summaries to 50% of their patients. I think many clinics & REC’s do not yet fully realize the workflow problems that this measure will create.

First, the items required to be included are pretty extensive: Patient Name, Provider’s office contact information, Date and location of visit, Reason for the visit, Symptoms, Updated medication list and Summary of current medications, Updated vitals, Procedures and instructions based on any discussions that occurred during the visit, Lab / diagnostic test orders, Lab / test results (if received within 24 hours after visit), Updates to the problem list (if applicable), Immunizations or medication administered, Summary of topics covered during visit, Time and location of next appointment / testing (if scheduled), Recommended next appointment (if not already scheduled), Other appointments / testing patient needs to schedule (including contact information)

Some of this will not be available until clinicians have finished their note. This will result in a bottle neck for many clinics because clinicians frequently finish notes after patients have left the office. Finishing notes is often done during the slack time in the clinic day (e.g., while waiting for lab, waiting for a late patient, or at the end of the clinic session). If a clinical summary is needed, it may require the clinician to stop their office flow to finish the visit note so that the summary can be generated before the patient checks out.

Second, the clause “Lab / test results, if received within 24 hours after visit” means that the patient may need to be given a 2nd updated summary when their lab results come in. Many labs these days are received by clinics with lab interfaces within 24 hours, so almost every patient with a lab draw will need to be given an updated summary if they were already given a summary at checkout. One way around this is to send out the clinical summary 24 hours after the visit to avoid 2 summaries being given. This would require thousands of dollars of extra postage unless the clinic utilizes secure e-mail for its lab results or a web portal (was this measure a back door method of requiring clinics to purchase a web portal for stage 1?).

Lastly, as a physician, I see this as the single hardest measure to meet as it will require a significant amount of staff time to achieve. The rationale & intent of the measure is very solid. With my EHR, I often opened a Word document to type out a “To Do” list for my patients (which I then cut and pasted into the end of my EHR’s progress note). It served as a helpful reminder for my patients, especially the elderly (often printed in 16 or 18 point font so they could read it). The measure as written, however, is very strict and detailed. What will happen if we see many of our clinics missing this measure by 10-20% at 90 days when they hoped to attest for MU? Since MU incentives are all or none (if you miss 1 core measure by 1%, you get $0), what if large numbers of clinics miss out on MU incentives due to missing this one measure? Will there be a large number of irritated clinics missing this measure who make a very public outcry? Will ONC be able to backtrack on this number? (This sort of thing happens periodically with QIO grants when the measure set was unrealistic and was later thrown out, however these things happen quietly away from media eyes.)

Hopefully this isn’t coming across as too negative, but it’s something to start thinking about. Any advice would be appreciated.

A: The only realistic way to achieve this is via a patient portal or personal health record. I do realize that these are not widely deployed. The nature of the requirements and workflow dance require asynchronous communication. I am curious how many of the EMR practices or organizations that RECs are working with have implemented these electronic tools for patients. In our REC region, large physician practices on an EMR for 3 years or more are implementing Patient Portals. Hospitals have been slower. There is some uptake of PHRs, but so far a disturbing lack of sponsorship. The state of Indiana HIE plan does have PHR connectivity to HIE planned in the next 1-2 years.

Interesting. And that ("Visit Summaries," 170.304.h) is generally considered to be one of the easier measures.


I've been closely following the news out of Japan since last Friday in mute horror and dismay. The continuing nuclear disaster added to the earthquake and tsunami catastrophe just leaves you speechless. It reminds me of a time in my life 25 years ago.
In the spring of 1986 I was managing a Radiological Environmental Monitoring Program database and reporting system (REMP) I’d developed for the environmental radiation lab in Oak Ridge where I worked. One of our clients was Perry Nuclear of Ohio (they intended to build a nuke plant there). The REMP stuff comprised an ongoing environmental baseline study via which to establish natural radionuclide levels across the breadth of matrices within a 5 mile radius of the proposed plant site — soils, vegetation, water, milk from local cows, all manner of biota, and the air.

The air filter analyses always came back “below LLD” (Lower Limit of Determination, i.e., in this case “LT 0.04 pCi/cu.m." (less than 4-100ths of a trillionth of a Curie). I had a macro code snippet that simply populated that field with that update ongoing.

One week after Chernobyl we had elevated positive lab readings across all air filter locations. I-131. Given its 8.05 day half-life, it descended back down to below LLD after about 5 weeks.

Nonetheless, it was a bit creepy.

Other, heavier radionuclides like Cs-137 were blown all over the arctic regions. Scientists are probably STILL studying biota uptake and rad migration on a lot of this stuff.
I confess, I’m not a big fan of using intrinsically toxic unstable heavy elements to boil water for turbine steam to produce general electricity. The only net upside of nuke is the absence of greenhouse gases at the point of power production (and, in fairness, that is indeed a significant benefit). But, for that you trade all the other externalities -- e.g., the destructive pit mining, the long-term waste, and the requisite Nuclear Security State.

Neither do I buy the False Dilemma of “either nuke or coal.” See one of my old blog posts, "0.0143%"

For now, I just hope they can get those crippled Japanese plants under control. Even absent a Chernobyl-esqe event, it is pretty clear at this point that they now have a set of permanently damaged reactors that will end up in a fate similar to that of Three Mile Island Unit 2 (which cost an initial billion dollars to safely sequester). Talk about "sunk costs."

My heart goes out to the people of Japan. They'll be decades recovering from this.


Just got copied on an email from someone in our NV state DHHS:
"Found out from our Pharm Board that in NV, an e-prescribing system must be approved by the Board before it can be used."

Here's the link to the Nevada regulation (NAC 639.7102).

The email went on to list NV "approved" e-Rx systems:

  1. Allscripts, LLC
  2. Alteer
  3. BioMedix Vascular Solutions, Inc./TRAKnet DPM
  4. Cardinal Health Nuclear Pharmacy Services
  5. Catalis Inc.
  6. DrFirst Inc.
  7. e-MDs, Inc
  8. GE Healthcare
  9. Greenway Medical Technologies
  10. H2H Solutions, Inc. (H2H Digital Rx)
  11. Life-File
  12. MeridianEMR, Inc.
  13. McKession
  14. MedPlus
  15. MicroMD by Henry Schein Medical Systems
  16. MinuteClinic
  17. Misys Healthcare Systems
  18. Mountain Medical Technologies, Inc.
  19. Netsmart Technology
  20. NewCrop, LLC
  21. NextGen Healthcare
  22. Renown Health
  23. RxNT
  24. Sage Software Healthcare Division
  25. SRSsoft
  26. SuiteMed + Meditab Software
  27. SureScripts, LLC
  28. University Medical Center of Southern Nevada Outpatient Pharmacy
OK, as of today there are a total of 331 ONC certified ambulatory EHRs alone, 233 of them listed as "complete" systems (which by definition include e-Rx). There are a lot of big players that are not among the foregoing 28 Nevada "approved" e-Rx systems -- e.g., eClinicalWorks, a top-tier product (and the one most used to date among our REC clients) is not on this list.

Does federal law and regulation (and subsequent ONC certification) trump state law on this? Or, are many NV providers essentially in violation of the law here? Wow.

Now, #27, "SureScripts" is on the list, and clinics doing e-Rx typically transmit via their SureScripts interface accounts, so maybe that suffices by proxy. But, that would beg the question of why, then, have the other vendors on "the list"?

Someone needs to clarify this ASAP.


Last Sunday, on CBS' "60 Minutes"

“…counterfeit medications are not just being sold on the Internet. They are also making their way into mainstream pharmacies and hospitals. FDA Commissioner Margaret Hamburg says that while the vast majority of our drug supply is safe, there's reason for concern.

"You know, we don't really know the full dimensions of the problem. But, we do know that in certain countries somewhere between 30 and 50 percent of really important drugs for health are, in fact, counterfeit," Commissioner Hamburg said.

"How does all this increase in counterfeit drugs around the world affect the United States?" Gupta asked.

"Just consider that 40 percent of drugs taken in this country come from other countries; 80 percent of the active pharmaceutical ingredients in drugs taken in this country actually come from other countries," Hamburg said.

Even if the prescription medications are manufactured in the United States, the raw ingredients often come from overseas, through a complicated web of suppliers and distributors - and are increasingly vulnerable to counterfeiting…”

When we start doing large scale CER, to what extent might fake meds mislead us regarding "patient Rx compliance" and drug efficacy? e.g., Mr. Jones swears he's been religiously taking his 40 mg Simvastatin, but his lipids remain abnormally out of parameters.

More to come...