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Wednesday, March 13, 2013

HIE - "Bank" on it?

Really? Really?

I used to work in banking (credit card risk modeling and portfolio management). Somehow the words "health records" and "banking" in the same phrase activate my Dubiety Detector.

This article today sparked my renewed attention.
Group sees health record banks as best way to share EHR information, not HIEs
March 13, 2013 10:43 am by Stephanie Baum
Health information exchanges in which electronic medical records can be transmitted between providers has been the most challenging requirement to prove Meaningful Use as spelled out in the HITECH Act. So much so that the Office of National Coordinator for Health IT, part of the Department of Health and Human Services issued a request for information last week to get ideas that would accelerate electronic health record exchange between providers.

An article published in the Journal of the American Medical Association this week argues that health information exchanges are unworkable and takes the view that cloud-based health record banks as the best way forward.

William Yasnoff, one of the three author of the article, is the founder and managing partner of National Health Information Infrastructure — a consulting firm that helps communities and organizations develop health information infrastructure systems, is also a member of the Health Record Banking Alliance. He says if electronic health records are banked in communities around the country, it would create a more scalable way for patients to share their information that makes sense. He compares the idea to credit reports that can be updated by each bank that receives (or doesn’t receive) monthly credit card payments from consumers. Patients’ electronic health records would be maintained in cloud-based banks in communities across the country although their local provider would have their own copy.If you move, you could have your records transferred to a bank that’s more convenient...
Neither do I find this cute little Cloud-Meets-Filing-Cabinet image particularly comforting

Warrants further and deeper study. The Baum article summarizes:
How will health record banks be monetized? Yasnoff said there could be a range of accounts from basic accounts that would be free and would be financed by accounts that had extra level of service such as apps that would be relevant to their needs. He suggested having convenience apps such as letting loved ones know if you have been admitted to the hospital for an emergency or loved ones could get it on your behalf. Account holders could also pay extra to be notified of clinical trials.

Yasnoff’s argument that health record banking would put more control of patient records in consumer hands will resonate with supporters of the e-patient initiative. But the amount of investment that has already been allocated to building health information exchanges would be difficult to simply give up and walk away. We seem to be at a crossroads for figuring out the best way to share patient information and it will be interesting to see where we are come late April.
Interesting. Smells like HealthVault Teen Spirit.

apropos of the topic, from The Health Care Blog
Moving Toward An Identity and Patient Records Locator

Last week, five health IT vendors came together to announce the CommonWell Health Alliance, a nonprofit focused on developing a national secure network and standards that will:
  • Unambiguously identify patients
  • Provide a national, secure record locator service. For treatment purposes, providers can know where a patient’s records are located.
  • Enable peer-to-peer sharing of patient records requested via a targeted (or directed) query
  • Enable patients and consumers to withhold consent / authorization for participation in the network
  • Unambiguous patient identity matters
In banking, without certainty about identity, ATM machines [sic] would not give out cash. And in healthcare without certainty about identity, physicians are working with one hand tied behind their backs.
This problem will never be solved by the Feds. In fact, Congress has restricted any spending on it by the government at all.  Industry working together may be the only practical alternative.
CommonWell doesn’t intend to create a national patient identifier. Instead it will use practical, robust identity mechanisms that a patient or consumer could provide to each physician or caregiver.  That might be based on a one-way hash of a cell phone number, an email address or a swipe of a driver’s license. The Alliance members will decide on this as part of its standards...
Yet another "Alliance." Interesting.
Margalit Gur-Arie comments: March 13, 2013 at 10:02 pm
May I ask how Surescripts is able to conduct hundreds of millions of prescription transactions between hundreds of thousands of providers, without a National Patient Identifier?

Why is this not good enough? How often is it clinically imperative to obtain all medical records for a patient, from unknown sources, in an emergency situation, where offline requests for a push are impossible?

To Steve’s comment at the very top, lack of a national patient identifier is absolutely not the reason why the “competing” hospital down the street will not share data with you.

I don’t see why the Feds should not be the ones charged with such departure from current process. The Feds should, and this should go through Congress and get and up or down public vote.

I am not certain that an Alliance of private, for-profit corporations should be enabled to make these decisions for the entire nation. I don’t mean to imply anything about the integrity of all involved, all of whom I greatly respect, but this is just wrong.

I understand the need of entrepreneurs and all sorts of other entities, but I am not certain of the medical reasons for someone in Florida to routinely query medical records of folks in Washington State. And please, let’s leave out the 1 in a million use cases.

Data mining, even for rare and pure purposes is supposed to be just secondary use of data. Shouldn’t we first take care of the primary problem?

Is our primary problem inability for non health care providers to mine health data? Is our primary problem the 5 minutes it takes a patient to fill out intake forms multiple times? Is it the inability of the world renown surgeon at Mayo to get all of the patient’s records in under 50 seconds?

We don’t need anything of this magnitude just so a handful of medical facilities within a 20 miles radius can exchange information about this or that patient. Health care is still local. Although other things are not. 
Margalit never disappoints.

"We now have good data that the Hospital Readmission Reduction Program disproportionately penalizes big academic teaching hospitals (that care for the sickest patients) and safety-net hospitals (that care for the poorest)." - Ashish Jha

AcademyHealth blog
One word: "Nil."

Imagine a 3-D bell-curved mound viewed from directly above. Approximately a random scatter around the center (they used "medians" for the X-Y center coordinate), with increasing outcomes density toward the central "peak." I'd be wanting to burrow further into the 4 quadrant strata separately, for one thing.

We've been study re-admits since before I joined the QIO. In fact, my first analytic assignment after hiring on with HealthInsight 20 years ago was to drill down into Nevada acute care hospitals' 5- and 30-day readmissions, using Stata. Back then we had only "HCFA" Medicare Part-A claims data, and could only make the wispiest of demographic inferences. As these investigators above concluded, there may well be causal correlates, but, controlling for other factors such as age, gender, and race,  they have significantly more to do with acute multiple morbidity and poverty (itself correlated with race) than "quality of care." Notwithstanding, studying re-admits is once again in vogue, and brings with it the potential force of payment penalties under the PPACA.


Is your ZIP code "PII"?
(Personally Identifying Information)
Collecting customer ZIP codes violates state privacy law, Massachusetts high court rules

Posted Mar 13, 2013 6:15 AM CDT By Debra Cassens Weiss
ABA Journal

Massachusetts' top court has ruled that consumers whose ZIP codes are retained by retailers in the state can sue for a violation of state privacy law.

The decision issued Monday by the Massachusetts Supreme Judicial Court paves the way for a would-be class action against Michaels Stores, the Patriot Ledger and the National Law Journal report. The court ruled in response to certified questions by a federal judge considering the consumer lawsuit.

The suit claims Michaels used ZIP code information to look up customers' phone numbers and addresses so the retailer could send them marketing materials. State law bars companies from requesting personal information unless it is needed for shipping or it is required under the credit card agreement, the Patriot Ledger says.

The court said a ZIP code can be considered “personal identification information” under the law, and a plaintiff may sue for a violation of the statute absent identity fraud.
We'll see where that one goes. This concern first got national ink by Dr. Latanya Sweeney, who demonstrated that all she needed was ZIP code, DoB, and gender to gain entry to the medical records of former MA Governor William Weld. She estimated that she'd had a nearly 90% aggregate chance of doing so given just those 3 metrics (I'm not sure I buy that, but, the winners get to write the history -- Publication Bias 101).

Think about that.

You have probably put your DoB and locale and gender (and much more) on Facebook alone.

Remember (or learn here and now), the Constitution does not protect you from privacy violations by private parties.

#EHRbacklash update

Dr. Scot at his fulminating best.
The issue I have with the piece is - and I am finding this true of many articles critical of today's health IT - the ending, which I'm finding to often be PR.  Or, perhaps it would be more accurate to call the endings of late a "salvage operation-style" attempt to save face for the informatics community, who let this domain be overrun by the corporate IT sector and terrible products that violate many of the precepts of design of good health IT learned during five decades of research...
Translating the statement into plainer English, it seems to me that Cimino is saying this:
"Doctors, shut up, stop complaining about the chaos and patient/professional risk today's bad health IT is causing, take the medicine your betters have prescribed for you, and don't be uncompromising patient advocates as patients are secondary in this quest to reach IT-based Healthcare Utopia - which we will reach come version 2.0."
(This comes, ironically, at a time when physicians are starting to get a voice, e.g., Twitter's #EHRbacklash.)

In my view, this salvage mentality sprinkled with euphemisms and Utopian rhetoric spoils an otherwise constructive piece.  This type of language and utopian predictions about HIT have also appeared in other major medical publications by informatics and healthcare leaders (including top governmental office holders), as for example here.

Now, I know Jim Cimino and he is a good scientist.  However, I truly wish the non-scientific, "wait for version 2.0", utopian P.R. would stop.  As a member of the Medical Informatics profession myself, it's actually become embarrassing.
You can tell Smith-Corona / IBM Selectric academic antiquation in the "period, double-space, Capital" consequtive sentences writing style; a learned artifact of the Courier / Prestige non-kerned fixed-char typeface era. Some of us learned to quit doin' that crap once we got Times in WordPerfect on DOS machines (pdf). It fills your pages with "white holes."

Nonetheless, the reflexive habit widely continues.

Friday update
CMS: 27.5k EPs received $425m in EHR incentives last month
Kyle Murphy, PhD, EHR Intelligence

According to the most recent estimates from the Centers for Medicare & Medicaid Services, a record number of eligible professionals (EPs) received incentive payments in February 2013 for the EHR Incentive Program for Medicare. During the monthly meeting of the Health Information Technology Policy Committee (HITPC), Rob Anthony provided an update from CMS for both the Medicare and Medicaid portions of the EHR Incentive Programs for January 2013 as well as estimates for last month’s figure, which should push the total amount disbursed through meaningful use slightly over $12.3 billion...
Get it while it lasts, my friends.

Get a load of this:
Republicans, EHR vendors want ONC to take over medical app regulation
Brian Dolan | Mar 14, 2013

There has been a painfully slow chess game playing out in Washington DC these past two years over the fate of FDA regulation of mobile medical apps...

To get a better sense of where all this is going and what the future of mobile medical app regulations might look like, be sure to read this letter [pdf] from McKesson’s head lobbyist and Vice President of Public Affairs Ann Richardson Berkey. It calls on Dr. Farzad Mostashari to ”clearly identify ONC as the agency to exercise appropriate oversight of health IT to support both patient safety and innovation” and to “synchronize [ONC's] patient safety Plan with related meaningful use and other health IT requirements”...

Berkey goes on to write that the ONC should serve as the “convener” of all these “patient safety” initiatives. She also “urges ONC to include any anticipated near-term patient safety requirements as it finalizes the scope of Meaningful Use Stage 3.”

Last year when the FDASIA legislation was amended to sweep mobile medical app regulation under the heading of “health IT”, it paved the way for ONC to take over from the FDA. Next week’s congressional hearings on mobile health apps will likely steer toward this idea that the FDA should not be regulating apps as medical devices, even though the FDA has been doing so for almost 20 years now. The debate will likely shift to whether ONC should lump mobile medical app regulation into some kind of certification process that is self-policed by the industry — all in the name of “patient safety”, of course.

During her Fox News interview, Rep. Blackburn also let slip that she already had drafted legislation to entirely stop the FDA from regulating mobile medical apps:

“I have draft legislation which is coming out, which would be an express prohibition, prohibiting the FDA from getting into these mobile medical applications as a healthcare medical device,” she said.

If the FDA has any interest in holding onto its regulatory purview, it should issue final guidance for mobile medical apps immediately.
That is effectively a call for no substantive regulation.

More to come...

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