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Wednesday, October 13, 2010

Mulligan: 7.5 months into my REC adventure

I was re-hired on March 2nd by HealthInsight for the REC initiative. Been a most intense, interesting, and at times sleep-deprivingly frustrating experience. I have a number of developments and concerns on which to report. I started this post on September 3rd, but my heavy work and travel schedule and a bout of illness have necessitated a Mulligan. So, here we go again.

As with most of my blogging, this will necessarily be incremental as time permits, as this is a personal, assiduously off-the-clock independent project
(albeit rather unloved by one of my Sups nonetheless) in support of the REC effort.

Among other things, I will reflect on my experience at the recent Salt Lake City REC Regional ONC Conference, the subsequent inaugural (sparsely attended) "Digital Medical Office of the Future Conference" in Las Vegas, the interesting October 12th Nevada Health Care Forum 2010, as well policy developments in the wake of the release of the 864 page Stage One Meaningful Use Final Rule and the subsequent announcements of both the release of NIST test specifications for ARRA Certification of EHR systems and the first two Certification Registrars -- CCHIT and The Drummond Group (I believe there is now a 3rd Registrar in place as well).


You ought read this timely, excellent piece ever so closely, yellow highlighter and red pen at the ready
(click the title image above for a PDF copy). A couple of takeaways: While everyone is focally anguishing over the intensified HIPAA privacy and security implications of HIT going forward, this legal writer (a medical liability attorney) points out that
  • routine use of HIT (inclusive of both EHR and HIE) will likely become an integral part of accepted legal "standards of care," e.g., "it seems logical that a liability inquiry will turn to how information technology has been used by clinicians and whether that use itself comports with the standard of care for maintaining and using medical records."
  • relatedly, issues of data accuracy, security (specifically with respect to inadvertent or intentional data corruption), and retention for "E-Discovery" are likely to find their way into court (including issues relating to the net probative value of the soon-to-be-mandatory always-on "audit logs" in certified EHR systems).
Calls continue for FDA regulation of EHRs as de facto "medical devices," and there are now legislative stirrings for mandating EHR use a condition of medical licensure.
"...from the health care law and medical liability perspective, EHRs mark a fundamental shift in how we use and collect electronic medical evidence, as well as what we must think about when anticipating health care litigation."

A lot to consider here. Download it and read it carefully.

BTW, I'd like to give an unsolicited shout-out to fellow (literally neighboring) HIT blogger John Lynn. I check his blogs every day (among the numerous others within which I routinely lurk), and comment there regularly in the spirit of engaging constructive dialogue. Click the images below for direct links (they're also in my "Links" column on the right).

Also: The NIST EHR Certification test SOPs:

There are 46 SOPs, addressing the full range of Meaningful Use criteria across outpatient and inpatient settings, e.g.,
§170.302 (g) Smoking status. Enable a user to electronically record, modify, and retrieve the smoking status of a patient. Smoking status types must include: current every day smoker; current some day smoker; former smoker; never smoker; smoker, current status unknown; unknown if ever smoked.
The standard here is silent on exactly how the options are to be presented to the EHR user. Mutually exclusive "radio buttons"? A drop-down menu choice list? (It is also silent on the underlying data structure -- which I would assume to be mostly SQL RDBMS tables. The entries could be stored literally as text strings [all lower case, as per the std?], or they could be recorded in binary 0/1 integer fields mapped to the "human-readable structured data" responses a user sees on the screen or in a printed report?)

One could also interpret this standard to mean that some pre- ONC certification EHRs already comply, with no upgrade revision necessary for this particularly criterion. See, for example, a screen shot I clipped of the current release of e-MDs:

One could, I suppose, manually (or via a macro) enter "current every day smoker" or one of the MU-requisite forced-choice alternatives into this catch-all "Tobacco/Alcohol/Supplements" free-text box.

Cleanly and efficiently tabulating/reporting the data back out, however, would likely be a mess. Let us count the ways user could (and would) misspell these.

One more example:
§170.302 (h) Incorporate laboratory test results.

1) Receive results. Electronically receive clinical laboratory test results in a structured format and display such results in human readable format.

2) Display test report information. Electronically display all the information for a test report specified at 42 CFR 493.1291(c)(1) through (7).

3) Incorporate results. Electronically attribute, associate, or link a laboratory test result to a laboratory order or patient record.
A question arose recently regarding lab findings that typically come back in as simply "positive" or "negative" (or "POS"/"NEG") or, equivalently, "present" or "not found/not present" etc text. Again, the standard is silent, in that the specified "test data sets" all simply provide numeric lab values for the variety of assay parameters the EHR must be able to replicate for certification.

The phrase "human-readable structured data," it should be apparent, goes beyond numeric values, and the standard does not address this.
[BTW: It should be noted that not all of the MU criteria involve capturing numerator data in the EHRs for subsequent reporting. e.g., §170.302(a) Drug-drug, drug-allergy interaction checks, §170.302(o) Access Control, §170.302(p) Emergency Access, §170.302(q) Automatic Log-off, §170.302(r) Audit Log, etc. Just to observe that, for the criteria that do involve numerator/denominator data, effective analysis and reporting assume uniform data input, as no one in clinical settings is likely going to have time or inclination to to any post-hoc "data cleaning."]



The final of five 2010 ONC regional meetings. I was struck by the large number of very young (to me) ONC staffers, an ebullient, brash cadre of ambitious MBAs and MPHs mostly, full of evangelistic energy and smarts (but most of them relatively short on direct operational HIT experience). I wanted to card some of these people during the evening open bar reception.

It was very well attended, and very busy; a packed agenda, the most contentious of which was the "Meaningful Use Deep Dive" session. A harbinger of the frequently inscrutable, vexing interpretations of the Meaningful Use criteria that continue to this day. At our REC we continue to hold bi-monthly Meaningful Use Study Group teleconference sessions to help us clarify issues as they emerge during interaction with our providers.

One fun activity during the Plenary Session: "Meaningful Use Jeopardy," LOL.

Your tax dollars at work. They did a good job with this, I have to say. The questions spanned the gamut, and were often very tough. My HealthInsight REC tied for first place.

One of the principal ONC operatives present was Thomas Tsang, M.D., M.P.H., Medical Director, Meaningful Use. I approached him during an intermission to ask why the RECs had not been made mandatory as part of the legislation (regarding which he'd been involved in drafting), lamenting that we were burning up a lot of FTE "marketing" our federally subsidized services, in lieu of focusing on actual technical assistance activities -- that it opened the administration up to the criticism of just wildly throwing money at the problem at cross-purposes.

He ever so politely blew me off, responding that "you are federal grantees, you are not part of the federal government."

Right. Well, my very same not-for-profit federal contractor company is also the NV-UT Medicare QIO, and our QA/beneficiary protection "statutory side," while equally "not [directly] part of the federal government" is nonetheless mandatory for providers who serve Medicare beneficiaries. You provide medical services to Medicare benes, you will submit to QIO statutory review purview, period.

I dropped the line of inquiry. He obviously didn't want to hear it, and it was moot by now in any event.


The MassPro QIO people led this session. It was very good, though much of the material struck me as "warmed-over DOQ-IT" (the now discontinued CMS HIT initiative within I which I worked during 2005-2007). My concern here is that both the ends and the scale of the Meaningful Use program require a significant re-thinking of the "adoption support" workflow M.O.

Notwithstanding, one has to give MassPro credit for sharing their considerable experience and expertise.


When I began this blog series, I noted that the Health IT Research Center, "whose purpose is to gather relevant information on effective practices from a wide variety of sources across the country and help the Regional Extension Centers (RECs) collaborate with one another and with relevant stakeholders to identify and share best practices in EHR adoption, effective use, and provider support" was not slated to be in place until FY 2012. Happily, though, I can report that this online resource is in fact now up and running, with REC staff nationwide contributing and sharing tools and ideas.

Not without bursts of silliness here and there, though. Some REC folks have had the earnest idea of doing "SWOT analysis" on the Meaningful Use criteria themselves. This is what ensues, I suppose, when MBAs go unsupervised. SWOT analysis is a tactical tool for assessing the competitive characteristics of organizations.

How about mere "pros and cons," folks? To me, this is somewhat methodologically akin to calculating Likert Scale data out to four decimal places (and then maybe even doing regression analyses on them, just because Excel makes it so easy).

Another bit of puzzlement. Someone enthusiastically posted to the HITRC regarding the nascent "ONC branding logo." I quickly grabbed the image and merged it with our corporate logo for a quick bit of Photoshop "co-branding" imagery (at the request of my Sup)...

Only to be subsequently informed that the ONC logo was not yet available for REC use, as it was still "undergoing the trademarking process."

A taxpayer-funded graphic. "Trademarked"?

Legalistic "ownership" and "use in commerce" hair-splitting aside, why not just slap the common law "TM" on it and put it to use? Awaiting granting of a "registered" ® symbol seems pointless, given the typical long timeline (not to mention the expense) of that process. A good number of RECs may well have folded their tents by
"® Day."

Whatever. Your tax dollars at work.


Well, can you say "underwhelming"?

They gave us 40 comps. Telling, right there, I suppose. Obviously, they hoped we'd spread them around to our REC client and prospect providers. A tough sell here in southern Nevada, asking marginally viable docs to give up a couple of days of billable visits to come and hear yet more rah-rah about the virtues of HIT.

When I arrived and looked in the attendee packet, there was a total of 88 people on the attendee list -- seven of which were us (from HealthInsight). The total actual body count was more like 60 or so. As I ambled about the expansive lower-level conference center of Green Vally Ranch, the quietude evoked scenes from "The Shining."

It was during this conference that I got my first taste of the overt vested-commercial-interest REC-bashing that has ensued. A presenter, who was also a presentation track chair (a private EHR consultant whom I will not name), launched into his session with an inappropriate slide deriding the "Socialist" federal HIT program, whereafter he went on to mischaracterize the RECs as all "choosing the EHRS" for their REC provider clients and all "driving doctors toward SaaS model platforms" (web-based EHRs). His presentation also inappropriately gave ample play to his own EHR evaluation website and newsletter and books.

I had to bite my tongue.


It picked up steam here, in an online article entitled "Five Reasons We Think RECs are RECkless," written by one Houston Neal, a person with no apparent experience in HIT (I emailed him to ask. He deflected with a vague non-answer, while at the same time having the amazing chutzpah to ask me if I'd have his derogatory article linked on our HealthInsight website).

His summary allegation:
In our opinion, there are five fundamental flaws with RECs:
  1. Doctor’s [sic] aren’t moving as fast as the money is flowing
  2. The market already delivers on what RECs promise
  3. “Preferred vendor lists” limit choice and free markets
  4. RECs won’t get doctors to “meaningful use” fast enough
  5. The REC model leads to under-staffed, ephemeral entities
Anyone who has troubled themselves to fully read my REC blog to date has to admit -- if honest -- that I am no Pollyana REC cheerleader, but, this this stuff is loaded down with dilettante and ulterior motive Straw Men. I cannot speak for every REC, but I bristle at the broad-brush assertion that we are all under- and otherwise inadequately staffed, that we don't deliver any value not already available via the commercial consultant market (that is patently absurd), and that we are all "limiting choice" via "preferred vendor lists" (HealthInsight is assiduously vendor neutral). Moreover, that the docs may not be moving as fast as the money and the MU deadlines is certainly not of our doing. We have play the hand we were dealt.

Finally, with respect to the "RECs can't compete with the private market for HIT talent" assertion, let me just observe that when I went through the HealthInsight re-hiring process, I was one of several hundred candidates.

Unhappily, this article got rather wide and mostly uncritical play (e.g., at The Health Care Blog and on one of my friend John Lynn's blogs). Like we need more sand in the gears (and, again, not to assert that we are above criticism).


Policy. Gets my juices flowing (my grad degree is in "Ethics and Policy Studies"). While I was not re-hired by HealthInsight for my policy chops (I'm a technical assistance project coordinator), it's nonetheless in my blood, and I was gratified to attend this event, which was all about a breadth of policy issues as they bear on the fiscally ailing state of Nevada. Our CEO Marc Bennett served on a discussion panel, and, to me, he was the most astute person on the podium that day (and I am not sucking up, either, we have very little contact, notwithstanding that I have known him since 1993).

One upshot of my attending was my being invited to present on Nov 18th statewide via live audience and teleconference to the Nevada Chapter of the Health Care Financial Management Association on the subject of health policy reform, about which I've written rather extensively, e.g.,
Should be fun. One question I will pose goes to the implications of this image from the recently-released 2010 NCQA HEDIS-based report.

Zero apparent linear "Pearson-R" relationship between cost and quality of outcomes (albeit via their summary "quality vs. cost" proxy scales). The foregoing plot addresses cardiovascular disease, but the scattergrams in the report illustrating other major chronic conditions (hypertension, diabetes, COPD) evince the very same random buckshot patterns. My red rectangle upper left quadrant annotation above is meant to focus on the question this begs of me: are we, consequently, paying too much? What is it about the "above average quality/below average cost" segment that we might discern were we able to "peel the onion back" in search of relevant causal correlates? Is use of HIT a factor? And/or other organizational factors? ( The NCQA report is silent on such implications).

We have seen a similar kind of thing before, e.g.,

Evidence a decade ago of a weak inverse relationship (just a tad this side of purely random, unlike the NCQA/HEDIS data) between per capita Medicare expenditures and "quality ranking." Again, of interest to me analytically would be the lower cost/higher quality outcomes cohort.

I am again reminded of the words of Dr. Atul Gawande last year in "The Cost Conundrum" -
"Dramatic improvements and savings will take at least a decade. But a choice must be made. Whom do we want in charge of managing the full complexity of medical care? We can turn to insurers (whether public or private), which have proved repeatedly that they can’t do it. Or we can turn to the local medical communities, which have proved that they can. But we have to choose someone—because, in much of the country, no one is in charge. And the result is the most wasteful and the least sustainable health-care system in the world...

...In the sharpest economic downturn that our health system has faced in half a century, many people in medicine don’t see why they should do the hard work of organizing themselves in ways that reduce waste and improve quality if it means sacrificing revenue."


More to come...