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Sunday, February 27, 2011

Poof! Where did THAT year just go?

Wednesday March 2nd will be my first year anniversary back with HealthInsight, this time amid the REC initiative. The developments keep coming fast and furious, with accelerating pace. There will continue to be no shortage of things to ponder and post on (e.g., how about this? "The Connected Patient: Charting the Vital Signs of Remote Health Monitoring" [PDF] i.e., anytime/anywhere telemetry -- or, as the more paranoid might say, "ObamaCare medical surveillance").

Last week I was pleased to be asked to give a presentation to a class of med students at Touro University. My PPT deck is here. My opening slides below...

LOL. I took a big canvas shopping bag full of "props" with me for some ancillary IT-related Show & Tell. Told the kids I felt like Carrot Top as I rifled through it. Below, a couple of my props, my way expensive 1986 IBM-XT Seagate 20 megabyte hard drive (yeah, I took the drive cover off, it's just a museum piece now), along with my company Blackberry, and (bottom right) a freebie 2 gigabyte USB flash drive I acquired at some EHR event last year (100 times the capacity of my old disk drive, cheap enough to give away nowadays).

My Medical Director Dr. Bill Berliner had come along to give some follow-on remarks (I jokingly introduced him as "my Iraqi Minder"). He picked up my old hard drive prop and told the students about the time when he was a med student, and got to tour the UNIVAC computer site -- which occupied an entire building.

More to come, including the possible ACO/PCMH/"payment bundling" implications of the dust-up now making the rounds about the "RUC."

 Jeez... Click the graphic above for the source (PDF, American College of Radiation Oncology).

Also, recent wisecracks about the Meaningful Use program becoming merely "Clicking For Cash" (it gives me no pleasure to have to admit that the phrase has a good bit of resonance).



From BNet "Jobs Are Plentiful in Healthcare — the Only Question is For How Long"

Department of redundant occupations department

Now let’s suppose, for a minute, that accountable care organizations emerge and begin to take financial responsibility for care in Michigan and other parts of the country. If these ACOs pay hospitals and doctors from an annual budget, they’ll need experienced accountants and people who know how to run information systems. But billers and coders will be unnecessary. In other words, an army of healthcare workers — perhaps more numerous than clinicians — could become redundant.

On the other hand, other categories would grow in importance. ACOs would need far more care managers and patient educators than we have today. And health IT would continue to add positions as it became woven into the fabric of health care. It’s already doing so. As Secretary of Health and Human Services Kathleen Sebelius pointed out in a keynote speech at a recent Orlando conference, “Health IT is one of our most promising new frontiers.”

She’s right, and more investors are committing to health IT as providers gear up to show “meaningful use” and garner up to $27 billion in government incentives. While it’s unclear how many new are jobs being created, HHS is providing money to community colleges to train up to 10,000 new IT technicians per year...


Adroitly using health data...


[Neither an express nor implied endorsement of this product, btw]

Monday evening, Feb 28th. We were just given access to an eCW ONC-certified version (9.0) remote desktop "sandbox" via which to kick the product's tires and learn our way around in order to better serve our REC providers, accompanied by a thorough 241 page PDF file instruction manual replete with workflow steps and screen shots. This will really help us to assist our REC clients on this particular EHR platform.


When I first logged in and searched out one of the simpler MU compliance criteria ("Record Smoking Status," regarding which I've posted before), The NIST-specified six mutually exclusive response options were not there (in the default Social History template). Instead were simply "current smoker," "former smoker," and "never smoker."

Well, here's why (pg 45 of the manual):

Configuring Tobacco Use Structured Data Items

The appropriate Structured Data items must be properly mapped in order to record a patient’s tobacco use from the Progress Notes.

Note: In order to map tobacco use Structured Data items, they must first be created in the local system. For more information, refer to the section titled Creating Smoking Status Structured Data Items on page 169.

IMPORTANT! These Structured Data items are automatically mapped for new installations of eClinicalWorks. Only existing clients that are being upgraded need to configure Structured Data items...

OK. In other words, unless you're an eCW client buying 9.0 new (either converting from paper or from a different system), there's some onsite MU conversion setup data mapping to do by the client in advance of your attestation period (while the database upgrade aspect of this makes perfect sense, eCW doesn't do this for you). I'm still going through the manual to determine what other setup scut work lurks with respect to other MU criteria (one cautionary thing I've noted is that they list five different navigation paths for doing CPOE).

In fairness, notwithstanding the potential hassle factor here, overall this really is a valuable MU user guide -- the sort of thing that every ONC-certified vendor needs to supply to their clients (if you've read all of my posts you may recall that I noted previously that I would have made such a condition of certification).


'ACOs have been called “HMOs on steroids.” They will have capitated payments and, like the traditional HMO, the ACO will get to keep any money it doesn’t spend. But the organization will also incorporate all the latest fads in health policy: electronic medical records (EMRs), pay-for-performance (P4P) incentives, quality report cards, etc.'

HIT is a "fad"?
'Evidence-based policy would admit ignorance about what works and why, and would let a thousand flowers bloom. It would pay more for low-cost, high-quality care, regardless of how it is achieved.'

OK, I see, we don't know what constitutes clinical quality ("what works" -- not that I wholly disagree, but that's the point of pushing out HIT/HIE), but, like obscenity, we'll somehow know it when we see it. But, only, if it comes out of the for-profit sector -- which, of course, will magnanimously and freely promulgate its findings, notwithstanding the otherwise differential "business intelligence" value of the data.


From FierceHealthIT:

Insurance companies' leap into HIE field will change health IT

...David Classen, MD, senior partner at consulting firm CSC, says that health plans are "looking at their future business model under healthcare reform." They view health information exchange (HIE) as an implementation tool for the value-based reimbursement methods that are coming, he says. Accountable care organizations (ACOs) also will be a big issue, and Classen expects hospitals to partner with health plans to create ACOs. Health plans have core competencies that most providers lack but will need for ACOs, such as the ability to analyze data and manage care, he notes.

Steve Tolle, senior vice president of provider markets for Ingenix, states that United's desire to partner with ACOs and to help providers form these organizations are among the reasons for Ingenix's acquisition of Axolotl. The company's purchases of other firms like Lighthouse MD (now CareTracker), Picis and A-Life similarly reflect its desire "to get close to the doctor and hospital workflow."

Tolle points out that Ingenix can bring "payer analytics" to bear on ACOs, helping them with care coordination and management. Axolotl will supply clinical data that can be analyzed and used in decision support. He adds that doctors need not fear that their patient data will be made available to United. Ingenix serves many payers and understands how to maintain data security, he says...
Think about all that.



"Patient privacy safeguards are woefully missing from initial draft criteria for Stages 2 and 3 of meaningful use, according to Deborah Peel, M.D., founder of the Patient Privacy Rights organization."
Interesting. I've been following "privacy" issues since before graduate school. See here, and here, as well. Ironic, in a way, given that I'm rather public; I've had the same web address and associated core email address since I was in grad school (1993-98), and given that I have both MySpace and Facebook pages. And, moreover, since I willingly revealed some very personal information in my painful web essay "1 in 3."

What are the legitimate concerns?

Some ought be obvious. A for-profit health insurance company still wants to find every possible legally defensible reason for disqualifying you from coverage (even after they've started taking your money). A prospective employer wants to likewise learn of your possible "dirt" (even if it cannot be substantiated). In a world still of ~five applicants for every available position in the U.S., odds of your possibly becoming "false positive" collateral damage, well, that's your problem, given the reality of your having no substantive recourse should they get it wrong (or even your unlikely awareness of the fact that they got it wrong). More mundanely, marketers of every stripe are looking to more effectively sell you stuff. Are you an indentfiable prospective statins, cholesterol, diabetic, PAD, "erectile dysfunction" (or other "worried well") customer, etc?

More on all of this shortly. For now, Google "Moral Hazard" and "Adverse Selection." You can also Google "Deborah C. Peel" and "Latanya Sweeney," the latter of whom is widely notable for her claim (published, no less, in "Scientific American" some years ago) that all she needs is your gender, date of birth, and ZIP code to have a better than 80% chance of identifying you.


First, from an interview with ONC's
Farzad Mostashari, MD, deputy national coordinator for health IT:

Q: How can ONC and the Centers for Medicare & Medicaid Services (CMS) enforce usability of EHRs? It shouldn't be so complicated that it takes extensive training and refreshers every six months to make EHRs work.

A: I don’t think we should set standards for what a user interface looks like. You don’t want government telling you what it should be. We need more transparency, with agreed-upon metrics for measuring usability first. That’s what we’re doing this year. By next year's HIMSS, there will be--as a result of an open process with industry participation and comments--some initial guidelines and metrics around aspects of usability and measurability. We need to get the current systems to have incentive for usability and transparency. We’ve gone too far not to have some guidelines.
Nothing exactly radical there. I've commented on "usability" issues before (see, e.g., my January 2nd, 2011 post). It 's a net good thing that they're finally paying some attention.

Then there was this, reported by John Moore over at The Health Care Blog:

Some Miscellaneous HIMSS Snippets:
Much to the chagrin of virtually every EHR vendor at HIMSS (still far too many and I just can’t even begin to figure out how they all stay in business) Chuck Friedman of ONC announced in his presentation on Sunday that they are looking into usability testing of EHRs as part of certification process [PDF]. Spoke to someone from NIST who told me this is a very serious consideration and they are putting in place the necessary pieces to make it happen.
OK. But, look at this slide of Dr. Friedman's...
 Your tax dollars at work.

I'm sorry, all attempts at (duly "branded") Powerpoint cutesy-ness aside, that is just flat wrong. ("Rigorability"? LOL.)

Another beauty from his presentation: "End users of health IT will ideally form a seamless cognitive and psychomotor bond with the technology."

Yeah, "we are all The Matrix."

 Or, how about "fighter jet and pilot become One"?

In fairness, I wasn't there, and there's no YouTube of his presentation, so maybe it was pretty good overall. Still, why not just stick to the basics? If it ain't broke, don't fix it.

Look, "Usability" simply refers to three overlapping (for better or worse) and mutually reinforcing core elements.

  • Effectiveness: the extent to which an application achieves its intended purpose, i.e., by capturing (and providing the capability for reporting back out) the requisite breadth of data;
  • Efficiency: the end-user operational task times-to-completion and associated error rates;
  • User experience/satisfaction: the more "subjective" / cognitive component. The extent to which using the app gives you a migraine or elevated BP.
Don't take my Great Unwashed word for it. See NISTIR 7714, issued just back in November (start with page 10).
See also "4.4. What Usability is Not" (pg 13 et seq).

"If usability is defined as above, it can be instructive to distance usability from some common misunderstandings.
  • Usability is not User Acceptance Testing (UAT). UAT involves taking use cases or procedures for how the system was designed to perform. and ensuring that someone who follows the procedure gets the intended result. That is, UAT examines whether the system is capable of performing all specified functions but not necessarily how well the system supports users in performing those functions..."
"UAT" rather precisely describes the ONC-ATCB HIT certification process, no? Read through the NIST Cert stds.

On the topic, check this out.

How We're Botching Our Attempts to Redesign the Healthcare System

- Roderick McMullen

Fixing our floundering healthcare system may be the single most complex design challenge ever. Bad design forced Dr. Bruce Mason (not his real name - BG), the clinical director of a large outpatient department at one of the preeminent teaching hospitals in the country, to force out one of the best doctors in his department. The doctor who was let go, Dr. Davis, didn’t violate the doctor’s code of ethics. He wasn’t old enough to retire. He hadn’t been sued for malpractice. In fact, he was a renowned practitioner.

Ultimately, Dr. Davis failed because he was unable to produce the required levels of documentation in the hospital’s version of an Electronic Health Record (EHR)...



 The "father of the Macintosh interface"...
A summary of design rules
Jef Raskin

The first principle

When using a product to help you do a task, the product should only help and never distract you from the task.


A gesture is an action that you finish without conscious thought once you have started it. Example: For a beginning typist, typing the letter "t" is a gesture. For a more experienced typist, typing the word "the" is a gesture.


Designing a human-machine interface demands that both the human and the machine be understood as well as possible. A understanding of the relevant portions of cognitive psychology, ergonomics, and cognetics is essential. That is not all that is needed, but it is a prerequisite.

Rule 1
An interface should be habituatingCommentary
If the interface can be operated habitually then, after you have used it for a while, its use becomes automatic and you can release all your attention to the task you are trying to achieve. Any interface will have elements that are habituating, but the principle here is to make the entire interface habituating.

Rule 1a
To make an interface habituating, it must be modeless

Modes exist where the same gesture yields different results depending on system state at a time when your attention is not on system state. In the presence of modes, you will sometimes make mode errors, where you make a gesture intending to have one result but get a different and unexpected result, distracting you from your task.Rule 1b. To make an interface habituating, it must be monotonous. Commentary
"Monotony" here is a technical term meaning that you do not have to choose among multiple gestures to achieve a particular sub-task. Crudely, there should be only one way to achieve a single-gesture subtask.

The second principle
An interface should be reliable

Aside from not crashing, the system should never lose any work you have done or any information you have received or retrieved, even if you make a mistake or are forgetful. This is often not thought of as a property of an interface, but one can build a reliable interface on top of an unreliable system (of the order of unreliability of todays operating systems).

Rule 2:
The system should neither lose your work nor through inaction allow your work to be lost.

The third principle

An interface should be efficient and as simple as possible.


Time is an irreplaceable asset. An interface should not take more of your time than is necessary, either in use or in learning.

Rule 3

Good engineering practices should be applied to interface design. Quantitative measures should be used, and an interface should be close to its theoretical minimum in terms of the time it takes to do an operation.


The GOMS model and information theoretic measures of efficiency (to name two particular techniques among many) must be mastered and used by interface designers. Another set of techniques and measures can be used to help judge learnability.

The fourth principle
The suitability of an interface can only be determined by testing.


All of the theory in the world, and the wisest guru, cannot always predict how an interface will work in practice. One must test, objectively observe, and modify the interface if testing shows that users have difficulties. It is never the user's fault, but also remember that people find it difficult to change, so difficulties based on previous habits may not be dispositive.

The fifth principle
An interface should be pleasant in tone and visually attractive.

How messages are phrased is important, how the interface looks is also important. But these are of secondary importance in terms of task completion. When use of the interface has become habitual, these elements go unnoticed. All of the principles, if followed, create learnable interfaces.


An interface should be effective, habituating, reliable, efficient, and tested. To the extent that doing so does not conflict with these essentials, an interface should also be attractive.

See also


Usability. Not exactly a new topic. But, it'll be interesting to see how ONC will manage to develop and administer appropriate EHR "usability" certification standards this year and incorporate them into the already hugely contentious proposed Stage 2 Meaningful use criteria (and concomitant HIT vendor "UAT" re-certification).

It's worth keeping in mind that the maximum MU reimbursement incentives are skewed in favor of the earliest participants, and decline year after year (e.g., below, example on the Medicare provider side), so, at the same piling on more complex and operationally onerous requirements will indeed comprise a challenge to the long-term viability of the program (and this assumes Congress won't be able to rescind the MU money now on the table).

March 3rd a.m. news update:
Meaningful use updates available by e-mail
Physicians and health care organizations can sign up with CMS for news about the payment process and tips on wading through the incentive program.
By PAMELA LEWIS DOLAN, amednews staff. Posted March 3, 2011.


 Ah, the jousting within science, e.g., the "Frequentist" vs the "Bayesian" (count me in the latter camp, net).

As I've noted, one of my favorite daily hangs is Apropos of "Evidence-Based Medicine" (EBM), I love this March 4th post:

Of SBM and EBM Redux. Part IV, Continued: More Cochrane and a little Bayes...

Bayes Revisited
A few years ago I posted three essays about Bayesian inference... The salient points are these:

  1. Bayes’s Theorem is the solution to the problem of inductive inference, which is how medical research (and most science) proceeds: we want to know the probability of our hypothesis being true given the data generated by the experiment in question.
  2. Frequentist inference, which is typically used for medical research, applies to deductive reasoning: it tells us the probability of a set of data given the truth of a hypothesis. To use it to judge the probability of the truth of that hypothesis given a set of data is illogical: the fallacy of the transposed conditional.
  3. Frequentist inference, furthermore, is based on assumptions that defy reality: that there have been an infinite number of identically designed, randomized experiments (or other sort of random sampling), without error or bias.
  4. Bayes’s Theorem formally incorporates, in its “prior probability” term, information other than the results of the experiment. This is the sticking point for many in the EBM crowd: they consider prior probability estimates, which are at least partially subjective, to be arbitrary, capricious, untrustworthy, and—paradoxically, because it is science that is ignored in the breach—unscientific.
  5. Nevertheless, prior probability matters whether we like it or not, and whether we can estimate it with any certainty or not. If the prior probability is high, even modest experimental evidence supporting a new hypothesis deserves to be taken seriously; if it is low, the experimental evidence must be correspondingly robust to warrant taking the hypothesis seriously. If the prior probability is infinitesimal, the experimental evidence must approach infinity to warrant taking the hypothesis seriously.
  6. Frequentist methods lack a formal measure of prior probability, which contributes to the seductive but erroneous belief that “conclusions can be produced…without consideration of information from outside the experiment.”
  7. The Bayes Factor is a term in the theorem that is based entirely on data, and is thus an objective measure of experimental evidence. Bayes factors, in the words of Dr. Goodman, "show that P values greatly overstate the evidence against the null hypothesis."
Awesome. I've cited Bayes before, e.g.,
 As I wrote, "Relax, it's only algebra."
  • Let p(t|+) = the probability of being a true positive ("t") given a positive test finding (+);
  • Let p(+|t) = the probability of testing positive (+) given that you are in fact a "t";
  • Let p(t) = the "prevalence" of true positives, e.g., the proportion of true positives in the aggregate population;
  • Let p(+|f) = the probability of testing positive (+) given that you are in fact NOT a "t" (i.e., the false positive rate);
  • Let p(f) = 1 - p(t), the proportion of true negatives in the population.
A concrete example:

It goes to both the empirically established "accuracy" of a test (how reliably it can return the value of a known reference standard) and the "prevalence" (proportion) of true positives in a population. Not widely enough understood. In practical terms, should you test "positive" for some rare condition, you might want to question the extent of the "known accuracy" of the assay (and how much it varies in production from lab to lab) before getting all bent out of shape (ruminate on #5 above). There's a danger, particularly in light of the new national push for HIT-enabled CER, for those (both researchers and patients) who take lab results at face value.

"[P]rior probability matters whether we like it or not, and whether we can estimate it with any certainty or not."


Click above for the full article.

Hans Rosling's 200 Countries,
200 Years, 4 Minutes - The Joy of Stats - BBC Four

From poor and sick to healthy and wealthy.

Pretty cool. Go to for more.


Props to my email correspondent pal health care Futurist Joe Flower for turning me on to this awesome, radically simple yet profound book.

[ click the book cover image for the author's website ]

While I wish I'd read it prior to giving my Touro University presentation, I'm gratified to know that I'd intuitively gotten some of the Jobsian presentation principles right, -- i.e., [Numero Uno] attempt to answer the audiences' question "why should I care about any of this?" right at the outset (i.e., "what's in this for me?"). Then build your case via a "story," using core "story" principles: Conflict, Villain(s), Hero, and Resolution.

Yeah. A widely known trial lawyer maxim is 'he/she with the best story wins."Keep it simple. Headline that could fit in a Twitter post. The Power of Three. Zen. Less Is More. No bullet lists. Use images. Use props. Eye contact. Body language. Vocal inflection variations. Never Let Them See You Sweat (i.e., woodshed your material so much that it's virtually autopilot for you, so the likelihood of sweating it out is next-to-nil). Be self-deprecating. Have fun.

Highly recommended read. Everyone in my REC (and ONC) ought to read this book. There are also a number of nice summary / reinforcing YouTube clips online, e.g..
BTW, Joe also recommended to me "Presentation Zen," which I already had in my book stash.

Sunday, February 13, 2011

Bottlenecks, bugs, barriers...

I'm increasingly out in the clinics these days doing gap analysis visits with our growing number of REC providers, and, I probably have to list as foremost among the "gaps" at this point is the vendors' pushing out of the ONC-ATCB certified upgrades to their clinical clients. Nothing in the Meaningful Use program moves forward absent those installs (and subsequent user proficiency with them), and we've been concerned about an EHR vendor upgrade backlog piling up for quite some time. Now we're starting to see it. I have an increasing number of unreturned timeline inquiry vendor phone calls and unreplied vendor emails.


We have one REC client (of only a few) who has in fact gotten his MU-certified install. I won't name the product, but, suffice it to say it's one of the major brands. This doc is totally tech-saavy, and is ready to undergo Year One Attestation. But...

His correctly entered CPOE entries [§170.304 (a)] are returning an erroneous zero numerator**. His e-prescribing [§170.304 (b)] entries are incorrectly counting "impermissibles" (e.g., controlled narc scripts requiring a paper Rx with a wet signature) in his e-Rx denominators (diluting his compliance percentage). His 2-way structured data labs' interface [§170.306 (g)] is sometimes taking 2 weeks to return results into his EHR, long after the specimens have been processed and results calculated.

It's gonna be a long spring and summer upcoming.

[**] UPDATE: this one, as we have subsequently learned, turns out to be a "workflow/training" issue. There is an additional documentation step for MU reporting of CPOE not required by prior releases of the platform.


In my prior post I cited some excerpts from the PCAST Report exhorting the potential of "Comparative Effectiveness Research" (CER), proffered to be one of the major potential health care benefits flowing from nationwide EHR/HIE adoption. But, I have to acknowledge one rather forceful skeptic of some significant cred:

Comparative Effectiveness Research” and Kindred Delusions.

...I am no Luddite. For me “evidence based medicine” is not a shibboleth; it’s an axiom. Furthermore, having trained as a physical biochemist, I am comfortable with the most rigorous of the quantitative sciences let alone biostatistics. However, you can’t compare treatments for effectiveness unless you are quite certain that one of the comparators is truly efficacious. There must be a group of patients for whom one treatment has unequivocal and important efficacy. Otherwise, the comparison might discern differences in relative ineffectiveness.

The academic epidemiologists who spearheaded the CER agenda are aware of the analytic challenges but are convinced these can be overcome. I would argue that CER can never succeed as the primary mechanism to assure the provision of rational health care. It has a role as a secondary mechanism, a surveillance method to fine tune the provision of rational health care, once such is established...

Pretty interesting. I'm not certain that the PCAST authors are arguing that "CER can ... succeed as the primary [emphasis mine] mechanism to assure the provision of rational health care." Nonetheless, this is a highly recommended cautionary read.

Speaking of barriers... 

Doctors' digital divide could widen health care disparities
Government and private entities are looking to ensure that health IT adoption doesn't leave out physicians who treat poor and minority patients.
By PAMELA LEWIS DOLAN, amednews staff. Posted Feb. 14, 2011.

...In October 2010, David Blumenthal, MD, national coordinator for health information technology, published a letter on the Office of the National Coordinator's website. In it, he cited analyses of the Centers for Disease Control and Prevention's 2005 and 2006 Ambulatory Medical Care reports that found EMR adoption rates in minority and large Medicaid population communities were much lower than mostly white communities and those predominately covered by private insurance. Dr. Blumenthal, who recently announced he was resigning as head of the ONC, said that despite the government's efforts since those numbers were released, EMR adoption rates remained low for practices serving poor and minority communities. He expressed concern that the incentive program would only exacerbate the disparities.

To help prevent a digital divide, the letter solicits help from the vendors and those heading the regional extension centers that assist small practices in selecting and implementing EMRs so the practices may qualify for incentive pay.

Dr. Graham said since Dr. Blumenthal's call for help, his office has helped coordinate several public-private collaborations aimed at outreach in minority communities. Many of these efforts have included regional extension centers, which recently got a funding boost from Dr. Blumenthal's office. RECs were set up to help physicians with health IT adoption.

The ONC announced in January that it was providing an additional $12.2 million to the RECs to continue funding them by 90% for four years instead of two. The RECs are responsible for the remaining 10% of funding. Dr. Graham said several vendors are also in discussions with the RECs to offer loan programs to the practices that come to them for help....


To collect Meaningful Use incentive reimbursement funds starting this year, outpatient primary care providers on the Medicare eligibility side (and hospitals) will have to attest (this year, under potentially auditable penalty of perjury) to having met or exceeded 15 "Core Set" criteria and 5 of 10 "Menu Set" criteria via their "certified" EHRs. Amid the "core set," however, is the attestation requirement pertaining to six (of 44 Stage One) "Clinical Quality Measures" (CQM, per §170.304 (j). e.g.,
  • Eligible professionals (EPs) must report on 3 required core clinical quality measures (CQMs). If the denominator of 1 or more of the required core measures is 0, then EPs are required to report results for up to 3 alternate core measures.
  • EPs also must select 3 additional CQMs from a set of 38 measures (other than the core/alternate core measures).
  • In sum, EPs must report on 6 total measures: 3 required core measures (substituting alternate core measures where necessary) and 3 additional measures.
In the following, Bold red = "Core CQM," Bold blue = "Alternate Core CQM"
  1. NQF 0001 Asthma Assessment
  2. NQF 0002 Pharyngitis- Children
  3. NQF 0004 Alcohol and Drug Dependence
  4. NQF 0012 Prenatal Care: HIV Screening
  5. NQF 0013 Hypertension: Blood Pressure Measurement
  6. NQF 0014 Prenatal Care: Anti-D immune Globulin
  7. NQF 0018 Controlling High Blood Pressure
  8. NQF 0024 Youth Weight Assessment
  9. NQF 0027 Tobacco Use Cessation
  10. NQF 0028 Preventive Care: Tobacco Use Assessment and Cessation
  11. NQF 0031 Breast Cancer Screening
  12. NQF 0032 Cervical Cancer Screening
  13. NQF 0033 Chlamydia Screening for Women
  14. NQF 0034 Colorectal Cancer Screening
  15. NQF 0036 Appropriate Medications for Asthma
  16. NQF 0038 Childhood Immunization Status
  17. NQF 0041 Influenza Immunization
  18. NQF 0043 Pneumonia Vaccination
  19. NQF 0047 Asthma Pharmacologic Therapy
  20. NQF 0052 Use of Imaging Study: Low Back Pain
  21. NQF 0055 Diabetes: Eye Exam
  22. NQF 0056 Diabetes: Foot Exam
  23. NQF 0059 Diabetes Control: Hemoglobin A1c >9.0%
  24. NQF 0061 Diabetic Patients who elevated mmhg V140/90
  25. NQF 0062 Nephropathy Screening- Urine
  26. NQF 0064 Diabetes Control: LDL <>
  27. NQF 0067 Antiplatelet Therapy
  28. NQF 0068 Ischemic Vascular Disease: Aspirin or other Antithrombotic
  29. NQF 0070 Coronoary Artery Disease: Beta Blocker Therapy Post Myocardial Infarction
  30. NQF 0073 Blood Pressure Management: Ischemic Valve Disease
  31. NQF 0074 Coronary Artery Disease: Lipid Lowering Therapy
  32. NQF 0075 IVD: Complete Lipid Panel and LDL Control
  33. NQF 0081 Heart Failure: ACE/ ARB Therapy For LVSD (LVEF <40 span="span">
  34. NQF 0083 Heart Failure: Beta Blocker for LVSD
  35. NQF 0084 Heart Failure: Warfarin Therapy
  36. NQF 0086 Primary Open Angle Glaucoma
  37. NQF 0088 Diabetic Retinopathy: Macular Edema
  38. NQF 0089 Diabetes Management: Retinopathy Screening
  39. NQF 0105 Depression Management
  40. NQF 0385 Colon Cancer: Chemotherapy
  41. NQF 0387 Breast Cancer: Hormonal Therapy
  42. NQF 0389 Prostate Cancer: Avoid overuse of Bone Scan
  43. NQF 0421 Adult Weight Screening
  44. NQF 0575 Diabetes Control: Hemoglobin A1c <8 .0=".0" span="span">
While I screen-scraped all the foregoing stuff from the ONC website and pasted it in, I did fix the myriad misspellings rather than otherwise repeatedly putting "[sic]" in the requisite numerous places. They were embarrassing to look at.

You can surf to the ONC Certified HIT Products site and sift through the hundreds of thus far certified platforms (click the graphic below). 

To date, I've only been involved on the ambulatory side, working with primary care outpatient clinics. As of tonight (Feb 14th) there are 269 listed there (as well as 101 Inpatient products). Click "Ambulatory Practice Type," then "Browse All Ambulatory Products." Pick one and click it.

You'll see lists such as these (click the images to enlarge): 

Should you take the trouble to surf through a number of these EHRs, you will find that relatively few of them have certified to all of the CQM items (the 3rd checklist graphic directly above). The foregoing example is from AthenaClinicals v10.12 (cert'ed for all 44 CQM in addition to the general criteria). Many of the EHRS only certify to 9 or 10 of the CQM (and not uniformly the same ones beyond the core and alternate core measures).

As of this posting, we lack ONC clarity as to whether this means a provider could not choose a given CQM not appearing on these lists as individually "certified."


Apropos of "CER," (in addition to the foregoing Stage 1 CQM) about which I've previously posted, this goes toward that:

NQF Posts Specifications for Electronic Measures that will Reward Meaningful Use of HIT

WASHINGTON, Feb. 15, 2011 /PRNewswire-USNewswire/ -- The National Quality Forum (NQF) announces the conversion of 113 NQF-endorsed measures from a paper-based format to an electronic "eMeasure" format. The conversion, requested by the Department of Health and Human Services (HHS) in compliance with the Health Information Technology for Economic and Clinical Health (HITECH) Act, will allow the measures to be more easily readable by electronic health record (EHR) systems. The converted measures will be available for public and member comment through April 1, 2011.

The use of eMeasures offers many benefits and efficiencies including: greater consistency in measure development and in measuring and comparing performance results; providing more exact requirements or "specifications" about where information should be collected; greater standardization across the measures; and greater confidence in comparing outcomes and provider performance. This conversion should ensure that performance measure data are consistently defined, implemented, and usable in the context of an EHR and support the meaningful use requirements.

"eMeasures represent the future of quality improvement," said Janet M. Corrigan, Ph.D., MBA, president and CEO of NQF. "They are core to successful implementation of incentive programs to reward meaningful use of HIT. But even more importantly, eMeasures will enable a system where measurement is automated and quality data are available at the point of care."

In July 2010, 44 of the 113 measures were published in PDF format in the Centers for Medicare and Medicaid Services' Electronic Health Record Incentive Program Final Rule...

Link to a PDF document summarizing all 113 draft "eMeasures" here. These are the kinds of measures coming for Meaningful Use Stages 2 and 3.


So, the other day we were granted remote desktop login "sandbox" access to yet another major EHR platform (I will not name the vendor), one of now about six regarding which we've been accorded REC access. After clicking around the (ostensibly "ONC-ATCB Certified") system a bit via a dummy patient record, ("Demographics" were MU-compliant for the now-requisite "race/ethnicity/preferred language," BMI was there in Vitals, etc), I jumped over to the "Social History" template for a look at "Smoking Status" and clipped this out of a screen shot: 

Recall my prior post (Jan 2nd, below), wherein I cited the now minimally required response options

Uh, OK, whatever...


Health IT: Hope, Hype, and How to Avoid the Road to Hell

"In November 2009, Dr. Mark Smith gave a keynote address at the AMIA annual symposium, highlighting the overarching need for connected health IT systems and the key role of AMIA members in ensuring this need is met."

Given that now, owing to Cheryl's work and our 2nd residence necessity, I am a proxy resident of The Peoples' Republic (to whom I now get to pay state income tax), I follow California news regularly, particularly with respect to health care issues.

Dr. Smith is the President and CEO of the California Healthcare Foundation. Click here to go to his "On Practical Progress" page and scroll down to get at this video (which may require updating your streaming video utility). 46 minutes of unmitigated inspirational ass-whup clarity on the future of HIT. This is a Must-View.
Wow, just wow. There's no transcript available, or I'd be citing excerpts. Neither do they provide any embed code, or I'd have dropped it in here. (I'd already saved a PDF copy of his 2008 speech to AHIP. I printed it out and bled all over it with red pen and yellow highlighter. Equally humbling and inspriational.)



Some extremely interesting observations here, many of them about national health care policy. Brought to you by this man (click the graphic below). 


February 18, 2011

Office of the National Coordinator for Health Information Technology

Department of Health and Human Services
Attention: Joshua Seidman
Mary Switzer Building
330 C Street, SW, Suite 1200
Washington, DC 20201

Submitted electronically at

Re: Health Information Technology Policy Committee Request for Comments Regarding Meaningful Use Stage 2

Dear Mr. Seidman:

The College of Healthcare Information Management Executives (CHIME) appreciates the opportunity to respond to the request for comments regarding meaningful use (MU) Stage 2, as reflected in the preliminary thinking of the Health Information Technology Policy Committee (HITPC) and its Meaningful Use Workgroup...

...Before providing comments regarding the proposed meaningful use objectives and measures for Stage 2, CHIME would like to make a few important observations. First, we think it would be far preferable to be in a position to evaluate actual experience under MU Stage 1 prior to considering potential MU objectives and measures for Stage 2. Absent such as assessment, we greatly fear that the HITPC’s proposals for Stage 2 may be unduly ambitious, even unattainable, for many eligible hospitals (EHs) and eligible professionals (EPs)...

...Second, as further consideration is given to Stage 2 MU objectives and criteria and the related timeline, CHIME believes that it would be prudent not to move to Stage 2 until about 30 percent of EHs and EPs have been able to demonstrate EHR MU under stage 1. We believe this approach would strike a reasonable balance between the desire to push EHR adoption and MU as quickly as possible and the recognition that unreasonable expectations could end up discouraging EHR adoption if providers conclude that it will be essentially impossible for them to qualify for incentives...

Full 15 page PDF document here. A very interesting, detailed read, e.g., from pp 12-13:
Below CHIME is pleased to provide input regarding the additional, specific questions posed by the HITPC.

[3]...CHIME believes that the primary focus should be on providing incentives for the meaningful use of electronic health records by hospitals and health professionals. Any issues affecting patient access to health information technology should be addressed separately and not “shoe horned” into certification standards for EHRs or meaningful use objectives and criteria applicable to hospital and health professionals...

[4] What are providers’ and hospitals’ experiences with incorporating patient-reported data (e.g., data self-entered into PHRs, electronically collected patient survey data, home monitoring of biometric data, patient suggestions of corrections to errors in the record) into EHRs?

CHIME’s impression is that physicians are extremely leery of incorporating patient-reported, electronic data (especially data self-entered into PHRs) because of concerns that the data may be incomplete or misleading. The problem is exacerbated by the attempt to allow patients to omit certain data based on privacy preferences. Also, such data have not had the benefit of a health professional’s interpretation based on direct, preferably face-to-face interaction with the patient. Such data, once incorporated into an EHR, could take on a life of their own, and the data’s origin and limitations could easily be lost, forgotten or misunderstood. We believe it is premature to impose demands on hospitals and health professionals with respect to the incorporation and use of patient-reported data.

Just one opening salvo in what will no doubt be a year of sustained contention over the proposed MU Stage 2 measures. With respect to the latter concern aired above by CHIME [4], expect some pushback from patient stakeholder organizations such as The Society for Participatory Medicine.

Much contending interest group jousting about to ensue in full froth, I would think.


Click either image.


"The Office of the Inspector General (OIG) recently released its Recovery Act Implementation Overview and Work Plan (Plan) for 2011. Unsurprisingly, while the Plan covers multiple subject areas, a significant portion of the work plan items relate to health care information technology (HIT). HIT items include review plans for the Electronic Health Record Incentive Program (Meaningful Use), Regional Extension Centers (RECs), HIPAA compliance, and the Office of the National Coordinator for Health Information Technology (ONC). With regard to HIT, the OIG seems especially concerned with information security.

The Meaningful Use incentive program contemplates a large outlay of government funds to eligible professionals and hospitals who have met technically exacting criteria regarding the implementation and use of varied HIT. It should not come as a shock that the OIG intends to monitor this program closely.."

As reported on


ONC Offers Advice on Vendor Transparency
Also during the HIMSS conference, Farzad Mostashari -- deputy national coordinator for programs and policy at the Office of the National Coordinator for Health IT -- called for more transparency among EHR vendors in areas such as contract provisions and market share, Health Data Management reports.

According to Mostashari, regional extension centers could work with vendors to develop standard contract provisions, but it is too early to say whether stages 2 and 3 of the meaningful use program will have requirements related to transparency...
"...regional extension centers could work with vendors to develop standard contract provisions"?

Right. Yeah, that would really help endear the RECs to vendors
, many of whom already view us as obstacles (particularly those RECs -- like mine -- maintaining "vendor neutrality"). Beyond the fact that we already have more than enough to do, we are not law firms (and we so advise our clients of that).

Get Me Re-Write...

"...ONC could work with vendors to develop standard contract provisions"

There, that's better.

Moreover, good luck getting free intel on relative EHR "market share" in the name of "transparency." If ONC thinks they have a snowball's chance in Hades of getting vendors to give up market share data (as perhaps a condition of Stages 2 and 3 certification), well, we shall see. That's a bet I would certainly take. There already looms a veritable cyclone of pushback on the proposed upped-ante next round clinical data reporting measures.

What would relative market share usefully tell providers? First, ONC, as of today (Feb 25th), has now certified 298 ambulatory and 129 inpatient EHR products (both "complete" and "modular"). The requisite stratified granularity of "market share" breakouts (e.g., by, say, clinical specialty, practice/institution size, and regionality) would tell us precisely what? How about their Dun & Bradstreets (and SEC filings for the publicly traded among them?). Those might tell us more. Maybe.

Not that I disagree with the possible intent of some of the sentiments (particularly as it bears on contracting). See my prior post "First, Do No 'Hold Harmless'."

Of course, Due Diligence is important, with respect to any contractual proffer (and some of this legitimately falls within the REC "technical assistance" advisory mandate). But, how about some transparent ONC-requisite findings focusing on comparative HIT USABILITY? (about which I've already written, i.e., the three-legged stool of effectiveness, efficiency, and user-experience). Y'know, a useful riff on that now-fashionable "VALUE = QUALITY / COST" thing with respect to HIT?