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.

OOPS...
 
 
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.

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MORE ON "CER"

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.
- NORTIN HADLER, MD

...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.
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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....
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CERTIFIED EHRs
AND CLINICAL QUALITY MEASURES (CQM) 

 
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."

FEB 15th UPDATE

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.
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A "CERTIFIED" SYSTEM "OOPS-Y"

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...
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ERRATA: LOL. ACOs EXPLAINED 

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.)
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DR. SMITH ON YOUTUBE RECENTLY
 

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

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FEB 18th UPDATE: CHIME OUT

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 http://www.regulations.gov

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.
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LOL!
 
Click either image.
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OK, BACK TO SERIOUS STUFF

"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 Lexology.com
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HIMSS11 UPDATE:
YOU'RE KIDDING, RIGHT?

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?
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