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Monday, May 30, 2011

Meaningful Use, or meaningless "hoopla"?

From Healthcare IT News the other day:
Is Meaningful Use Really Just a Bunch of Hoopla?
May 27, 2011 | Jennifer Dennard

There seems to have been a wave recently of articles, blogs and general sentiment by providers that – surprise, surprise – jumping through the hoops of Meaningful Use may be more trouble than it’s worth. This sentiment is nothing new, of course. Meaningful Use has had its detractors from day one. But the healthcare IT evangelists and the government has always carried the larger voice, and spoken through a much larger PR machine.

So why now? Why does it seem that the detractors are more vocal? Is it because providers are further along in the attestation processes, and have a better understanding of the true value to their particular bottom lines – particularly smaller physician practices and hospitals with correspondingly smaller budgets?

Is it because the funding handed out by the government to entities such as regional extension centers for marketing purposes has dried up, precluding them from continuing to spread the good word?

...I’d like everyone to take a few days over the holiday weekend to think about this. Come back to the healthcare IT-mindset on Tuesday refreshed, not-too-sunburned, and ready to comment on what you think the general sentiment around Meaningful Use seems to be at this point.

Be interesting to see the volume and tenor of comments. I posted the first one under the article (May 31st). We'll see what (if anything) ensues.


All of three comments to date, including mine. No "hoopla" there.


Prominent national health associations publish tough criticisms of the new final ACO rule
...Dark Daily predicts that implementation of ACOs will be one of the single most disruptive reforms contained in the ObamaCare bill that became law in 2010...
Richard L. Reece, MD
Why Accountable Care Organizations are destined to fail, and may not even get off the ground, is no mystery to me. Why would hospitals and physicians join together to form an organization that requires $11 million $26 million to form (AHA estimate); that demands an inordinate amount of time, trouble, and grief to negotiate; that is designed, even guaranteed, to decrease reimbursements of hospitals and doctors; that hands over the reins of dispensing “savings” to your competitors and the government; that CMS may choose to reduce in the future; that subjects you to the risk of being sued by the Department of Justice for monopoly behavior; that requires you to be accountable financially for the behavior and complications of populations of patients before, during, and after hospitalization over whom you have little control; that 94% of members of the Medical Group Association of 400 integrated health organizations, supposedly ideal candidates for ACOs, have said they will choose not to join. Hospitals, doctors, and leaders of integrated health organizations are not dimwitted lemmings anxious to jump off the ACO cliff into an unknown abyss.

One last ACO smackdown for now...
Matthews: Berwick’s Accountable Care Organizations Similar to Clinton-Era ‘Managed Competition’

Sunday, May 22, 2011

Health Policy Research: a promising new resource

Interesting news item here:
ANN ARBOR, Mich., May 20, 2011 /PRNewswire-USNewswire/ -- A new health care policy institute – one that is expected to become one of the largest of its kind in the nation – will be established at the University of Michigan's North Campus Research Complex.

The Institute for Healthcare Policy and Innovation was approved May 19 by the University of Michigan Board of Regents. The Institute's mission is to enhance the health and well-being of local, national and global populations through innovative, interdisciplinary health services research.

"The research done at our new Institute will inform and influence public policy and enhance public and private efforts to improve the quality, safety, equity and affordability of health care services," says James O. Woolliscroft, M.D., Dean of the University of Michigan Medical School and Lyle C. Roll professor of medicine...

I hope that among the topics investigated will be subjects such as HIT "usability" and effectiveness (a contentious issue that I've written about at some length in prior posts) and, relatedly, health care delivery process improvements, among other things.

To the latter point, I am again reminded of the words of John Toussaint and Roger Gerard in "On The Mend" -

Governments can tweak payment systems and probably get some temporary fiscal relief. But until we focus reform efforts on where most of the money goes, which is healthcare delivery, we will remain stuck in a revolving door of near disaster and narrow escapes. To get to the point where all people have access to high-quality healthcare, affordably, we must focus our attention on how the healthcare delivery system determines costs and quality. Then we need to change that delivery model entirely.

In fact, hospitals, physicians, and nurses—all of healthcare—must change. First, we must emphasize the science of medicine over the art. This means turning to evidence-based medicine, which is already underway in some sectors. But we are also talking about evidence- based delivery, work that has barely begun...

...We do not mean to suggest, however, that the external environment of healthcare—payment systems, insurance coverage, and regulations—does not need to be overhauled. It is a badly broken system requiring major surgery. But we are convinced that the healthcare debate needs to start from a deep understanding of how healthcare value is actually delivered.

This is an understanding we all need—policy makers and patients, as well as medical professionals.We all have a role to play in reforming healthcare. Caregivers need to rethink their priorities and remake their working environments. Lawmakers need to rewrite the rules to ensure that value is rewarded instead of waste. And patients must understand how healthcare works in order to demand truly effective change.

Only when we all have clear insight into the work going on inside the black box can useful reforms be crafted...



I call him "Sensei."
How to Blow the Big One: A Methodology

Healthcare has, right now, the greatest opportunity we have seen in our lifetimes to make a big change, to rebuild itself in a hundred ways to become better for everyone, and cheaper—to get cheaper by getting better. We’re not talking “bending the cost curve,” cutting a few points off the inflation chart. We’re not talking a little cheaper, a little less per capita, a few percentage points off the cut of GDP that healthcare sucks up. We’re talking way cheaper. Half the cost. You know, like in normal countries...

His "Five Frameworks" papers are among the very best I've ever read on health care, btw.

"Half the cost. You know, like normal countries."

Yes, well, notwithstanding that laudable goal, Let us not forget the Really Big Numbers that will remain with us. Below, from the recent California Health Care Foundation report (PDF):

The CHCF report posits an economically enervating $8,666 per capita health care expenditure this year, based on a population estimate of ~312.7 million people. A few observations:
  • A 50% reduction would still leave $4,333 per capita, or roughly $1,444 per month for a family of four;
  • Health care expenditures have never been nor will they ever be uniformly distributed and billed. According to recent AHRQ data, ~5% of the population account for nearly half of health care costs while half of the population spend little to nothing per year on health care (hence the "free rider" problem), and the rest of us are somewhere in between (and moving inexorably toward the age-correlated ever-higher cost strata).
  • Also on the subject of "per capita," we should also necessarily recall that the adult taxpaying cohort of the aggregate population is far less than 312.7 million.
It will remain a vexing, seemingly intractable (and mostly dishonest) political fight over how these costs -- many of them frustratingly irreducible -- get distributed in the coming decades. While it has indeed been fashionable in recent years to reflexively demonize the for-profit corporate health care sector, the industry does have its defenders. As noted by Wendy Lynch, PhD (May 27th):
Eliminating profit motive is not the answer.

I sometimes hear people discussing healthcare who place blame on businesses for wanting to make a profit on other people’s misery. However, we cannot assign fault to medical device-makers or drug manufacturers any more than we can blame hospitals for maximizing revenue, or doctors for lobbying lawmakers to cover their services under Medicare. Every stakeholder does what they can to secure survival and success. Even undertakers make a living providing necessary services, as much as we wish we didn’t need them. It isn’t distasteful for medical professionals to make money, but it is offensive to do so by hiding prices from the public and hoping consumers never ask...

It has been even more fashionable of late to "blame the victims," i.e., the patients themselves. It is argued that were we not all such Crappy Shoppers unconcerned with price, health care costs would be well below current levels. The theory that "Shopping" for health care services is no different than shopping for flat panel HDTVs, clothing, automobiles, Carnival Cruises, or groceries, etc.

Begs far too many Socratic questions to delve into here. I looked into some of these questions two years ago on one of my other blogs.
I will by no means be the first to note that our medical industry is not really a "system," nor is it predominantly about "health care." It is more aptly described as a patchwork post-hoc disease and injury management and remediation enterprise, one that is more or less "systematic" in any true sense only at the clinical level. Beyond that it comprises a confounding perplex of endlessly contending for-profit and not-for-profit entities acting far too often at ruinously expensive cross-purposes...

...Irrespective of your preferred data source, suffice it to observe for the purposes of this essay that Americans undeniably spend approximately twice per capita on health care than do their comparable industrial nation "consumer"/patient counterparts. I suppose that such would be defensible were we getting twice the "bang for the buck" (in terms of clinical outcomes quality and concomitant public and personal health) but, sadly, the aggregate data suggest significantly otherwise...

The U.S. health care policy morass

If you're not confused, you've not been paying attention, IMHO.


Apropos of the foregoing policy thoughts, a great New Yorker piece, Atul Gawande's commencement address to the Harvard Medical School class:
Cowboys and Pit Crews May 26th, 2011

...The distance medicine has travelled in the couple of generations since is almost unfathomable for us today. We now have treatments for nearly all of the tens of thousand of diagnoses and conditions that afflict human beings. We have more than six thousand drugs and four thousand medical and surgical procedures, and you, the clinicians graduating today, will be legally permitted to provide them. Such capabilities cannot guarantee everyone a long and healthy life, but they can make it possible for most.

People worldwide want and deserve the benefits of your capabilities. Many fear they will be denied them, however, whether because of cost, availability, or incompetence of caregivers. We are now witnessing a global societal struggle to assure universal delivery of our know-how. We in medicine, however, have been slow to grasp why this is such a struggle, or how the volume of discovery has changed our work and responsibilities...

...We are at a cusp point in medical generations. The doctors of former generations lament what medicine has become. If they could start over, the surveys tell us, they wouldn’t choose the profession today. They recall a simpler past without insurance-company hassles, government regulations, malpractice litigation, not to mention nurses and doctors bearing tattoos and talking of wanting “balance” in their lives. These are not the cause of their unease, however. They are symptoms of a deeper condition—which is the reality that medicine’s complexity has exceeded our individual capabilities as doctors.

The core structure of medicine—how health care is organized and practiced—emerged in an era when doctors could hold all the key information patients needed in their heads and manage everything required themselves. One needed only an ethic of hard work, a prescription pad, a secretary, and a hospital willing to serve as one’s workshop, loaning a bed and nurses for a patient’s convalescence, maybe an operating room with a few basic tools. We were craftsmen. We could set the fracture, spin the blood, plate the cultures, administer the antiserum. The nature of the knowledge lent itself to prizing autonomy, independence, and self-sufficiency among our highest values, and to designing medicine accordingly. But you can’t hold all the information in your head any longer, and you can’t master all the skills...

Read all of it. It is excellent. His summation:
The problems of making health care work are large. The complexities are overwhelming governments, economies, and societies around the world. We have every indication, however, that where people in medicine combine their talents and efforts to design organized service to patients and local communities, extraordinary change can result.


ACOs will fail, say Senate Finance Committee members

Accountable care organizations can't seem to catch a break lately. On the heels of the American Hospital Association's report that ACO costs may be higher than federal agencies realize, seven members of the Senate Finance Committee sent a letter this week to Department of Health and Human Services Secretary Kathleen Sebelius and Centers for Medicare and Medicaid Services (CMS) Administrator Donald Berwick, MD, voicing their concerns about the regulation of ACOs...

...All 10 members of the Physician Group Practice (PGP) CMS demonstration project have expressed reservations about the regulation’s current construction, the authors added. “It is troubling that their participation is doubtful, since these PGP members and experience are cited more than 75 times in your Agency’s 400+ page proposed rule as a model for the ACO regulation.”

Citing feedback from providers, who said incentives and accountability are misaligned, the committee members branded the proposed regulations as a failure that will not accomplish the intended purposes. “Therefore, we respectfully ask that you withdraw this proposed rule and re-engage experienced stakeholders to craft a new rule that fulfills the promise of ACOs.”

Another good recent article on the challenges of ACOs and HIT: Advanced Health IT Needed For ACO Initiatives
Key technologies will enable an ACO to deliver on its promise of providing efficient care that contains costs, Hanover said. These include the following:
  • Clinical applications such as electronic health records and computerized physician order-entry systems. These are essential to collecting the data that providers will need to measure and start to affect the performance of the ACO. These systems must adhere to meaningful-use requirements.
  • Clinical decision support systems. These allow providers to implement interventions at the point of care. By identifying those interventions, providers can improve care coordination, care quality, and outcomes for patients, which will lower costs.
  • Data analytics tools. These tools allow providers to analyze clinical, administrative, and financial data to help ACOs better manage their operations in order to optimize and begin to perform and profit as an organization.
  • Care management applications. The function of an ACO is to coordinate care; to engage members in their care; and to help to coordinate the service providers, the members, and the payers in order to deliver the best outcome to patients and help with compliance.
  • Data center technologies that help to cut costs. These include virtualization and service-based technologies for storage and server management.
  • Revenue cycle management technology. This prepares ACOs for ICD-10 and 5010 HIPAA electronic transaction requirements as well as future revenue cycle challenges associated with accepting, negotiating, and managing a bundle payment structure.

Below, perhaps of interest in light of the foregoing:
Health care goes unwired
In the fast-changing technology of medicine, physicians are turning to iPads rather than fax machines to deliver test results.

MIAMI - When Dr. Jose Soler got a late-night call about a critically ill patient, he grabbed his iPad and checked the results of the electrocardiogram test that just had been administered. Thanks to an app that zooms within half a millimeter of every heartbeat rhythm variation, Soler made a diagnosis within two minutes.

Before the Northwest Medical Center cardiologist began using the AirStrip Cardiology mobile application, he had to wait for a nurse to fax him a printout or log into a computer to load the data in PDF format, which was often hard to read.

"Having the ability to get that information on your iPhone to make a quick decision versus looking for a fax machine -- it just changed the paradigm," Soler said.

Soler is among 40 cardiologists at HCA East Florida Hospitals who are the world's first physicians to incorporate the EKG-reading app into their practices. Doctors at three HCA hospitals began using it recently on their personal iPads and iPhones.

Increasingly, doctors are using mobile apps to access patient information. Hard data is scarce. For instance, the annual market for mobile monitoring devices is estimated to be a $7.7 billion to $43 billion industry, as cited by a PricewaterhouseCoopers report, "Healthcare Unwired," released in September 2010.

But the trend is clear.

"This level of adoption is unprecedented. Things are changing very quickly," said health care innovation analyst Chris Wasden of PricewaterhouseCoopers...

Information flow alignment at the point of care.


From the folks at comes "Uncovering the ONC-ATCBs: What’s the Difference?" Pretty comprehensive article covering the current crop of six Meaningful Use certifiers.

The passage of the HITECH Act under ARRA has brought whirlwind changes and generated many questions in the electronic health record field. The ONC certification program is among the new changes that have impacted the way EHR vendors operate in the current climate. To ensure that their product meets meaningful use criteria, vendors must submit their EHR system for rigorous testing and certification processes by an ONC Authorized Testing and Certification Body (ONC-ATCB). While EHR vendors have quickly realized that their EHRs need to be ONC certified to remain viable in the marketplace, vendors may have trouble understanding which ONC-ATCB to seek these services from. While the six ONC-ATCBs have been approved to administer ONC-approved testing and certification, there are differences between each of them that encourage competition in the marketplace...

Definitely worth your time.


Apropos of ONC EHR "Certification," I ran across this curious bit of "letter from the CEO" misinformation on a vendor's website recently:
EHR Certification

I am sure that by now you have heard of the HIT certification program where if you have fully certified documentation software system, and are an allowed provider, you can be paid up to $44,000.00 over the next 4 or 5 years by the Federal Government. You are also probably aware that the amount paid to you is based upon 75% of your Medicaid or Medicare billed dollar volume.

There are many requirements that have to be met both by EHR vendors and by you the provider. Our company has been hard at work for nearly a year to meet these requirements and it has been moving along nicely. Some of the requirements are good and some are specific for a medical type practice.

The reason it takes so long to get certified is because we have to incorporate many features that our clients may never use, features that are geared directly for a medical practice. But to be eligible for payments you have to have a fully certified package which means you have to have purchased all of these features, not just the ones you would use. Features like drug-drug interaction software and drug allergy software. As silly as this sounds, in late December this was confirmed as true by the Federal Government.

Some have asked why we haven’t gotten certified as a module? We could get certified as a module right now but that would be of no value to you as you have to have a fully certified package to receive payment. So being certified as a module is a bit of a scam. You think you are getting something but it’s not what you need. Maybe it makes people buying a new package feel better, but in reality it doesn’t help them. It’s fully certified or nothing!

Now for the kicker, just a few weeks ago the U.S. House of Representatives submitted a bill that would fully defund the program which would in fact cancel it. This bill is H.R. 408. Now people say this bill will never get by the Senate and the President would veto it. That is most likely true. However, the $27 billion to pay doctors is not automatically funded. It must still pass through the House to get approval to spend. In this political and economic climate I just can’t see that happening. How are you going to justify to the American people that 27 billion dollars needs to be spent paying doctors to computerize, when they are looking at having to cut spending nearly everywhere?

Recently a House Republican was asked what this meant for the future of the HIT program. The response was that it would not get funding so consider it repealed.

So what does this mean? We are continuing to program but only the parts of certification that we think people will use. In the mean time, we will be watching to see what the future of the program is. There are a couple of possible scenarios.
  1. The HIT program gets funded somehow and it moves along as originally envisioned. (Not Likely.)
  2. The program continues but doctors don’t receive payment and they impose the penalties starting in 2015. (Possible, but without money would likely get repealed in 2012 depending on elections. Less possible, that it stays in unfunded limbo until the 2012 election when it gets its funding again.)
  3. The HIT program is dead and will fade into the sunset. (In my opinion, this is the most likely outcome.)
So for now, we keep programming and watching and waiting to see what comes about. Maybe, we can also sneak some fun features into the software – features that will actually help you be more efficient and better prepared for what gets thrown at you. I will keep you posted.


{name withheld}, CEO

I sent this vendor an email asking for the source of their information. Someone responded with links to a couple of irrelevant and dated blog articles. I subsequently replied by citing the following:
It is our understanding that the incentive funds are allocated within the CMS budget for the life of the program and not subject to annual appropriations bills – notwithstanding that Congress could in fact try to repeal various provisions of HITECH, but absent veto-proof success with that via both Houses, it’s not going to happen. Yes, we had heard that the Republicans were going to try to claw back “unobligated funds,” but the Meaningful Use incentive reimbursements are in fact “obligated” at this point.


(a) In General- The Secretary shall, using amounts appropriated under section 3018, invest in the infrastructure necessary to allow for and promote the electronic exchange and use of health information for each individual in the United States consistent with the goals outlined in the strategic plan developed by the National Coordinator (and as available) under section 3001…

For the purposes of carrying out this subtitle, there is authorized to be appropriated such sums as may be necessary for each of the fiscal years 2009 through 2013…
I also subsequently rubbed it in by sending them links to articles like this one:

Nonetheless, they have yet to retract the egregiously false assertion (as of May 28th). Interesting marketing strategy, 'eh? We have a great (albeit as yet uncertified) EHR product, but we can't get some basic ARRA/HITECH facts right.


This fellow finally took down his error-ridden "letter from the CEO" and replaced it with a new message that included this:
Over the past few months I have been telling everyone to wait due to statements that were made by Representatives in the House. Fortunately or unfortunately, depending on your political viewpoint, nothing has been done to defund the program as of the time of this writing. Could it still get defunded, sure. Will it, I don’t know. I do know that time wise it is getting too late to just sit around and wait. It is time to move forward as if it was going to happen and going to happen soon.
Uh, OK...


“A new science in informatics is emerging, termed ‘eIatrogentics,’ or studying errors that are caused by technology,” John Poikonen, PharmD, clinical informatics director, UMass Memorial Health Care in Worcester, Mass., told Pharmacy Practice News. He said more centers are adopting the technology and disagreed with the numbers cited by Dr. Cohen.

“From a recent survey [Pharm Purch Prod 2010;7], it’s more like 35% for CPOE and as high as 53% in hospitals with over 400 beds, with 89% saying they will be implementing the technology in the next five years. And 41% now use BCMA [bar code medication administration]. But it is still just 5% for closed-loop medication management systems,” Dr. Poikonen said.

Nursing workarounds are a very large problem with BCMA, he emphasized. “They can give a false sense of error prevention—like the nurse who has all of the insulin bar codes on the inside of her uniform and scans them until she gets the right ‘beep,’” he noted. “Then there is reporting of how many errors were averted because of mis-scans, when all the time the mis-scans were really workflow issues and not averted errors.”

Dr. Poikonen said he believes there is a woeful lack of evidence regarding the true medication error rate and the return on investment with BCMA. “The data and science around workarounds is better than the data from any studies showing value from BCMA,” he said.

Finally, with regard to smart pumps, Dr. Poikonen said that, although national standards would be a good thing, individual health systems should not be waiting for them. “They should be working to standardize at their facilities.”

See Medication Safety Technology Can Cause Its Own Errors


More to come...

Sunday, May 15, 2011

A year of REC blogging

370 days since I began this effort, to be exact. I hope I have managed to add a bit of value as I've tried to sort my way through the myriad issues. Sometimes the overwhelming complexity and contention of all of this gets a bit wearing. But, one presses on...

Wednesday, May 4, 2011

Athena Health CEO Jonathan Bush on the RECs

Courtesy of EHR Bloggers:
Jonathan Bush, Chairman and CEO of AthenaHealth discussed his opinion of the Regional Extension Centers (RECs). During the quarterly earnings call, Mr. Bush was asked how the REC strategy could be improved. He replied, "A bullet. Give the money back. Quick bullet, they won’t even know. There’s no one in the office, so there’s no one to even take the boxes out."

Whatever. I can find nothing in the press where he expanded on those remarks. Tasteless cheap joke metaphorical allusion to firearms violence aside, it'd be nice to know precisely what is his beef with the RECs. One might also be forgiven for wondering what proportion of his company's recent dramatic revenue growth emanates from the incentives comprising the ARRA/HITECH Act under which we work.

This (below), from the "news" column on the Athena website is pretty interesting.

From the recent CalHIPSO press release:
Jonathan Bush, Chairman and CEO of athenahealth said, “Many California physicians find themselves in the exact same situation as physicians all across this country, trying to adapt to a world where electronic health records are becoming a necessity – but this change isn’t easy. The good news for California doctors is they’ve got a great organization in CalHIPSO to turn to for support and we look forward to bringing our deep understanding of the benefits cloud-based EHR services can bring to a host of new physicians and helping them receive financial reimbursements for embracing the future of healthcare.”

So, you'll extoll your involvement with RECs where it suits you, while otherwise trashing us?

Mr. Bush interviewed on EHRtv at HIMSS 2009, asked about the impact of the ARRA/HITECH Act:
[0:40] “Part of me is ecstatic because, why not have more ‘schtimulus,’ and, part of me is, like, well, now we’re gonna ‘schtimulate’ all these losers, and, so, why couldn’t we just let them die, and we’ll just do it ourselves?”


Now that Meaningful Use Attestation is underway, we might make note of some accountabiity provisions. First, the anticipated CMS audits:
Any provider attesting to receive an EHR incentive payment for either the Medicare EHR Incentive Program or the Medicaid EHR Incentive Program potentially may be subject to an audit. Here's what you need to know to make sure you're prepared:

Overview of the CMS EHR Incentive Programs Audits
  • All providers attesting to receive an EHR incentive payment for either Medicare or Medicaid EHR Incentive Programs should retain ALL relevant supporting documentation (in either paper or electronic format used in the completion of the Attestation Module responses). Documentation to support the attestation should be retained for six years post-attestation. Documentation to support payment calculations (such as cost report data) should continue to follow the current documentation retention processes.
  • CMS, and its contractors, will perform audits on Medicare and dually-eligible (Medicare and Medicaid) providers.
  • States, and their contractors, will perform audits on Medicaid providers.
  • CMS and states will also manage appeals processes.
Preparing for an Audit
  • To ensure you are prepared for a potential audit, save the supporting electronic or paper documentation that support your attestation. Also save the documentation to support your Clinical Quality Measures (CQMs). Hospitals should also maintain documentation to support their payment calculations.
  • Upon audit, the documentation will be used to validate that the provider accurately attested and submitted CQMs, as well as to verify that the incentive payment was accurate.
Details of the Audits
  • There are numerous pre-payment edit checks built into the EHR Incentive Programs' systems to detect inaccuracies in eligibility, reporting and payment.
  • Post-payment audits will also be completed during the course of the EHR Incentive Programs.
  • If, based on an audit, a provider is found to not be eligible for an EHR incentive payment, the payment will be recouped.
  • CMS will be implementing an appeals process for eligible professionals, eligible hospitals and critical access hospitals that participate in the Medicare EHR Incentive Program. More information about this process will be posted to the CMS Web site soon.
  • States will implement appeals processes for the Medicaid EHR Incentive Program. For more information about these appeals, please contact your State Medicaid Agency.

In a nation where crooks routinely scam everyone from 9/11 victims to Katrina and tornado survivors, it would not surprise me one whit to see completely fake providers and clinics try to cash in on Meaningful Use. Now would it surprise me for some providers to fake some of their attestation data. One hopes that the audit program will have teeth.


I find this one particularly interesting. It appeared originally in the April 2011 edition of the "Liability and the Lab" column at
Q: What is the Office of the Inspector General’s (OIG) role in electronic health records (EHR)?

A: The OIG recently released its Recovery Act Implementation Overview and Work Plan (Plan) for 2011. A significant portion of the Plan items relate to healthcare information technology (HIT), including meaningful use. With regard to HIT generally, 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. The OIG intends to monitor this program closely. In total, the Plan includes a half dozen different items related to meaningful use. The OIG intends to:
  • review the ONC’s oversight of the ATCBs to ensure that the ATCBs have properly reviewed and tested the security features of EHR products put forth for certification (this review will include a review of some EHRs that have already received certification);
  • determine whether Centers for Medicare & Medicaid Services’ (CMS) HIT system enhancements include the standards adopted by the Department of Health and Human Services (HHS) and provide sufficient security for sensitive personal information;
  • assess CMS’ compliance with the current Breach Notification Rule (which is described at and CMS’ response to breaches;
  • identify incentive-program payments made in error and review CMS’ response to identified erroneous payments;
  • determine the progress states have made toward CMS approval for incentive payment plans and determine when states intend to make Medicaid incentive payments available to program participants;
  • review states’ IT controls for capturing meaningful use data and track payments made; and
  • determine whether states’ initial plans for incentive payment processes and incentive payments eventually claimed were both in accordance with Recovery Act requirements.
As part of the meaningful use program, the Office of the National Coordinator for Health Information Technology (ONC) sets standards for the certification of EHR systems and modules. Providers may only receive incentive payments where they use meaningful use-certified EHR technology. Final testing of EHRs and final determinations of certification status is made by Authorized Testing and Certification Bodies (ATCBs) named by the ONC. With regard to the ONC, the OIG intends to:
  • review the ONC’s oversight of the ATCBs to ensure that the ATCBs have properly reviewed and tested the security features of EHR products put forth for certification (this review will include a review of some EHRs that have already received certification);
  • determine whether the ONC’s process to develop HIT-related standards properly considered security concerns; and
  • determine whether the federal Regional Extension Centers are providing IT security support to healthcare providers.
Finally, the OIG Plan included as an independent work item examination of providers’ compliance with HIPAA and Recovery Act requirements and the HHS Office of Civil Rights’ (OCR) compliance with the enforcement responsibilities authorized by the Recovery Act. The OIG’s plan to review the certification of certain EHR technologies raises the question of whether a negative review could result in the “de-certification” of previously certified EHR technologies that providers have already implemented. In addition, the OIG’s plan to review the enforcement activities of the OCR should remind all healthcare providers that properly executed and implemented HIPAA policies, procedures, and training must remain a foremost compliance concern.

Potential for "decertification" of CHPL certified EHR products? Wow. That should be interesting. Equally bracing is their intent to assess "
whether the federal Regional Extension Centers are providing IT security support to healthcare providers," something regarding which we had better pay close attention, given the resource-intensive nature of this aspect of MU and the potential to simply pay it lip service.

RECs are to be performance-evaluated by ONC early next year in mid-contract reviews independent of this OIG thing
, so, we'd better all be up to speed across the board.


As the CHPL certified versions of EHRs get rolled out, we are increasingly out in offices walking through the Meaningful Use criteria workflows with our REC client providers. Much of what we see is a bit disturbing. A number of these platforms simply do not capture MU data correctly and report out readily, and vendors are often just deploying the upgrades without any relevant MU training. Relatedly, there are reports of increasing vendor support bottlenecks and testiness, with providers having to "open a support ticket" on the phone to get a single question answered.

I have sometimes gone to vendors' Facebook pages to pose questions, in attempts to end-run support queues on behalf of my clients. For instance, on of my co-workers came back from a visit to report that eClinicalWorks does not enable its users to picks just any 90-day attestation period (as is their right under the terms of the federal program).

Following this exchange I posted one more follow-up question asking for confirmation that eCW does not provide for ad hoc MU report period queries.

They deleted it.

It's gonna be a long summer.


There isn't one. After CMS reported 150 attestations on Day One (April 18th), there has been virtual silence regarding aggregate attestations to date. What are we to make of that? It'd be illuminating to know the vendor mix, outpatient EPs-vs-hospitals relative proportions, daily trend, and aggregate dollar amounts thus far.


Well, I made email contact at CMS, and they answered the question:
"As required by the American Recovery and Reinvestment Act of 2009, CMS will post the names, business addresses and business phone numbers of all Medicare eligible professionals, eligible hospitals, and critical access hospitals that receive EHR incentive payments. It is expected that the 2011 report will be posted on the CMS website in May 2012 There is no such requirement for CMS to publish information on eligible professionals and hospitals receiving Medicaid EHR incentive payments, although individual states may opt to do so."

Not what I'd wanted to hear.

A year? Moreover, what would be helpful to the RECs in particular would be an early tally of which CHPL certified EHRs were "ready for prime time" straight away, as inferred by early attestations.


As I've mentioned before, one of my favorite blog hangs is that of Science Based Medicine. Today's article by Harriet Hall, "Cognitive Traps," is really very nice. It addresses some of the cognitive liabilities regarding which "experts" such as physicians may be vulnerable, notwithstanding that they'd likely be overwhelmingly loathe to admit it.

Even more fascinating than the essay itself is one of the comments:
Ed Whitney on 10 May 2011 at 1:46 pm

Some of these cognitive biases in medicine are associated with deeper biases induced by the socialization of physicians. “You’re a doctor; do something” bias permeates the entire health care system, leading to many kinds of overtreatment. The need to act comes first; the rationale for acting comes later.

George Bernard Shaw nailed it 100 years ago in “The Doctor’s Dilemma.” Cutler Walpole is a surgeon who has a single explanation for everything: “Ninety-five per cent of the human race suffer from chronic blood-poisoning, and die of it. It’s as simple as A.B.C. Your nuciform sac is full of decaying matter—undigested food and waste products—rank ptomaines. Now you take my advice, Ridgeon. Let me cut it out for you. You’ll be another man afterwards.”

Confirmation bias appears to be part of human nature. There is strong statistical evidence that there is no such thing as a hot hand in basketball, but just try to watch the NBA playoffs and deny that players are hot or not in particular games.

There is an article in the current “Behavioral and Brain Sciences,” whose abstract is [here]. This article is likely to become widely quoted and cited. The authors propose that the function of reason is primarily argumentative rather than cognitive; we reason in order to be able to persuade others of our intuitively arrived at opinions rather than to arrive at truth. A preliminary copy of the entire paper is [here PDF].

If reason’s function is primarily social, then it requires considerable effort to adapt it to a different purpose, namely sitting alone and using it to arrive at a position which may contradict our own intuitions and argumentative preferences. Medical schools would have to teach students to transcend their own human nature, and this would entail instruction at a higher logical level than is used in preparing them to pass the standardized tests upon which their fate so often depends.

Wow. Read the entire paper. It is rather exhaustively documented. Much to consider. I have to add that to my research stash.

A couple of Money Quotes from pages 51 and 53 of the paper:
Some of the evidence reviewed here shows not only that reasoning falls short of reliably delivering rational beliefs and rational decisions, but also that in a variety of cases, it may even be detrimental to rationality. Reasoning can lead to poor outcomes not because humans are bad at it but because they systematically look for arguments to justify their beliefs or their actions. The argumentative theory however puts such well-known demonstrations of ‘irrationality’ in a novel perspective. Human reasoning is not a profoundly flawed general mechanism; it is a remarkably efficient specialized device adapted to a certain type of social and cognitive interaction at which it excels... might be tempted to point out that, after all, reasoning is responsible for some of the greatest achievements of human thought in the epistemic and moral domains. This is undeniably true, but the achievements involved are all collective and result from interactions over many generations (on the importance of social interactions for creativity, including scientific creativity see (Csikszentmihalyi & Sawyer, 1995; K. Dunbar, 1997; John-Steiner, 2000; T. Okada & Simon, 1997). The whole scientific enterprise has always been structured around groups, from the Lincean Academy down to the Large Hadron Collider. In the moral domain, moral achievements such as the abolition of slavery are the outcome of intense public arguments. We have pointed out that, in group settings, reasoning biases can become a positive force, and contribute to a kind of division of cognitive labour. Still, to excel in such groups it may be necessary to anticipate how one’s own arguments might be evaluated by others, and to adjust these arguments accordingly. Showing one’s ability to anticipate objections may be a valuable culturally acquired skill, as in medieval disputationes (see Novaes, 2005). By anticipating objections, one may even be able to recognize flaws in one’s own hypotheses and go on to revise them. We have suggested that this depends on a painstakingly acquired ability to exert some limited control over one's own biases. Even among scientists, this ability may be uncommon, but those who have it may have a great influence on the development of scientific ideas. It would be a mistake, however, to treat their highly visible, almost freakish, contributions as paradigmatic examples of human reasoning. In most discussions, rather than looking for flaws in our own arguments, it is easier to let the other person find them, and only then adjust our arguments if necessary...

Apropos of the topic of reasoning, rationality, cognitive liabilities, and wrongness, some observations of "Being Wrong" author Kathryn Schulz, during a TED talk:
So let me tell you a story. A couple of years ago, a woman comes into Beth Israel Deaconess medical center for a surgery. Beth Israel's in Boston. It's the teaching hospital for Harvard -- one of the best hospitals in the country. So this woman comes in and she's taken into the operating room. She's anesthetized, the surgeon does his thing -- stitches her back up, sends her out to the recovery room. Everything seems to have gone fine. And she wakes up, and she looks down at herself, and she says, "Why is the wrong side of my body in bandages?" Well the wrong side of her body is in bandages because the surgeon has performed a major operation on her left leg instead of her right one. When the vice president for health care quality at Beth Israel spoke about this incident, he said something very interesting. He said, "For whatever reason, the surgeon simply felt that he was on the correct side of the patient." The point of this story is that trusting too much in the feeling of being on the correct side of anything can be very dangerous.

This internal sense of rightness that we all experience so often is not a reliable guide to what is actually going on in the external world. And when we act like it is, and we stop entertaining the possibility that we could be wrong, well that's when we end up doing things like dumping 200 million gallons of oil into the Gulf of Mexico, or torpedoing the global economy. So this is a huge practical problem. But it's also a huge social problem.

Think for a moment about what it means to feel right. It means that you think that your beliefs just perfectly reflect reality. And when you feel that way, you've got a problem to solve, which is, how are you going to explain all of those people who disagree with you? It turns out, most of us explain those people the same way, by resorting to a series of unfortunate assumptions. The first thing we usually do when someone disagrees with us is we just assume they're ignorant. They don't have access to the same information that we do, and when we generously share that information with them, they're going to see the light and come on over to our team. When that doesn't work, when it turns out those people have all the same facts that we do and they still disagree with us, then we move on to a second assumption, which is that they're idiots. They have all the right pieces of the puzzle, and they are too moronic to put them together correctly. And when that doesn't work, when it turns out that people who disagree with us have all the same facts we do and are actually pretty smart, then we move on to a third assumption: they know the truth, and they are deliberately distorting it for their own malevolent purposes. So this is a catastrophe.

This attachment to our own rightness keeps us from preventing mistakes when we absolutely need to and causes us to treat each other terribly. But to me, what's most baffling and most tragic about this is that it misses the whole point of being human. It's like we want to imagine that our minds are just these perfectly translucent windows and we just gaze out of them and describe the world as it unfolds. And we want everybody else to gaze out of the same window and see the exact same thing. That is not true, and if it were, life would be incredibly boring. The miracle of your mind isn't that you can see the world as it is. It's that you can see the world as it isn't. We can remember the past, and we can think about the future, and we can imagine what it's like to be some other person in some other place. And we all do this a little differently, which is why we can all look up at the same night sky and see this and also this and also this. And yeah, it is also why we get things wrong.

1,200 years before Descartes said his famous thing about "I think therefore I am," this guy, St. Augustine, sat down and wrote "fallor ergo sum" --"I err therefore I am." Augustine understood that our capacity to screw up, it's not some kind of embarrassing defect in the human system, something we can eradicate or overcome. It's totally fundamental to who we are. Because, unlike God, we don't really know what's going on out there. And unlike all of the other animals, we are obsessed with trying to figure it out. To me, this obsession is the source and root of all of our productivity and creativity.

Highly recommended book, btw.

These items give me pause for even more cautionary reflection on my REC work. We pretty much take it as a given that more effective/extensive and more efficient capture and reporting of clinical patient data via HIT will inexorably improve patient care across time -- that caregivers will, in the aggregate, make objectively better decisions leading to improved outcomes in the wake of ready access to more voluminous and finer-grained "evidence."

The truth may in fact be considerably more complex. Below, yet another good read on the topic:

...Dr Groopman explores both rational and irrational factors that bear on medical decision making; he explains in detail where and how misdiagnosis can occur. A snap judgment that leads to a right decision can just as easily lead to a wrong one. A prior experience can influence a current case. Rapport with a patient or lack thereof can affect a potential diagnosis.

In the hurly burly of everyday medicine, the Socratic principle of well thought-out diagnosis often gives way to what Dr Groopman and others have called “pattern recognition.” This quick gestalt is often subtly influenced by one of several premises: availability—the reach for the most plausible explanation; commission bias—the need to do something; confirmation bias—the selective use of information supporting what one expects to find; attribution errors—the use of stereotypes that then bias decision making; and diagnosis momentum—where a diagnosis is accepted as definitive despite contrary or incomplete data...

BTW: Another favorite quote of mine:


More to come...