Search the KHIT Blog

Thursday, June 21, 2012

The Association of Regional Centers for Health Information Technology (ARCH-IT)

National Association Created to Represent Regional Extension Centers for Health Information Technology

New national group formed to provide a strong voice for the 62 Regional Extension Centers that provide assistance and guidance for the adoption and use of health information technology.

Silver Spring, MD (PRWEB) June 21, 2012 -- A new national association has been formed to provide a strong voice for the 62 Regional Extension Centers that provide assistance and guidance for the adoption and use of health information technology. The Association of Regional Centers for Health Information Technology, or ARCH-IT, represents Regional Extension Programs and the unique needs of the independent health care providers served by RECs in every state across in the United States.
“We are excited about this development and look forward to working with the Office of the National Coordinator and other stakeholders to promote health information technology adoption through the country,” said Jonathan Fuchs of the Arkansas Foundation for Medical Care, ARCH-IT’s President.

The intent and mission of ARCH-IT is to compliment [sic] activity in the HIT environment, create enduring sustainable organizations and “to promote and facilitate the integration of operational efficiency, clinical efficacy and revenue maximization in clinical practices through the adoption and use of health information technology.”

In 2009, Congress passed and President Barack Obama signed into law the Health Information Technology for Economic and Clinical Health (HITECH) Act, which aimed to advance the goal of promoting EHR adoption. It was out of the HITECH Act that the REC program was born. As of April, more than 140,000 health care providers had enrolled in REC programs nationwide; more than 77,000 have installed an EHR; and nearly 11,500 have already demonstrated “meaningful use” of EHR technology.

“In the short time they have been operational, RECs have become trusted advisors for the health care providers they serve and play a crucial role in helping small practices adapt to the rapidly evolving health care environment,” noted Lisa K. Rawlins of the South Florida Regional Extension Center, ARCH-IT’s Vice President. REC programs are modeled on extension center programs such as the Department of Commerce’s Hollings Manufacturing Extension Program and the Department of Agriculture’s Cooperative Extension System which provide vital technical assistance as part of a long-standing tradition of public-private partnership.

The formation of ARCH-IT comes at a critical point in the history of the REC program, as there is no scheduled federal support for the program beyond 2013, even while the small medical practices that desperately need REC services are facing another decade of major technological challenges and operational reform.

“In the near future, these small practices will see significant changes affecting all aspects of their performance: from revamped payment models to Stage 2 and 3 of Meaningful Use, and from privacy and security compliance to the transition to ICD-10. The need for unbiased, trusted advisors like RECs will only grow,” said Greg Schieke of the Nebraska/Wide River Technology Extension Center, ARCH-IT’s Treasurer.

ARCH-IT’s officers include representatives from many of the REC programs across the country, representing some of the leaders and vanguards in health information technology today. The officers include Jonathan M. Fuchs, HITArkansas, President; Lisa K. Rawlins, South Florida REC, Vice President; Greg Schieke, CIMRO of Nebraska/Wide River Technology Extension Center, Treasurer and David M. Bergman, Executive Director.

I wish them all well in this effort. I don't think one can overstate the difficulty the REC effort faces. I'm probably too radioactive to be of any direct help.
REC programs are modeled on extension center programs such as the Department of Commerce’s Hollings Manufacturing Extension Program and the Department of Agriculture’s Cooperative Extension System which provide vital technical assistance as part of a long-standing tradition of public-private partnership.

Yeah. See my immediate prior post, "ObamaScare Section 5405."


False congratulations on the road to meaningful use
Ed Burns, June 22, 2012 

...The numbers certainly are positive. They indicate that the nation is making progress toward the goal of achieving a fully networked healthcare system. But is the new data and the accomplishment of this supposedly ambitious goal really worth celebrating?

Reading the HHS release, in which very serious government officials congratulated each other for this remarkable progress, brought to mind the so-called “You’re not Special” commencement speech delivered recently by a high school teacher in Wellesley, Massachusetts. In the speech, David McCullough bemoans the fact that “we have of late… to our detriment come to love accolades more than genuine achievement.” Could it be that government officials are putting self-congratulations ahead of actual achievements?

Let’s look at the numbers. Sure, 110,000 physicians is a lot. As the HHS release notes, one in five Medicare and Medicaid eligible professionals has already started receiving incentive payments. What’s more, 133,000 primary care physicians and 10,000 specialists were working with Regional Extension Centers by the end of May. That’s a lot of doctors preparing to attest.

But at the time when Mostashari and Tavenner set the goal for attestation progress, more than 59,000 physicians had already started receiving incentive payments, by the pair’s own accounting. Furthermore, about 120,00 doctors were already working with Regional Extension Centers.

With physicians needing to complete attestation by mid-2012 in order to qualify for the full amount of meaningful use incentives and the high numbers of doctors already started on the road toward meaningful use, did the officials really believe it would be a challenge to get some 40,000 eligible professionals to complete the process over the course of the year?

Of course, we should not belittle the hard work of government agencies and medical professionals that helped bring the nation’s healthcare system to this point. Progress is being made. This much is hard to deny. But while we shouldn’t belittle this hard work, we also shouldn’t preemptively congratulate people for achieving something that has yet to be accomplished.

Yes, a good deal of progress has been made in a relatively short period of time. But a significant amount of work remains to be done before the healthcare system is on solid footing again. The problems of runaway costs and relatively poor treatment outcomes call for immediate action. They won’t wait while public officials congratulate themselves on a job well done.

So rather than crow about every minor gain in technology adoption – another 10,000 physicians receiving incentive payments, another $1 billion in bonuses distributed – perhaps officials should let us know when the meaningful use program starts making some meaningful progress toward accomplishing its true goals of creating a healthcare system that efficiently delivers high value by affordably keeping people well. That would be a real sign that congratulations are in order.


In addition to all the health care / HIT stuff I have to and want to read, here are just a few other items of late.

I finished "Debt: the first 5,000 years" a couple of weeks ago (compelling; emblematic of the word "scholarly"). I've been aware of David Friedman's "Law's Order" for quite a while, and have been reading the online draft episodically for a number of months. I coughed up last night via the deadly "one-click" for the published Kindle edition. And, I just started Dr. Farnsworth's "The Legal Analyst." Loving it thus far. The competing practical and ethical implications of ex post and ex ante considerations and all that.

The three, taken together, are presenting me with a nice triangulation -- which in concert don't have anything to do with health care per se, except to the extent of their mapping to the various health care economics arguments.

David Friedman:
If there were only one man in the world, he would have a lot of problems, but none of them would be legal ones. Add a second inhabitant, and we have the possibility of conflict. Both of us try to pick the same apple from the same branch. I track the deer I wounded only to find that you have killed it, butchered it, and are in the process of cooking and eating it.

The obvious solution is violence. It is not a very good solution; if we employ it, our little world may shrink back down to one person, or perhaps none. A better solution, one that all known human societies have found, is a system of legal rules explicit or implicit, some reasonably peaceful way of determining, when desires conflict, who gets to do what and what happens if he doesn’t.
Indeed. David Graeber:
Here we come to the central question of this book: What, precisely, does it mean to say that our sense of morality and justice is reduced to the language of a business deal?
Ward Farnsworth:
We have spoken of minimizing waste. We also could have called it maximizing wealth. A trade increases wealth by making the parties to it better off (that's the only reason both sides would agree to it); this is another way to think about a point discussed a moment ago: the value of contracts.
Is health care just another consumer commodity, one properly governed by contract law in the service of "efficient markets"?

What, indeed, is the moral justification of "markets"? Simply caveat emptor / winner-take-all?
"A trade increases wealth by making the parties to it better off."
Well, I would alter that to read "to the extent that it make the parties to it better off." "Win-win." Easy to advocate; difficult to effect. But, even in a large zero-sum or negative-sum game, there are -- short-term, anyway -- "winners."

Therein lies the difficulty. In the socioeconomic drama sine wave that comprises the evolutionary path of post- hunter/gatherer human history, you can "Texas Sharpshooter" cherry-pick your way into whatever empirical historical trending segments suit your pre-ordained fancy. Kind of like citing Bible verses or otherwise pet philosophers, buttessed by tactically proffered "stories." (See "Why Do Humans Reason?" and "This Time is Different.")

See also Michael Lewis' "Boomerang" for a niftly recent travel guide through the worldwide whack-a-mole propagation of financial risk obligation repudiation, an international Three-Card-Monty game that continues apace at this writing (I think my favorite chapter might be "Beware of Greeks Bearing Bonds").

Yeah, that stuff starts to "exceed my [REC grunt] scope."


Well, yes, that's our whole QC/QA/QI schitck, isn't it, at root? (I've documentably drunk the Kool Aid.) "Improvement" by definition "reduces waste" (and, "Lean" theory makes waste elimination the explicit goal. See The-Money-Is-In-The-Margins John Toussaint. And, see Deming, and Shewhart before him). But, Farnsworth points out that "minimizing waste," by some accounts, comprises the entire moral justification basis for a system of law. I'd never really thought about it acutely and at length that way. A criminal prosecution or a tort action diverts resources away from otherwise productive endeavors. More centrally, people who do wrong, either intentionally or through negligence are wasting resources.

Notwithstanding, it begs a ton of questions. Is "efficiency" the underlying sine qua non of human socioeconomic existence and progress? I'll have to think about that a bit more. The very notion of a perfectly frictionless economy escapes me.

Cars (and governments) will continue to come equipped with brake pedals, and will continue to operate at less than 100% theoretical "mechanical efficiency."

None of which is to argue that we shouldn't always try to improve things -- to the net benefit of society in the aggregate, I would insist.


UPDATE: From a recent Thedacare white paper
Linking cost and quality of patient outcomes to drive organization and industry improvements
February 2012

Few in the United States are satisfied with the quality of healthcare and the escalating costs to deliver that care. The United States spends more per capita on healthcare than any other industrial country — nearly 18% of gross domestic product — but ranks in the bottom quartile for life expectancy. Despite criticism of U.S. healthcare performance — from patients, employers, insurers, government, and those working in and supporting the industry — the ability to link quality of care with the cost of care (healthcare value) has been elusive.

Gradually efforts have emerged around the country to enable healthcare professionals and consumers to better identify provider costs and quality performance. Recent work performed by the Wisconsin Collaborative for Healthcare Quality (WCHQ) establishes new ground in blending quality and cost into a single, actionable healthcare value measure specific to a healthcare condition. WCHQ proved that such a condition-specific value measure is possible, paving the way for broader development and dissemination of healthcare value measures...

...Quality data provided by WCHQ provider organizations, and Diabetes standard cost data, provided by the WHIO, which consisted of claims-based data submitted by WHIO insurer or payor organizations.

RUWG participants included representatives from several WCHQ organizations and strategic partners who have experience working with resource use data.

The RUWG developed a methodology by which the data from these two different sources could be merged to create a meaningful measure that would provide new insights about the value of the care provided to diabetic patients in Wisconsin. The first set of diabetes value-measure reports was presented to WCHQ members in December 2011. No timetable has yet been set to release the findings publicly. The December release lists diabetes value metrics for each WCHQ organization meeting the criteria for which “apples-to-apples” quality and cost comparisons could be applied, and displays the value metric in a quadrant-analysis format — high quality/high cost, low quality/high cost, low quality/low cost, and high quality/low cost (greatest value):

X axis = cost index (ranked 0.0 to 2.0), and
Y-axis = percentage of all-or-none diabetes control measure (0% to 40%)

(Click the title for the full paper.) Well, where have we seen this kind of nil Pearson buckshot before? e.g., HEDIS 2010 (scroll down, Oct 2010 post):

Can we methodically find the ops correlates connecting process efficiencies with clinical effectiveness? One of the many difficulties here is that of shooting at a moving target, i.e., therapeutic advances frequently surface randomly, once adopted they create their own demand (particularly should they be of the life-saving variety), and uniform workflow processes for their effective deployment do not simply fall into everyone's lap fully-formed.

Getting at "value" in health care is pretty messy.

Again. from Dr. Toussaint's "Potent Medicine" -
Physicians and healthcare leaders have relied too much on a strategy of revenue growth in recent years. We would buy a new gizmo or gadget—more advanced MRI machines or the latest in robotic surgery equipment—enabling us to charge more and, hopefully, grow market share by advertising new capabilities. With healthcare fast approaching 20% of the nation’s gross domestic product, however, this strategy is unsustainable. The nation cannot afford us.
Actual revenue for the healthcare system will decrease. We all see this coming. The questions are how we will live in the new reality and who will take the hit.
The answer is in the value stream. Organizations that see the value streams by which we deliver healthcare to patients, end to end, and learn to identify and remove waste will survive. Those that understand we are paid to maximize the health of patients will thrive.
Achieving financial stability in the new reality will mean removing waste from the system faster than revenue drops. When organizations reduce the cost of care, there will be money left over. When quality improves, there are fewer complications, infections, and readmissions due to error. When we perform fewer unnecessary procedures, less duplicative tests and consultations, wasted time and money is returned to the bottom line. The money, again, is in the margins. (Kindle Locations 2010-2017)
So, the margin will have to grow as a percentage relative to gross revenue, the latter of which has to decline ("Bending The Cost Curve"), per capita, anyway.

Tall order.

So, in recap,

Is health care just another consumer commodity, one properly governed by contract law in the service of "efficient markets"?

I would take issue with the framing assumptions implicit in the conventional question. The "Health Care Market" is anything but monolithic. Moreover, even countering "no, it's a right" need not assume a blank check. Some aspects might well be best served by private markets nimbly, "efficiently" serving their respective niches (I have to agree with that, btw). But, as I expressed 3 years ago on another blog of mine,
How can we say that people have an "intrinsic right" to military defense, or to police and fire protection, (or to safe food and water, or to otherwise safe products that won't electrocute us when we plug them in)? Well, we simply say it. And then we codify it. And, then, having codified it, we don't lie awake nights worrying that everyone will demand a Special Forces FOB dug into his or her front yard, or an occupied Metro PD Black & White, an ambulance, and a hook & ladder truck parked at the curb 24/7.



Doctors Say Medicare/Medicaid EHR Guidelines Onerous
Posted on June 21, 2012 by Amber Walsh

Doctors and organized medical associations are voicing their objections to proposed Stage 2 Medicare and Medicaid guidelines, saying the new standards are far too demanding for many smaller and less-sophisticated medical practices. Practitioners are asking that requirements be within a physician’s control and not rely on a third party’s use of technology; e.g., a patient or laboratory. The AMA, as well as 98 state and specialty societies, also argue that EHR penalties should not be backdated. These organizations also strongly oppose CMS (Centers for Medicare & Medicaid Services) plans to cut rates by 1% in 2015 and 2% in 2016 for not meeting ‘meaningful use standards’ by October 2014. It should be said that CMS has provided exemptions from penalties in certain practices...

Yeah. I have my doubts that RECs will be around to assist with this..

More to come...


  1. I want to take issue with your re-post of the section on healthcare value. My contention is this: any concept of value that is dependent on cost will invariably fail in the healthcare domain. Why? There are too many perversions of cost to use it as an independent variable in calculating value. It's like using a bungie cord to measure distance when you're calculating miles per hour. Value as a concept is the perception of the purchaser about a transaction. Until purchasers have better tools to assess the marginal impact of healthcare interventions, value is going to remain a vague concept. But let's at least be cognizant that imputing value from cost is dead end.

  2. Thanks for you comment. And, if you take the trouble to read the breadth of my postings, you should see that I don't in general uncritically buy hazy notions. I have to disagree that "value as a concept" is totally subjective. Hip replacement surgery that costs $1x at hospital A and $2x at hospital B, with clinically equivalent outcomes on patients who were clinically equivalent going in means, in any commonsense use of the word, that hospital A delivered twice the "value." "Dollars" are ratio-level data.

    Not that we don't need more refined tools and methods for value analytics.

    1. I think we're getting tripped up on the two definitions of value, which may be a bigger problem than we let on. Value is both the abstract perception of utility, AND the ratio of utility to cost. Economists typically punt on the issue of perception of utility (the increasingly unhelpful "Utils") since they assume that individuals can determine utility for themselves. I'm less convinced that consumers of whatever stripe but particularly regarding healthcare are adequately prepared to determine utility since our consumer instincts are so off base in healthcare.

      I wholeheartedly agree with your last statement that we need more refined tools/methods for value analytics. From a consumer perspective, I want to know what the marginal benefit to my life is of three versus four days of exercise per week. Or of losing weight. Or of keeping my cholesterol low. Now it's just "do it because it's good for you" which undermines decision-making concerning classic economic utility maximization. How do I evaluate the choice between eating the cheesecake and running for 30 minutes?

  3. Katanga, keep 'em coming.

    "our consumer instincts are so off base in healthcare"

    Boy, is THAT ever true. But, it's a generalization -- "healthcare. There are indeed aspects of health care that lend themselves most effectively to a consumerist decision perspective. But, the generalization troubles me. See the works of medical economist J.D. Kleinke in that regard.

  4. More detailed thoughts on consumer instincts in healthcare: