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Friday, September 28, 2012

Time to play nice

I saw your latest blog post, including the piece about ARCH-IT.  It's nice to know that others are paying attention to what we've been doing, even if it isn't evident on our website. Much as I would like to report more website progress--as well as a launch date--that would be premature.  Suffice it to say that we are working on it, but our other work has been somewhat more urgent.  And yes, due to your prodding, we are making our website development a much higher priority.

In other news, I am pleased to report that our membership continues to grow.  We now have more than 20% of RECs as members, and we are actively in discussions with a number of others.  But perhaps more importantly, we have had a host of fruitful meetings with members of congress to educate them about the good work that REC programs are doing.  For example, over the summer I met with staffers from two senate offices, and just this week I met with committee and legislative staff serving the Energy and Commerce's Subcommittee on Health. It was a great meeting, and they are pleased to hear both about ARCH-IT and what RECs are doing in districts around the country.

At ARCH-IT, we have mostly been focused on member recruitment and on government relations, with a growing focus on program development.  We are exploring a number of initiatives to bring RECs with similar revenue generation models together, as well as to leverage the REC purchasing power on behalf of RECs.  Given the heterogeneous nature of REC programs, we're focusing the business opportunities, not on a total business model.  Sustainability is THE hot button issue right now.  We hope to make a program announcement in the coming weeks which I hope you'll attend.

Of course, you should know that, unlike the RECs, ARCH-IT didn't even start with seed funding, so we're not only doing this with limited staff, but with limited funds, too.  I realize this is all chicken and egg kind of stuff, but given that we have only existed since April, I'm pleased with our progress, even if I'm not yet satisfied with the results.  Your involvement and your clear web savvy would be a huge help, if you're willing to lend us a hand. 

Again, I want to thank you for keeping us honest with regard to our website development, but I assure you that a lack of reported activity via the website is not the same as no activity.

Should you have any questions, please don't hesitate to reach out to me.  I can be contacted as noted below, and would welcome an opportunity to talk to Healthinsight about joining ARCH-IT.

I look forward to speaking to you soon.



David M. Bergman
Executive Director
Association of Regional Centers for Health Information Technology

Hi, David

I pay attention to everything HIT, every day.

I will post this on my blog -- with your permission, -- and I will quit cracking on you. Thanks for not taking personal offense. I bet I've irritated some of your startup participants. But, we're all after the same goals, and I always have taken pains to not call anyone out by name.

And, yes, you can count on me to help. I offered that at the outset, I believe, and never heard a word in response. I believe my reaction at the time was "I guess I'm just too radioactive."  :)

BTW- Health 2.0 granted me a press pass for the San Francisco conference Oct 7th to 10th, so I'll be there soaking it all in.

Amid distractions...

BTW, my Congressman is Joe Heck. I've talked with one of his staffers (nice young man) about the reported pending House Energy & Commerce Committee hearings on the Meaningful Use program. From the looks of the website, it seems like of their content was written by Sean Hannity's writers. Garishly hostile. So, I would expect that any Meaningful Use hearing would largely be an accusatory star chamber exercise via which to bash HHS/CMS/ONC.

I offered to come on my own dime and testify re my in-the-trenches POV. I rather doubt they'll take me up on it. Nothing's scheduled yet, anyway. They may have bigger fish to fry right now.

Good to hear from you.




Well, my apologies for not taking you up on your offer a little sooner--I'd love your help.

Can we set up some time to talk next week?  Thank you!

Yes, you should feel free to post this--I wrote it with that in mind.

I'm aware of the MU hearing, but was told that it wasn't scheduled yet.  I was also told that we (Arch-it) would be a great addition. I'll keep you posted on any developments on that front.

Thanks again for your prodding!


How about 9 Pacific next Tuesday, Oct 2nd? (noon your time) I can call you.

My Mondays are always hell, meetings all day.


Sorry, Bobby.  I can't do Tuesday.  How about Thursday?  Say 10:00 AM PDT? 



OK. Want me to call you?


Sure. Thanks,


It's all good.


I'm not the only wiseass out there in Snarkland:

Blog: An empty-chair conversation with Eric Holder on EHRs
Here’s a conversation somebody should have had with an empty chair.

Let’s pretend the chair is U.S. Attorney General Eric Holder.

“You know, Mr. Holder, we pay doctors as if they're sewing shirtwaists in some sweatshop loft in New York's garment district in the 19th century. If they whip in some more-elaborate stitching, so to speak, we try to keep track of that and pay them a little more, but basically, we just pay them like pieceworkers.

“So, Mr. Holder, work with me on this analogy.

“Let's suppose, instead of making them sew (i.e., treat patients) the old-fashioned way, whipping in stitches (I mean documenting their work) with needle (pen) in hand, let's make them all get pedal-powered sewing machines (by that, of course, I mean electronic health-record systems).

“Old ways die hard, Mr. Holder, and the best of these machines are, admittedly, kinda clunky, but still, I think we can sell the docs on switching over to them by explaining that once they buy and install the machines and once they figure out how to use them, they should be able to crank out in a given day a lot more shirtwaists (by that, I mean patient visits).

“But this is the real selling point, Mr. Holder. With the machines, the docs' production of the more-difficult, intricately stitched shirtwaists (the more thoroughly evaluated patients) will jump. That'll be good for the patients and docs, particularly if we don't change the piece rate.

"So, the sales staffs of the machine vendors will sell the docs on the machines by saying they're gonna make a lot more money. It's brilliant.

“We can try this first as a pilot, Mr. Holder. Then, we'll toss in a few billion bucks for down payments on new machines. We'll get all that money back and more through the docs' increased productivity.

“But wait, just thinking out loud here: Won't we have to pay the docs more? Because once they get handy with these machines, they'll produce more, especially the higher-cost stuff.

“What's that, Mr. Holder? You've got an idea? Cut the docs' piece rate, right?



“Accuse the docs of fraud?


“You're kidding, right?

“You'll come off like Claude Raines in Casablanca.

“Didn't we just tell the docs to use the machines?

“And what if this all comes down in an election year?

“OK, so you figure, it's a big country, someone will have to be using the machines up against the chalk lines. Right, and then you say, 'I'm shocked, shocked!' Just like Claude Raines. We'll have a couple of show trials and the docs will dial it down on their own.


“Do you really think it will work?

“Nah, me neither.”


Can't have enough visual analogies. Let's say you start in the lower left, at "8 o'clock a.m.," and then go around in circles every day (often shutting of the lights and going home by 7 pm if you're lucky).


Uplift Medical, P.C. (Uplift) failed to provide forty-one individuals with timely access to their medical records and failed to cooperate with an HHS investigation of complaints regarding the company's noncompliance with HIPAA. Uplift argued that the medical records were not available because they were being used in a criminal hearing. As a result, HHS proposed a $4,351,600 penalty. Seems reasonable? Uplift did not request a hearing to challenge the penalty which was subsequently imposed by HHS.

Surprisingly, Uplift was no more cooperative in paying the fine than in cooperating with the investigation. As a result, HHS filed a complaint against Uplift and its owners to collect the penalty, alleging that Uplift continued operating after its corporate charter had been forfeited. HHS contended, and the court agreed, that Uplift had become a de facto partnership and its owners were therefore liable for the HIPAA civil money penalties as de facto partners. The court also held that the owners were barred from challenging the penalty for failure to exhaust their administrative remedies, by requesting a hearing and by the doctrine of res judicata.
Interesting (PDF).

Tuesday, September 25, 2012

The 2014 CEHRT 3rd Wave

So, after work tonight I downloaded and combined the draft NIST 2014 CEHRT stds to date in Adobe Acrobat, "waves 1 through 3" (nearly 300 pgs).

After which I keyword-searched the following:
  • usability;
  • ease of use;
  • efficiency; and
  • workflow.
"Usability"? Nada. Zilch.
"ease of use"? Nada. Zilch.

"efficiency"? Maybe 8 references, all unrelated to "usability."
"workflow"? 13 or so, all also unrelated to "usability."

2014 Edition Test Procedure for §170.314.a.16
Electronic medication administration record – inpatient setting only For Public Comment, September 21, 2012

The Tester shall use and apply the provided test data during the test, without exception, unless one of the following conditions exists:
  • The tester determines that the Vendor-selected message format requires some modification to the test data.
  • The Tester determines that the Vendor product is sufficiently specialized that the provided test data needs to be modified in order to conduct an adequate test. Having made the determination that some modification to the provided test data is necessary, the Tester shall record the modifications made as part of the test documentation.
  • The Tester determines that changes to the test data will improve the efficiency of the testing process; primarily through using consistent demographic data throughout the testing workflow. The Tester shall ensure that the functional and interoperable requirements identified in the criterion can be adequately evaluated for conformance and that the test data provides a comparable level of robustness.
CMS/ONC/NIST have effectively just punted on the "usability" thing this time around.

"Stop it! This is Hard!"

BTW: I found this repetitive statement equally revealing:
Any departure from the provided test data shall strictly focus on meeting the basic capabilities required of EHR technology relative to the certification criterion rather than exercising the full breadth/depth of capability that installed EHR technology might be expected to support.
Emphasis mine. I keep having that Clinic Monkey Moment.

So, here's the logic: EHR "usability" will flow naturally as a byproduct of vendors having a "QMS" in place (Quality Management System). I guess they'd intended to promulgate one, but, well...

From the 2014 CEHRT Final Rule (pdf):
We have adopted a certification criterion that accounts for the fact that we did not publish the quality management document as we had proposed. The certification criterion we have adopted is more general and provides more flexibility. The certification criterion expresses that for each capability an EHR technology includes and for which that capability's certification is sought, the use of a QMS in the development, testing, implementation and maintenance of that capability must be identified. Unlike our proposal, any QMS may be used to meet this certification criterion and even an indication that no QMS was used for particular capabilities for which certification is requested is permitted. The commenter who stated that they are implementing the FDA’s Quality System (QS) regulations (for example, under the MDDS rule) would – by definition – be meeting this certification criterion so long as they cite their compliance with FDA’s QS regulations for certification. Given this flexibility, we cannot foresee any reason why this certification criterion cannot be satisfied nor do we believe that it will be a significant burden to indicate the QMS used (or not used) in the development of capabilities for which certification is sought.

We understand that some EHR technology developers have several teams who work on different functional components of EHR technology. In the case where the whole development organization uses the same QMS (or not at all) across all teams, then this certification criterion may be met with one report. Where there is variability across teams, the EHR technology developer will need to indicate the individual QMS’ followed for the applicable certification criteria for which the EHR technology is submitted for certification.

We encourage EHR technology developers to choose an established QMS, but developers are not required to do so, and may use either a modified version of an established QMS, or an entirely “home grown” QMS. We also clarify that we have no expectation that there will be detailed documentation of historical QMS or their absence. As specified above, we believe that the documentation of the current status of QMS in an EHR technology development organization is sufficient.
[pp 106-107]
Emphases mine.

I have searched my PDF Waves 1 through 3 NIST stds repeatedly. Neither the acronym "QMS" nor the phrase "quality management" appear anywhere therein. I guess NIST didn't get The Memo.

Maybe I'm missing something. I again reviewed ARRA/HITECH itself (pdf):

Subtitle A—Promotion of Health Information Technology


The Public Health Service Act (42 U.S.C. 201 et seq.) is amended by adding at the end the following:

42 USC 300jj.    ‘‘SEC. 3000. DEFINITIONS.

‘‘In this title: ‘‘(1) CERTIFIED EHR TECHNOLOGY.—The term ‘certified EHR
technology’ means a qualified electronic health record that is certified pursuant to section 3001(c)(5) as meeting standards adopted under section 3004 that are applicable to the type of record involved (as determined by the Secretary, such as an ambulatory electronic health record for office-based physicians or an inpatient hospital electronic health record for hospitals)...
Again, emphasis mine. So, it's within the purview of HHS to set forth the specs of certification -- inclusive of requiring vendor documentation (or not) of an operative QMS. Well, I guess they're not exceeding their regulatory Brief.

Quite the contrary.

BTW, I'm not the only crank here.

EHR Certification 2014—Darwinian Implications?

The final EHR certification criteria for 2014 were released a few weeks ago, and I am surprised by how many of the more forward-thinking proposals made it into the final set.  The proposed criteria, released in March, contained suggestions that I thought were good ideas (e.g., usability testing, price transparency, and data portability requirements), but which seemed unlikely to survive the comment period.   I was shocked to see they made the cut!  Since these criteria affect how products are developed and sold, they may very well change the dynamics of the EHR market by helping some vendors and hastening the demise of others.  Their impact on the EHR market could be huge!  Let’s take a closer look at the three with greatest potential impact.

Usability Testing
This was the biggest surprise.  I thought usability testing would become part of certification, but not for the 2014 cycle. According to comments received by the ONC, EHR buyers liked the idea–vendors, not so much...

EHR usability rises to the forefront
September 27, 2012 | Bernie Monegain - Editor

Interview excerpt, Robert Tennant, senior policy advisor for the Medical Group Management Association:
Q. Is it a good idea to have usability as one of the measures for EHR certification?

A. I really think it’s a good step for ONC [the Office of the National Coordinator for Health IT] to start pushing the vendors toward more user-friendly systems, because if they’re not easy to use, it slows the clinician down, which we certainly don’t want to happen. It can frustrate them. It could lead to errors, and not taking full advantage of what these systems offer the clinician. User friendliness is especially important for what I would call the next wave of clinicians to adopt EHRs. The first wave, many of them had the systems in place, [and] a lot of them were technology-savvy. Now we’re trying to get at those physicians that aren’t necessarily technology-savvy. It’s absolutely critical that the interface be very friendly. Again, that’s going to increase the adoption rate among physician practices.

Q. Why has usability not been a consideration from the get-go?

A. We've been pushing the idea of usability for a long time. I was involved in the formation of CCHIT, the Certification Commission for Health Information Technology, which one of the six ATCBs now authorized to certify these products. I remember in the early days of CCHIT, I kept saying, "You know it’s not good enough just to test the functionality. If it takes a thousand keystrokes to get to something, well, it’s not very user friendly." The pushback came from two sides. One was from CCHIT, saying, "Well I don't know if we can test that. It’s difficult; it’s subjective." And the vendors themselves were leery about including usability in the testing criteria. We continued to harp on it over the years, and finally CCHIT added it to their test script. They have a whole protocol now in place to test it. My understanding is the product is assigned a rating from 1 to 5 in terms of its usability.


Implementation of a health IT product is one of the most challenging and time- consuming stages of the health IT life cycle. A database of user experience, including identification of new safety risks, would provide organizations with suggestions for ways to improve the efficiency, effectiveness, and safety of implementation. These organizations will benefit from lessons learned by similar health care organizations about how to improve the performance and safety of their existing systems. The information may include ideas on effective product upgrade practices or applications, safety risks associated with a specific vendor’s product, warnings about data entry combinations that could result in erroneous clinical orders, or suggestions for ways to enhance user training.

Health professionals responsible for setting up and managing clinical information ex- change will benefit from data on user experiences. The integration of health IT products with other clinical IT products (e.g., picture archiving and communications systems, pharmacy systems) and devices is complex and requires a significant amount of upfront configuration to en- sure that data are not lost or corrupted along any phase of the information exchange. A user experience database will help identify integration-related problems to avoid.

Health care organizations should also find comparative user experiences useful for workflow redesigns and new personnel infrastructures needed in a health IT–enabled health care system. In addition, organizations need to plan for the appropriate time and approaches to decommission an existing system. This can be facilitated through review of reports submitted by other health care organizations at similar stages of their health IT products’ life cycles. Many of these organizations will likely be working on the process of replacing their products with new products and should have information to share about what has worked well for them and what problems they encountered during the transition.

Ideally, this information could be parsed so that consumers of the data could easily find information relevant to their particular questions or contexts. In addition, an open and transparent approach to sharing user experience could create organic learning communities among different categories of professionals within the health care industry.
What's not to love there?
Multi-Modal Approach to Characterizing and Comparing User Experiences

No single measure can meet all needs for comparative user experiences. Different audiences—clinicians, vendors, implementers (e.g., chief medical informatics officer [CMIO]), organizational decision makers (e.g., board of directors)—will have different needs. Furthermore, no single measure can fully capture the strengths and weakness of a particular health IT product. Thus, multiple modalities of acquiring and reporting user experiences are recommended, including

  • in vitro “flight simulator” laboratory evaluation of test scenarios; 
  • in vivo point-of-use reporting; 
  • data mining of use patterns; 
  • third party–administered user surveys;
  • direct user-to-public reporting; and 
  • a formalized system of hazards reporting (see Table 1).
Some modalities will have more scientific rigor, such as formal surveys and “flight simulator” lab testing, while other modalities will be less scientific, but will provide an opportunity for input from a large number of users and hold the potential for discovery of unanticipated user experiences...
Stipulated. Nice report (PDF). Read the whole thing.
At present, some vendors prohibit users from sharing screenshots and otherwise effectively communicating with others about a problem with an EHR. There is currently no place for health IT users to share publicly the experiences they have had with their health IT products. However, even if a place were designated and developed a following, its use would be limited because of contractual prohibitions on sharing screenshots.
A voluntary multi-modal, multi-stakeholder approach to health IT safety reporting and communication may deter a more heavy-handed approach to regulating health IT vendors. Regulation by the Food and Drug Administration is a serious possibility on the horizon if improve-ment in health IT safety and usability is not achieved through a voluntary process...
The goal of collecting and publicly reporting user experiences is to improve products across the industry and promote safety. After a decade of development and experience, EHRs and other health IT products have not advanced sufficiently; nor have they been adopted widely and enthusiastically, in step with other consumer products such as smartphones and iPads. Some have referred to this as a market failure (Mandl and Kohane, 2012). With EHRs, unlike other consumer product areas, there has been little opportunity for cross-vendor comparison, which has stifled the evolution of this technology.

We believe that the development of meaningful metrics of comparative user experiences in domains such as cognitive workload, accuracy of decision making, time required to perform tasks, and implementation experience will support the purchaser in making wise decisions when choosing a health IT product, and will simultaneously provide the vendor community with incentives to improve products.
Finally, we believe that public reporting of user experiences, in a variety of forums, is essential to leveraging the power of the user and purchaser to affect change.
More thoughts on this shortly.


My Fetch FTP upgrade.

One, two, done, use...


Lucie wandered into my life in 1999, a red chow-huskie mix stray (one of my 3 rescue dogs and 1 rescue cat). She died slowly and peacefully in my arms last night. I shot that pic in the back yard earlier this year. I am heartbroken. It was a long night.

U Cal Davis HIE developments

California Health eQuality (CHeQ)

On May 16,2012, the California Health and Human Services Agency announced that IPHI had been selected to implement California's Health Information Exchange (HIE) programs under the State’s Cooperative Grant Agreement with the federal Office of the National Coordinator for Health Information Technology (ONC).

The administrative transition from Cal eConnect to IPHI is now complete; we appreciate your patience as we build out the California Health eQuality (CHeQ) website. In the interim, information on the status of funding opportunities begun during the transition is now available; new opportunities will be posted in the near future...


I relentlessly search out HIT related stuff every day and night. I should legally change my name to "Boolean Substring()"

I've increasingly noted, with a bit of frustration and irritation, that when I search out items via Google some of the top responses are links to my own REC blog!

Sept 28th update:

The comments section of this post just in oughta be interesting.


More to come...

Saturday, September 22, 2012

Weekend Updates

My quick Photoshop response to the "VDT' push. Shot the USB drive on my kitchen counter, imported it, and did the overlays. Plenty to say about this concept coming up. Some of you might recall the quickie iMovie/YouTube I did a while back.

And, yeah, I know, a PHR <--> Patient Portal is the significantly better way to go long-term, but, whatever works, and flash drives are way more convenient than burning stuff to CDs.

UPDATE: Quick news item:

10 EHR Vendors Pledge Patient Records Access Within Months
Joseph Goedert, SEP 21, 2012 11:51am ET

The Office of the National Coordinator for Health Information Technology recently challenged electronic health records vendors to have their systems support patients viewing, downloading and transmitting their health information by the 2013 HIMSS Conference in March.

View/download/transmit is an EHR functional requirement under Stage 2 of the meaningful use program. Four vendors initially took the pledge and the count now is up to 10. They are: Alere Wellogic, Allscripts, athenahealth, AZZLY, Cerner, eClinicalWorks, Greenway Medical Technologies, Intellicure, NextGen and SOAPware.

Vendors taking the challenge can Tweet their pledge to #VDTnow.


Again, After October 3rd, there will be some criteria regarding which you will be unable to make up any ground (i.e., once the doc has closed the note, she can't go back in and change any encounter-related data, including those needed for MU attestation).

On the Medicare side, having to attest in 2013 (no, it does not traverse the calendar year) will cost you $5,000 per EP, $3,000 of that in year one.


First three weeks of September are cookin'. I don't pay a whole lot of attention to my traffic numbers, as this is a non-commercial personal blog I use just to reflect upon my interests since I began my REC work. But, I gotta say, this is pretty nice to see. Probably has something to do with my getting the HIMSS12 and Health 2.0 Conference press passes.

If you're attending and have any topics/views you'd like to have me write about, give me an email shout and we'll hook up. BobbyG "at" BGladd "dot" com. Also, tweet me, @BobbyGvegas

This is pretty curious, my top traffic countries:

Norway? Norway?

Tusen takk, mine norske venner, og si hei til Ole Børud for meg!


Saw this linked in a tweet. Jeez...
Medicare Bills Rise as Records Turn Electronic

When the federal government began providing billions of dollars in incentives to push hospitals and physicians to use electronic medical and billing records, the goal was not only to improve efficiency and patient safety, but also to reduce health care costs.

But, in reality, the move to electronic health records may be contributing to billions of dollars in higher costs for Medicare, private insurers and patients by making it easier for hospitals and physicians to bill more for their services, whether or not they provide additional care.

Hospitals received $1 billion more in Medicare reimbursements in 2010 than they did five years earlier, at least in part by changing the billing codes they assign to patients in emergency rooms, according to a New York Times analysis of Medicare data from the American Hospital Directory. Regulators say physicians have changed the way they bill for office visits similarly, increasing their payments by billions of dollars as well.

The most aggressive billing — by just 1,700 of the more than 440,000 doctors in the country — cost Medicare as much as $100 million in 2010 alone, federal regulators said in a recent report, noting that the largest share of those doctors specialized in family practice, internal medicine and emergency care...
Over all, hospitals that received government incentives to adopt electronic records showed a 47 percent rise in Medicare payments at higher levels from 2006 to 2010, the latest year for which data are available, compared with a 32 percent rise in hospitals that have not received any government incentives, according to the analysis by The Times.

The higher coding has captured the attention of federal and state regulators and private insurers like Aetna and Cigna. This spring, the Office of Inspector General for the federal Health and Human Services Department warned that the coding of evaluation services had been “vulnerable to fraud and abuse.”

Some experts blame a substantial share of the higher payments on the increasingly widespread use of electronic health record systems. Some of these programs can automatically generate detailed patient histories, or allow doctors to cut and paste the same examination findings for multiple patients — a practice called cloning — with the click of a button or the swipe of a finger on an iPad, making it appear that the physicians conducted more thorough exams than, perhaps, they did.

Critics say the abuses are widespread. “It’s like doping and bicycling,” said Dr. Donald W. Simborg, who was the chairman of federal panels examining the potential for fraud with electronic systems. “Everybody knows it’s going on.”...

Many hospitals and doctors say that the new systems allow them to better document the care they provide, justifying the higher payments they are receiving. Many doctors and hospitals were actually underbilling before they began keeping electronic records, said Dr. David J. Brailer, an early federal proponent of digitizing records and an official in the George W. Bush administration. But Dr. Brailer, who invests in health care companies, acknowledged that the use of electronic records “makes it faster and easier to be fraudulent.”

Both the Bush and Obama administrations have encouraged electronic records, arguing that they help doctors track patient care. When used properly, the records can help avoid duplicate tests and remind doctors about a possible diagnosis or treatment they had not considered. As part of the economic stimulus program in 2009, the Obama administration put into effect a Bush-era incentive program that provides tens of billions of dollars for physicians and hospitals that make the switch...

Some contractors handling Medicare claims have already alerted doctors to their concerns about billing practices. One contractor, National Government Services, recently warned doctors that it would refuse to pay them if they submitted “cloned documentation,” while another, TrailBlazer Health Enterprises, found that 45 out of 100 claims from Texas and Oklahoma emergency-department doctors were paid in error. “Patterns of overcoding E.D. services were found with template-generated records,” it said.

The Office of Inspector General is studying the link between electronic records and billing...
Wow. Read the entire article, along with the 140+ comments (linked in the title). The touting of HIT is not going to get any easier. Add to the foregoing the pending conversion to ICD-10... May we live in interesting times.

We were cheerleading the notion of legit and defensible "upcoding" via EHRs all the way back during the DOQ-IT program (all part of the endless "ROI" pitch). I knew back then it was only a matter of time before there'd be major pushback on the payor side.

Expect the claims adjudication fighting to get ever more intense.


Center investigation suggests costs from upcoding and other abuses likely top $11 billion
by Fred Schulte
Thousands of doctors and other medical professionals have steadily billed higher rates for treating elderly patients on Medicare over the last decade — adding $11 billion or more to their fees and signaling a possible rise in medical billing abuse, an investigation by the Center for Public Integrity has found.

Medical groups argue that the fee hikes are justified because treating seniors has grown more complex and time-consuming, both due to new technology and declining health status. The rise in fees may also be a reaction, they say, to years of under-charging, and reflect more accurate billing. The fees are based on a system of billing codes that is structured to make higher payments for treatments that take more time and effort...

Among the investigation’s key findings:
  • Doctors steadily billed Medicare for longer and more complex office visits between 2001 and the end of the decade even though there’s little hard evidence they spent more time with patients or that their patients were sicker and required more complicated — and time-consuming — care.  The higher codes for routine office visits alone cost taxpayers an estimated $6.6 billion over the decade.
  • More than 7,500 physicians billed the two top paying codes for three out of four office visits in 2008, a sharp rise from the numbers of doctors who did so at the start of the decade. Officials said such changes in billing can signal overcharges occurring on a broad scale. Medical groups deny that.
  • The most lucrative codes are billed two to three times more often in some cities than in others, costly variations government officials said they could not explain or justify. In some instances, higher billing rates appear to be associated with the burgeoning use of electronic medical records and billing software.
  • Medicare administrators have struggled for more than a decade to crack down on medical coding errors and abuses, often in the face of opposition from medical groups including the American Medical Association, which helped design, and now controls the codes. Whether they make honest mistakes or engage in willful misconduct, there’s little chance doctors who pad their charges will face any serious penalties.
...Medicare officials deny the AMA and other medical groups have outsized influence over the payment system. But they concede that the system has been left in place for years because they could not reach an agreement on ways to improve it.

Most patients have no idea doctor pay scales exist because Medicare and other insurers don’t typically help people decipher them. As owner of the copyrights on the codes and their definitions, the AMA controls their publication and aggressively enforces its copyright.

Princeton University Professor Uwe E. Reinhardt, a prominent health care economist, said government officials could have paid the AMA a lump sum to develop the codes, simplified them and retained their ownership for taxpayers. Doing so would have opened up the process to public scrutiny and given patients a better understanding of health care finances. Other critics note that millions of seniors might help the government check on the veracity of medical bills if they knew the lingo and how to crack the codes.

“I wish I had some way to check up on the billing process,” said Judy Ryden, a retired community college teacher who is on Medicare and lives in Grants Pass, Ore. “Unless I had a degree in medical coding I have no idea what all that means. I can’t tell whether a charge is legitimate or not,” she said...
Again, read all of this. I found it here on THCB: Kill The Codes. Excerpt:
...Not long ago I asked readers what my time is worth on a per-hour basis.  Collectively and independently, they settled on a number of about $500/hr (see the comments).  Now look for a moment at what Medicare pays, even at its highest level of billing for a physician’s time for evlauation and management of a medical problem: for 40 minutes of a physician’s time, it’s $140 (or $210/hr) before taxes.  Again, we see another disconnect as to how doctors are valued in our current system.

Doctors are working long hours to collect these fairly low fees from Medicare while jumping more hoops than ever to do so.  They have become pseudo-experts at the coding game, trying to get as much money for their extra efforts as legally possible.  But these fees paid by Medicare do not cover payments for time spent on phone calls, e-mails, and working insurance denials.   These services are still considered by our system as gratis. To partially counteract this coding problem, doctors realized (and the government insisted) that doctors use electronic medical records.

But when independent doctors set out to implement these records they quickly discovered that the expense and long-term maintenance costs of local office-based EMRs could not compete with more sophisticated systems already in use by their neighboring large health care systems.  Because of ever-increasing cost-of-living and overhead costs, not to mention the threats of large fee cuts, doctors have migrated to large health systems faster than ever.  With the fancier electronic record at those systems (streamlined for billing, collections, and marketing) fields required for higher billing codes (but not always material to the problem at hand) are completed in less time.  So are doctors really the problem?

It depends on who’s looking.  Since every medical test and order is tied to a doctor’s name, then of course it looks like doctors are the problem.  And yet it’s the government who has mandated the codes, the requirements for chart completion, and the electronic records to which our electronic signatures are attached...


And, Mr. No Life is digging into May 2011 update of DURSA. Pretty interesting, actually. My recommendation to HealtHIE Nevada brass is that we leverage the experiences of those who've already gone down this path. No sense re-inventing wheels. HIPAA (and related) compliance gets you a good bit of the way to being a successful DURSA signer, but there are also a lot of technical testing specs to engage and document to demonstrate Trusted Secure Messaging.

Consistent weaknesses in sections of the Millenium clinical information System (CIS) are revealed in the combined study of the ERD, logical schema and the data tables. PK values are not always defined unambiguously at the design level and data tables reveal inconsistencies in declarations and data validation. There is evidence that keys are managed by software within the application rather than by the in-built functions available in the database management system leading to less confidence in data integrity.

Health reform is pressuring hospitals, health systems, and physician groups to demonstrate value, not just generate volume and that IT improvement has to be seen as part of that drive. To meet this challenge, all members of the care team will need to break down silos and collaborate more closely than ever before. Building trust with IT services is essential, but at the same time this will not occur without IT staff becoming committed to primarily clinical objectives. Success will require the enthusiastic engagement of physicians through the use of sophisticated CIS in quality improvement — and not just on isolated projects. This next level of interdependence and collaboration — known as clinical integration — is vital to any enterprise seeking improved quality, patient safety, and value. This study analyses the deployment of Firstnet in Emergency Departments from the viewpoints of ED Directors, systems analysts and software engineers and observes that the support needed by the EDs comes up well short of what is needed and that the shortfall is attributable to both the Health Support Services of NSW Health and the technology itself. If this situation is not rectified then the promise of the gains of the IT Age for clinical care will be well and truly squandered.

This document consists of a study, in 9 sections, into the deployment of the Firstnet software in the Departments of Emergency Medicine in New South Wales, Australia. The first section was published in October 2009 and later reissued in November 2009 (Part 1). Seven sections (Parts 2-8) cover work completed in the second half of 2010 and are published here. The ninth and final section captures the context in which this study was completed. It is a summary of five years research into the design and construction of clinical information systems and was published as a conference paper in November 2010.

The titles of the 9 sections are: 
  1. A Critical Essay on the Deployment of an ED Clinical Information System ‐ Systemic Failure or Bad Luck? 
  2. Discussions with ED Directors: Are we on the right track? 
  3. Discussions with Software Performance Experts. 
  4. Conceptual Data Modeling. 
  5. Database Relational Schema and Data Tables. 
  6. Coalescing the Analyses of the ER Diagrams, Relational Schemata and Data Tables. 
  7. The Integrated Assessment.
  8. Future HIT Regulation Proposals.
  9. Ockham’s Razor of Design: An Heuristic for Guiding Design and Development of a Clinical Information Systems Generator.
This kind of stuff is red meat for people like me.

I've post all of the unzipped PDF sections here.  

"PK values are not always defined unambiguously at the design level and data tables reveal inconsistencies in declarations and data validation."

Ya think?

(btw, "PK" means "Primary Key," a continuing bane of tight software development.)

It's not pretty. e.g.,

Compilation of Weaknesses
A complete study of each table and our observations about their weaknesses are presented in Appendix 1. A compilation of the principal weaknesses identified in the available schema and data tables has been collated in Table 2. The results show that there is no schema or table without a weakness of some kind. The most persistent weaknesses across the data set are non-integer PKs and non-declared FKs. Issues that would represent the highest risk for user sites would be: doubtful PKs, misnamed PKs, and overloading attributes as these potentially can interfere with more fundamental aspects of data management and hence veracity. Other weaknesses if they create disturbance to data will tend to be isolated to single items such as a single patient or pharmacy record.

Weaknesses in CIS implementation suggest a lack of attention to detail, particularly specific testing to validate schema designs and index/FK and PK selection. If the yellow key icon is truly an FK indicator then the apparent use of FKs for creating indices rather than their purpose of maintaining referential integrity is a misapplication of this functionality.
Identified weaknesses could reasonably be expected to produce faulty processing of user data manifesting as problems such as, missing parts of patient records, missing information about pharmacy products. Particularly, these occurrences will appear occasionally without any apparent systematic behaviour as they will not be triggered by each and every patient record but rather only where a particular record uses a combination of information that requires the correct data relationships. Hence any one clinical user will observe a fault on occasions so far apart in time they will not connect a set of failings as being related to an underlying systematic weakness.

That last paragraph is very important. Complete Part 5 PDF document here. Pretty cool; full of tables and screen shots of the various schema relational dictionary tables.

I know just a thing or two about RDBMS architecture, dated as my experience may be in some ways. While data types and functionalities have changed and grown (along with code bloat), the core, necessary logical / linkage concepts have not.

I can't believe we're still extending so much scut-work effort on de-duping stuff in our Microsoft CRM at the office.


Margalit never disappoints.
The health care crowd is abuzz with The New York Times revelation that Medicare billing rates seem to have increased by billions of dollars in parallel with increased adoption of EHR technologies for both hospitals and ambulatory services. The culprit for this unexpected increase is the measly E&M code. Evaluation and Management (E&M) is the portion of a medical visit where the doctor listens to your description of the problem, takes a history of previous medical issues, inquires about relatives that suffered from various ailments, asks about social habits and circumstances, lets you describe your symptoms as they affect your various body parts, examines your persona and proceeds with diagnosing and treating the condition that brought you to his/her office or hospital.

The more thorough this evaluation and management activity was, and the more complicated your problem is, and the more diagnostic tests are reviewed, and the more counseling the doctor gives you, the more money Medicare and all other insurers will pay your doctor. Makes perfect sense, doesn’t it?...

...There are ... administrative functions embedded in larger EHRs that allow those who employ physicians to ensure that the docs click on all the necessary things to ensure optimal billing and payment. It is very easy to be critical of clinicians in these scenarios, but let’s remember that if Medicare wouldn’t have defined the value of a doctor visit to be proportional to the amount of text generated during the visit, none of this would have happened.

So the “unintended consequences” of pushing physicians to use EHRs seem to consist of doctors actually using EHRs, as effectively as possible, to document all the little details Medicare wants to see. This can only surprise people who had no clue what EHRs are, how they work, and how they are used in everyday practice, which did not (does not) prevent said people from proclaiming themselves as health care experts, best suited to set the national agenda for EHR design and adoption.

It'll be interesting to read the comments in response to her post as they accrue.


Payers are making mistakes on roughly 1-in-5 claims they receive. Even the most meticulous coding can't protect your practice from payer errors. (Read more here.)

Those mistakes are wasting an estimated $17 billion annually in needless administrative cost -- not to mention delaying payments for your practice. It seems that payers are making it almost impossible for you to get promptly paid in full.

Who has the time and resources to compare each payment, denial and underpayment with changing rules and contracted rates to ensure complete compensation?

With CareCloud Concierge, you do. Our comprehensive revenue cycle management service features:

  • Automated claims-contract reconciliation
  • Proactive compliance
  • Daily aging of receivables
  • Instant rules updates
  • Highly effective internal controls
  • Vigorous denial management protocols
  • Expert support and guidance
Take the headache out of getting paid with CareCloud Concierge.
An obvious marketing response to the recent stories of upcoding and other billing controversies. I now have a REC client using CareCloud. They recently dropped Alteer, in the wake of persistent, maddeningly poor support, and migrated over. I'll be paying a Meaningful Use support visit to them this week to assess how well things are progressing.


That's funny. Sort of.

More to come...

Wednesday, September 19, 2012

"Savings promised by the government and vendors of information technology are little more than hype." - WSJ

The Wall Street Journal has just tossed a large cup of cold coffee on HIT.
OPINION September 17, 2012, 7:25 p.m. ET
A Major Glitch for Digitized Health-Care Records
Savings promised by the government and vendors of information technology are little more than hype.

In two years, hundreds of thousands of American physicians and thousands of hospitals that fail to buy and install costly health-care information technologies—such as digital records for prescriptions and patient histories—will face penalties through reduced Medicare and Medicaid payments. At the same time, the government expects to pay out tens of billions of dollars in subsidies and incentives to providers who install these technology programs.

The mandate, part of the 2009 stimulus legislation, was a major goal of health-care information technology lobbyists and their allies in Congress and the White House. The lobbyists promised that these technologies would make medical administration more efficient and lower medical costs by up to $100 billion annually. Many doctors and health-care administrators are wary of such claims—a wariness based on their own experience. An extensive new study indicates that the caution is justified: The savings turn out to be chimerical.

Since 2009, almost a third of health providers, a group that ranges from small private practices to huge hospitals—have installed at least some "health IT" technology. It wasn't cheap. For a major hospital, a full suite of technology products can cost $150 million to $200 million. Implementation—linking and integrating systems, training, data entry and the like—can raise the total bill to $1 billion.

But the software—sold by hundreds of health IT firms—is generally clunky, frustrating, user-unfriendly and inefficient. For instance, a doctor looking for a patient's current medications might have to click and scroll through many different screens to find that essential information. Depending on where and when information on a patient's prescriptions were entered, the complete list of medications may only be found across five different screens.

Now, a comprehensive evaluation of the scientific literature has confirmed what many researchers suspected: The savings claimed by government agencies and vendors of health IT are little more than hype...
 OK, pretty damning. But,let's surf over to the abstract page of of one of the referent "scholarly" papers cited in the WSJ article's cited meta-analyic study, "The Economics of Health Information Technology in Medication Management: A Systematic Review of Economic Evaluations."
Conclusion. The quality of the economic literature in this area is poor. A few studies found that HIT may offer cost advantages despite their increased acquisition costs. However, given the uncertainty that surrounds the costs and outcomes data, and limited study designs, it is difficult to reach any definitive conclusion as to whether the additional costs and benefits represent value for money. Sophisticated concurrent prospective economic evaluations need to be conducted to address whether HIT interventions in the medication management process are cost-effective.
 Meta-analytic research, recall, is comprised of studies that study other studies. So, this effort is akin to "Dr. Joyce Brothers Does HIT."

To conduct the study, faculty at McMaster University in Hamilton, Ontario, and its programs for assessment of technology in health—and other research centers, including in the U.S.—sifted through almost 36,000 studies of health IT. The studies included information about highly valued computerized alerts—when drugs are prescribed, for instance—to prevent drug interactions and dosage errors. From among those studies the researchers identified 31 that specifically examined the outcomes in light of the technology's cost-savings claims.
I'm gonna hold my fire until I can get access to the McMaster thing. We'll see. Although, I will crack on this from the WSJ article:
It is already common knowledge in the health-care industry that a central component of the proposed health IT system—the ability to share patients' health records among doctors, hospitals and labs—has largely failed. The industry could not agree on data standards—for instance on how to record blood pressure or list patients' problems.
That is unfair. "Failed"? It's just getting underway. We've known of the knotty "interoperability" problem for quite some time, and a lot of smart people are working tirelessly to solve it within the paradigm of private market HIT.

Much more to come on this. In the imterim, I exhort you to read the numerous accruing companion WSJ article comments (107 at this writing).

The heads-up on the WSJ thing came by way of being copied on a response to our CFO Dan Memmott by Sharon Donnelly (pdf), our SVP of Corporate Strategy (and who used to be our REC Executive Director).
Thanks for sharing. I appreciate the perspective of industry unduly driving the political agenda.

The article seems to confound two things: saving from HIT in cost of health care and saving from HIT in cost to the provider using it.

The evidence for the first is not there yet. Some think we have built the base needed to get the discrete actionable data to support electronically coordinating care and point of care clinical decision support that will eventually gain the savings. Others see us (primarily due to standards lag issue?) as far from there and legitimately question how current EHR and HIE architectures can support the needs of ACOs and other program designed to improve care and lower cost.   We may have a role in helping our community providers evolve together to a coordinated state that is required to see these benefits.

The second, savings to the practice or hospital, is almost completely dependent on the way the provider plans and implements HIT. Those doing it well reap huge savings in their operating costs. Unfortunately this often includes allowing them to document care in a way that they are reimbursed more, which of course drives the overall cost savings of healthcare in the wrong direction. 

No magic bullet here – just a lot of work!

Some pushback in the HIT press:
A little patience for the health IT revolution

How long did it take American farmers to widely adopt hybrid corn?

Honestly, I don't know, but I do remember what I was told about that kind of adoption—30 years.

I was age 22 at the time and had just started my agriculture extension training with the Peace Corps in Sierra Leone, where we learned the basics of rice paddy construction and swamp rice cultivation. It wasn't until later, when we were posted to our villages to serve our two-year hitches, that we learned just how hard it was going to be to convince wary farmers to abandon their familiar but ecologically destructive slash-and-burn cultivation techniques.

While covering health information technology during the past 12 years, I've thought a lot about that warning against short-run overexpectations. I thought about that warning, again, reading a recent article in the Wall Street Journal, "A Major Glitch for Digitized Health-Care Records."...

...Interoperability is a failure only if your time line is too short and you begrudge the incomplete successes that are happening around us. E-prescribing, one form of interoperability, is soaring. In a couple of years, the federally sponsored Direct protocols will similarly become the method of choice for peer-to-peer communication, replacing the phone and fax machine. Even the far more complex query-and-response form of exchange is coming along. Earlier this month, the VA demonstrated a potential breakthrough in consent management technology for privacy protection using Direct and off-the-shelf standards from HL7.

"This is no time to go wobbly" on health IT, to borrow a line from Margaret Thatcher. The past and future public investments in health IT were—and will be—both proper and necessary.

Now is the time to execute and innovate—and, yes, to be watchful and even critical. But also, and maybe of the most importance, it's time to be patient...

More pushback:
Asking the Wrong Questions About the Electronic Health Record

...Now that we have made an important investment in EHRs, we need to figure out how to use this new technology to address the fact that the healthcare system is a mess.  We need to figure out how EHRs can promote coordination of care across sites, seamless flow of good clinical information, and smart analytics, to name a few things.  We simply can’t do that in a paper-based world.  I am sure that the healthcare industry single-handedly keeps the fax machine industry alive.  We need to stop. Period.  Every other part of our lives has become electronic and the benefits are clear.  Our lives are better because we bank online, communicate online, shop online.

The debate over whether we should have EHRs is over.  Can we fix our broken healthcare system without a robust electronic health information infrastructure?  We can’t.  Instead of re-litigating that, we need to spend the next five years figuring out how to use EHRs to help us solve the big problems in healthcare.
Emphatically agree. Once again, down in The Weeds' -
“A culture of denial subverts the health care system from its foundation. The foundation— the basis for deciding what care each patient individually needs— is connecting patient data to medical knowledge. That foundation, and the processes of care resting upon it, are built by the fallible minds of physicians. A new,secure foundation requires two elements external to the mind: electronic information tools and standards of care for managing clinical information.

Electronic information tools are now widely discussed, but the tools depend on standards of care that are still widely ignored. The necessary standards for managing clinical information are analogous to accounting standards for managing financial information. If businesses were permitted to operate without accounting standards, the entire economy would be crippled. That is the condition in which the $2½ trillion U.S. health care system finds itself—crippled by lack of standards of care for managing clinical information. The system persists in a state of denial about the disorder that our own minds create, and that the missing standards of care would expose.”…

…this subject matter may seem like just a variation on current policy concerns with using “health information technology” to bring “evidence-based medicine” to “patient-centered” care. Yet, current policy fails to comprehend the needed discipline in medical practice and thus fails to define precisely what is needed from health information technology. A dangerous paradox thus exists: the power of technology to access information without limits magnifies the very problem of information overload that the technology is expected to solve. Solving that problem demands a meticulous, highly organized, explicit process of initial information processing, followed by careful problem definition, planning, execution, feedback, and corrective action over time, all documented under strict medical accounting standards. When this rigor is enforced, a promising paradox occurs: clarity emerges from complexity.”

- Lawrence Weed, MD and Lincoln Weed PhD, “Medicine in Denial
None of which mandates being an unreflective, Pollyannish HIT cheerleader, to wit,

Epic FAIL!
County health doctors air complaints about county's new $45 million computer system
By Matthias Gafni, Contra Costa Times
MARTINEZ -- One of every 10 emergency room patients at the county's public hospitals in September left without ever being seen by a doctor or nurse because of long waits -- a number rising since implementation of Contra Costa's $45 million computer system July 1.
One patient waited 40 hours to get a bed.
Dr. Brenda Reilly delivered the troubling news Tuesday afternoon to county supervisors. She was one of three dozen doctors in the supervisors' chamber complaining about EPIC, new computer software aimed at integrating all of the county's health departments to create a federally mandated electronic medical record for patients.
To allow for the major computer program installation and conversion, administrators cut doctors' patient loads in half, in turn cutting the number of available appointments in half.
In a letter to the supervisors, Dr. Ori Tzvieli -- medical staff president whose union has been negotiating a new contract with the county -- along with 14 doctor co-signers pleaded for administrators to continue scaling back physician workloads because doctors are over-stressed. Six doctors have left this year, said Dr. Keith White, a 22-year pediatrician.
"We were not ready for EPIC and EPIC was not ready for us," White told supervisors. "As a result, the providers are struggling to provide safe and effective care for 100,000 citizens of the county, many of whom are very ill. We often feel that we are failing. We are very tired... many doctors have left and all are considering leaving."...
Ouch. The runaway market share leader in "certified" EHR, both ambulatory and inpatient. Talk about "Major Glitches."


This hit my inbox last night:
Hi Bobby,

Thank you so much for applying for a press pass and congratulations on being chosen to attend the upcoming Health 2.0 Fall Conference in San Francisco on Oct 7-10 2012! We only choose the best and most qualified applicants to attend our exciting conference.

The press pass gives you access to the Health 2.0 conference and DC to VC. Below please find the instructions for registering and let me know if you have any problems...

...Please let me know if you have any additional questions or problems regarding registration and we look forward to seeing you in San Francisco soon!

Best regards,
Health 2.0
I am really grateful. HIMSS12 was a blast, and I will cover this event with equal gusto.



My beloved niece April was married this past weekend in Marquette, MI. I scored one big-time on this photo.


Now-husband Jeff Nyquist is Dr. Jeff Nyquist, Vanderbilt PhD in neuropsychology, CEO of Upper Peninsula Home Health, Hospice and Private Duty. I want to get to talk shop with him at some point regarding long-term care HIT.

Power couple.

Any excuse to go to Marquette and see my sister and the kids. Jeff calls me "Uncle Bobby." I love that.

Downtown Marquette, shot from the reception restaurant balcony looking back up the hill.

What a cool little town.

My new grandnephew Anthony (8 wks old) agrees (Great Aunt Cheryl was holding him out on the balcony when I shot that).



At the 6th Annual Fall Conference you will see the very latest technologies in Health 2.0, and we’ll maintain our tradition of hosting leading thinkers and fascinating conversation. This fall, new technologies will be presented in contextual environments woven around a developing narrative which illustrates the transformation occurring in the space. Change doesn’t come easily and a true, universal transformation requires the analysis, connection and redefinition of categories across all parts of the system. We’ll dive deeper into these issues with topics like big data analysis, personalized medicine, price transparency and keynotes from Health Futurist Joe Flower and Aetna CEO Mark Bertolini. Over two days we will progressively illuminate on stage, through mini-environments and discussion, that Health 2.0 is everywhere – it touches how we live, how we eat, how we interact with providers, patients and more. There’ll be lots of media coverage, hundreds of potential customers, and scores of potential partners to meet. If you want to get involved in health care innovation, you need to be at Health 2.0!
I booked my flights today. Awesome agenda. Starting with
Health Law 2.0
Health 2.0 has created a pre-conference session entitled Health Law 2.0 that addresses the pressing legal issues for both large and small Health 2.0 companies.   We have identified several key legal issues that face companies in the regulated world of health care and created two tracks of programming — one focused on Patient/Consumer Legal Issues and the other focused on Legal Issues with Providers, Plans and Life Sciences.

The panels we have assembled include the leading experts in each topic who will provide an overview and important updates.  The panel also will work through some interactive examples of problematic arrangements and provide insight on how to avoid legal risk.  In every session, there will be ample time for questions.

The tracks will run concurrently and you may attend sessions in either track.  This is a wonderful opportunity for all Health 2.0 companies to delve deeper into the legal issues so they can make better choices as well as identify potential opportunities and capitalize on them.  It’s also very useful to hear what different experts think about a particular issue so you can make informed decisions.

We look forward to seeing you at the Health Law 2.0 pre-conference!
You can bet I will be there. Then, Monday Morning:
Leading Health Futurist, Joe Flower, will discuss the practical solutions that health care organizations need to implement to deliver health care at half the cost. Joe is a regular columnist who contributes to Hospitals and Health Networks, has spoken at thousands of health care meetings and is the author of a new book Healthcare Beyond Reform: Doing it RIght for Half the Cost.

Aetna CEO, Mark Bertolini will discuss the how his company is leading the pack in a transformation from insurance company to health tech services company, while bringing along its partners -- both providers and technology companies -- and its customers -- employees & consumers. Last year they introduced the iNexx platform and in 2012 they are debuting the CarePass consumer platform, and on our stage will announce the results of the Aetna CarePass Platform and Medication Reminder Developer Challenge.

I've written of Joe's impressive work before:


Got it on Kindle last night. Looks like a safe bet for $9.99. I already know my "basics" and then some, but it never hurts to get another perspective. This is spot-on:
I believe that the range of approaches that many organizations are using creates a strong need for process improvement professionals to be “tool agnostic” and fluent in several improvement dialects. This would position these improvement practitioners to serve as trusted advisors or coaches to business leaders rather than true believers that specialize in the one best way they know to improve work.
-  Page 34, Kindle Edition.
UPDATE: While nominally "method agnostic," a quick first scan reveals this book to be fairly "Lean" favorable. A good thing, in my view. I like in particular the specific attention paid at the end to "knowledge work" (i.e., like, uh, HIT software development and management, ja?).

A handful of my conceptual visual mapping "workflow" overviews:

Click to enlarge.


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...

I know these people must be tired of me calling them out (and, note that I have not personally outed them). But, I'm still on the lookout for that "strong voice."

I have no Beltway Gucci Gulch experience, but, the lobbying strategy -- uh, "trade association strategy" -- escapes me. Nonetheless, I suppose should there be no federal dollars tied up in this "effort" (via the RECs), it's none of "my business."

WASHINGTON (HealthcareIT News) – There are no set appropriations for how much the federal government can spend on rewarding providers who adopt and use electronic health records under the Medicare and Medicaid meaningful use EHR incentive program, according to National Coordinator for Health IT Farzad Mostashari, MD.

"Whoever qualifies, gets paid; there's no hard cap," said Mostashari, who gave a keynote at the Annual Policy Summit for the Health Information Management and Systems Society (HIMSS) on Wednesday.

Mostashari said the federal government estimates it will pay out around $20 billion in incentives before the program shifts to a penalty in 2015, but there is no fixed budget set in the HITECH Act that mandated the program. The government recently announced it has paid out nearly $7 billion since the program began in 2011...
There is, however, a hard cap on REC funding, which will be gone this time next year. And time is rather quickly running out to do anything substantive about that.

More shortly. NIST 2014 CEHRT Testing Stds, 2nd wave release, more HIPAA breach follies and fines, more on "usability," AAFP on PCMHs and APNs, DURSA, #VDTnow...


Maybe I'll just start a new post. Some of the topics will just continue, as always.

Kansas HIE to hand over authority to the state
September 20, 2012, Anthony Brino, Contributing Editor, Healthcare IT News

TOPKEKA, KS – The Kansas Health Information Exchange will dissolve itself and hand over operations to the state’s health department after a long stakeholder debate about the costs of the public-private HIE, and its regulatory role, in a state with a growing provider-based HIE network.

The Kansas Health Information Exchange (KHIE) board voted last week to transfer its operations to the Kansas Department of Health and Environment by October 2013, when federal grant funding is set to expire. The plan still needs to be approved by the state legislature.

Cost was apparently the largest factor behind the decision. Staffing KHIE as an independent body was estimated to cost $400,000 a year, and the board was considering charging fees from providers or HIEs. Shifting KHIE’s regulatory operations to the state would cost about $54,000, state officials have estimated...

Created in 2010, KHIE evolved from an HIE commission created by then-governor and current U.S. Health and Human Services secretary Kathleen Sebelius. Initially intended to be an HIE, it eventually sought to be more of a regulator, as health systems started building their own infrastructure and connecting to the Kansas Health Information Network, a statewide HIE built with private funding by the Kansas Hospital Association and the Kansas Medical Society.

KHIE’s public-private nature has at times been controversial, and the effort to scale back what some might consider a bureaucracy comes as Republican Governor Sam Brownback’s administration is trying to scale back the role of government in other areas, like transitioning almost all of the state’s Medicaid recpients into managed care organizations.

It’s not entirely clear what will happen to the remainder of the roughly $9 million KHIE received from the Office of the National Coordinator.

“We would like to have some of the stimulus funds," Laura McCrary, executive director of the Kansas Health Information Network, told Government Health IT in August.

"There’s about $5 million left, and we’re hopeful we’ll get a portion of that," McCrary said. "It’d be great to have a bridge fund" for exchange infrastructure in the works.
Hmmm... a BobbyG Photoshop Moment inexorably ensues...

I have to wonder whether the HIT politics in Kansas are as fraught as they are in my state, Nevada. Our situation differs materially, in a way (perhaps it's sort of the inverse). HealtHIE Nevada is not the ONC HIE Grantee. Nevada DHHS is (though we are the ones with "boots on the ground" at this writing).
The Office of Health Information Technology is responsible for administering Nevada’s ARRA HITECH State Health Information Exchange (HIE) Cooperative Agreement, facilitating the core infrastructure and capacity that will enable statewide HIE and coordinating related Health IT initiatives...
As the initial phase of implementation to the State  Health IT Plan, NV DIRECT will soon be deployed.  NV DIRECT will allow participants to send authenticated, encrypted patient health information directly to known, trusted recipients.  This electronic capability will enable providers to share relevant and authorized patient medical information directly and securely with each other.
This latter thing (NV DIRECT) goes to stuff like the DURSA (Data Use and Reciprocal Support Agreement), which I am now tasked with assessing, with respect to resources likely to be necessary for compliance.

You don't just sign a DURSA pro forma.

One last thought before firing up a new one. OK, my Coda can be longer than most peoples' blog posts, I know. Dr. Rob Lambert wrote an interesting post the other day, "Care on the Continuum," wherein he discussed more on his decision to go "Direct Care" (i.e., Direct Patient Pay).
My change from a traditional practice to direct-care has caused me to challenge some of the basic assumptions of the care I’ve given up to this point.  Certainly, the nature of my documentation will radically change with my freedom from the tyranny of E/M coding requirements.

Perhaps the biggest change in my care comes courtesy of the way I get paid.  The traditional way to be paid is for service rendered (either at an office visit or procedures done).  This means that I am financially motivated to give the bulk of my attention to people when they are in the office.  They are paying for my attention, so I try to give them their money’s worth.  The corollary of this is that I tend to not think about people who are not in the office to be seen.  The end-result is an episodic approach to care that is entirely dependent on the patient paying for an encounter.

There is a huge problem with this approach to care: people live their lives between encounters.  Life does not go on hold between office visits for my patients, and the impact of my care is not dependent on what happens in the encounter, but what happens between visits.  My ability to help my patients depends on my ability to affect the continuum.  If I do a good enough sales pitch for a person taking their medications, and if I consider the life-circumstance which may affect their ability to take the medicine, then I am successful.  I don’t learn about the success until their next visit (usually), and I also don’t learn about problems until then.  People are reluctant to call with problems they are having with medications, new symptoms, or other important details, often waiting for many months to tell me things I really want to know.  Perhaps they don’t want to be “one of those patients who calls all the time,” perhaps they don’t understand what I said, or maybe they’re worried I will “force them to come in” to pay for another office visit.  Regardless of the reason, I get very limited interaction with my patients in this episodic care model...

...I keep getting new ideas of how to handle problems differently in this new model of care, but all of them benefit from the fact that it looks at patients before problems pop up, or at least at the time of the problem instead of after a potentially dangerous delay.  The waste in our system is, as has been noted often, huge.  But the assumption that episodic care is the proper model could be the most costly mistake of all.  People are afraid to engage our system because of the cost, and that fear ends up costing everyone by not dealing problems until they are “bad enough.”  Care on the continuum seems to accomplish the main goal of my care: keeping people away from the rest of the health care system unless it’s absolutely necessary.
 I posted a comment.
Very thought-provoking post. Thank you.

This is perhaps a weak analogy, but, nonetheless:

I used to work in Risk Management in a subprime credit card bank. I was the principal “portfolio management” officer/analyst. It was a big part of my job to monitor ongoing the shaky financial “health” of our financially halt and lame cardholders (we used to joke that it was like giving whiskey to alcoholics, granting credit lines to subbies). We had effective data mining pxs and predictive models for everything. Once we booked these people, he had to try to keep them profitably “healthy.”

I was a SAS and S-Plus and all-around RDBMS whiz.

I had access to tons of customer activity data every day. I could track your every transactional “move.”

The principal concerns were, of course, our “patients” “dying” on us (charging off and stiffing us), as well as the relentless outright fraud stuff (i have some funny stories).

We made successively record profits every year of the five that I was there. Data-driven, baby.


Before you go cracking on me, I quit in 2005 to go back into HIT work, at a 23% salary reduction. Today, I could make 3x my current salary (which is not quite what I earned at the bank back then when I left) were I to go back into “distressed consumer debt modeling and management.” The comp package numbers give me pause, but, I will not. Ever again. It’s just too jive. I have to sleep. And look in the mirror.

I will stay in the HIT space until I retire.

I have utter respect for clinicians. I work with them every day. I don’t see how y’all do it.
And then another, later in the discussion, in response to a prior comment:
“In the aforementioned DPC paper, the evidence suggests a significant decrease in ED visits, surgeries, hospitalizations and specialist visits. That may be good for the patient and whoever is picking up healthcare costs but obviously one person’s cost savings is another’s revenue. It’s clear why some orgs won’t embrace DPC if they see it harming their bottomline.”
This has long been the reform conundrum.

“Every misspent dollar in the health care system is part of someone’s paycheck.”

- Brent James, MD, M.Stat, IHC, 1995, during our CQI training sessions in SLC

Brent also noted (paraphrasing here) “Let’s not kid ourselves that we’re gonna QI our way out of the larger problem. Giving the best possible care today only ensures that you’re gonna have an older and sicker and more expensive patient down the line.”

See also “Allocating Health Care Morally,” 1994

It continues to be a socioeconomic and moral perplex.