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Tuesday, October 30, 2012

In the Federal Register Oct 31st: yet another healthcare workflow study proposal

A mere $800k ("$799,929" to be "exact"; props to EHR Intelligence).

Billing Code 4160-90-M

Agency for Healthcare Research and Quality

SUMMARY: This notice announces the intention of the Agency for Healthcare Research and Quality (AHRQ) to request that the Office of Management and Budget (OMB) approve the proposed information collection project: "Using Health Information Technology in Practice Redesign: Impact of Health Information Technology on Workflow." In accordance with the Paperwork Reduction Act, 44 U.S.C. 3501-3521, AHRQ invites the public to comment on this proposed information collection.

The Agency for Healthcare Research and Quality (AHRQ) is a lead Federal agency in developing and disseminating evidence and evidence-based tools on how health information technology (IT) can improve health care quality, safety, efficiency, and effectiveness.

Health IT has the potential to improve the quality, safety, efficiency, and effectiveness of care. In particular, health IT can aid health care professionals in improving care delivery by redesigning care processes to be more effective and efficient (e.g., engaging care settings in practice redesign). The use of health IT to support practice redesign requires a deep understanding of the interaction between health IT and workflow, ideally through a human factors and socio-technical framework.
Unfortunately, these health IT-workflow interactions are poorly understood and the research to date has largely focused on large academic medical centers and large health maintenance organizations, while the impact of health IT on workflow in smaller, ambulatory care practices is not well studied.

To that end, AHRQ conducted an in-depth study of existing research and evidence in the area of the impact of health IT on workflow, its linkage to clinician adoption, and its links to the safety, quality, efficiency, and effectiveness of care delivery. However, most of the articles found were not focused directly on workflow, so the quality of evidence related to workflow change varied substantially. The majority of studies described research completed in large clinics affiliated with academic medical centers, health maintenance organizations or national health systems outside the U.S., limiting applicability to other settings, particularly small and medium-sized primary care and other ambulatory care settings. Also, most of the studies did not use a scientifically rigorous design. Finally, most of the literature did not include descriptions of the socio-technical context of health IT implementations and use, making it difficult to understand the role of potentially conflating or mediating factors such as training, technical support, and organizational culture.

These gaps and limitations of existing research study designs and findings related to health IT and workflow limit the relevance and quality of the available evidence for health care organizations wishing to effectively implement health IT systems to support current work without negatively affecting existing workflow processes. The existing evidence is of equally limited utility to those organizations seeking to use health IT systems to support redesign of their ambulatory care settings.

The goal of the project is to understand the impact of implementing health IT-enabled care coordination on workflow within small community-based primary care clinics in various stages of practice redesign. The focus of this study is the interaction of health IT and care coordination workflow in the context of practice redesign. This study will focus on clinic staff caring for patients with diabetes within small primary care clinics to understand enablers and barriers to care coordination workflow through the use of health IT.

The study will be conducted over a 14-month period in six Vanderbilt University Medical Center (VUMC) affiliated-clinics that each have an electronic health record (EHR) but are in different phases of introducing the health IT component of a care coordination redesign program called My Health Team (MHT). MHT was launched at Vanderbilt University Medical Center to redesign ambulatory care delivery for patients with three chronic conditions (diabetes, hypertension, and congestive heart failure) through intensified patient engagement, dedicated care coordinators, and specific health IT tools to facilitate scalable chronic disease management. The health IT component of MHT, layered on a mature EHR, enables (1) diabetes, hypertension and congestive heart failure registries, (2) a shared view of the care plan for the patient among clinical staff, (3) alerts and reminders to track patients' acute care episodes, (4) closed-loop feedback of patient self-management through at-home physiological monitoring and two-way electronic clinical messaging (via the patient portal), and (5) frequent patient contact with coordinators in between physician visits by telephone and using a secure patient portal.

This study is intended to address existing gaps and generate findings of particular relevance to health IT and workflow by employing a mixed-methods, theoretically-grounded research design that focuses on the socio-technical factors in smaller, ambulatory care settings.
Combining this formal approach with iterative observations and analysis across six clinics for 14 months will generate a detailed understanding of changes in health IT workflow interaction for each clinic over time, and across clinics in various implementation phases (pre-MHT, early-MHT, or mature-MHT). Each clinic will be observed at two time points: the first (time = 0 months) to capture baseline interactions, and the second (time = 12 months) to capture interactions later in adoption. Although each clinic will be observed over a period of 12 months, the total study period will span 14 months to allow for staggered observation windows for the clinics. All clinics are anticipated to exhibit changes to health IT-workflow interactions over time given that learning and efforts to streamline workflow at each practice are ongoing. The early-MHT clinics, engaged actively in practice redesign, will be observed at a third time point — midway between the first and second observation period — since more changes, and possibly more rapid changes in workflow and the use of health IT could occur. The 6-month interval between observation periods was chosen based on prior experience with MHT implementation in which many adoption changes occur during a 3-5 month period during practice redesign. Thus, in clinics anticipated to experience slower change, an observation period of one year is anticipated to allow capture of workflow patterns that have occurred; in fast-changing clinics, a 6-month observation interval will improve capture of key interactions.

This study is being conducted by AHRQ through its contractor, RTI International, pursuant to AHRQ's statutory authority to conduct and support research on health care and on systems for the delivery of such care, including activities with respect to the quality, effectiveness, efficiency, appropriateness and value of health care services and with respect to quality measurement and improvement. 42 U.S.C. 299a(a)(1) and (2)...
What's not to love? (in particular the all-important "Billing Code")
Method of Collection
To achieve the goals of this project the following activities will be carried out:

1) Project orientation meeting—Researchers will hold an orientation meeting for clinic staff to introduce them to the study. Up to ten staff members at each clinic will be asked to participate in the orientation meetings. During the orientation meeting, research staff will explain the purpose of the study, provide an overview of the study schedule, explain processes for recruiting individual clinic staff to participate, and answer any questions that clinic staff might have.
2) Direct observation by researchers of clinic staff performing care coordination activities with patients, caregivers, and providers to capture their workflow, health IT usage, and work processes. A total of 14 observation periods will take place across the six clinics. Each site will have an initial observation period that occurs over several weeks, with an estimated 60 hours of observation time per site. The two sites in the early MHT phase of implementation will also have a middle observation period (at 6 months), and all six sites will have a final observation period (at 12 months). The middle and final observation periods, which build on data gathered during the initial observation period, are shorter—approximately 30 hours of observation per site, because observations will be more targeted as a result of the previously collected contextual data.
Observations will be recorded on the Direct Observation Field Notes Form. This data collection will not burden the clinic staff and is not included in the burden estimates in Exhibit 1.
3) Artifact and spatial data collection—Artifacts such as paper notes or forms, or reminder postcards identified by researchers during direct observations as relevant to understanding workflow and health IT, will be collected.
Spatial data, such as still photographs of the workplace and/or objects in the workplace, will be collected to augment observation data. These will enable the researcher to capture spatial relationships and other dimensions, such as the proximity of work stations, exam rooms, and technology. For example, a health IT tool may include the functionality to print information to give to the patient, but if the printer is not conveniently located for the user, busy clinic staff may choose not to use this function. An image or drawing of this spatial relationship can be included in the data and will be coded in the data analysis phase. The choice of using a photograph or a drawing will be dependent upon the type of information that is needed to better understand the context of the workflow. For example, to capture the overall configuration of the workspace, photographs will be taken. When other information such as process flows are being captured, the observer will draw a sketch of that process. This may include the steps that a nurse takes to retrieve a patient chart, call the patient from the waiting room, escort the patient to a station where vital signs are measured, and escort them to an exam room.
Artifacts and spatial data will be used to enrich the understanding of the environment in which care coordination activities and health IT interact and will add information that is important for modeling workflow. This data collection will not burden the clinic staff and is not included in the burden estimates in Exhibit 1.
4) Semi-structured individual interviews and surveys with clinic staff to further understand their use of health information technology and work routines. During each observation period, up to six staff members at each clinic will be
asked to participate in semi-structured interviews and to complete the Technology Assessment Model (TAM) survey. The interview will address up to five key topic areas: demographics; general experience with technology; work routines; interactions with computers in the work context; and strategies for dealing with unanticipated health IT or workflow challenges. The survey will be used to consistently assess the staff attitudes that may impact their experience of using health IT and adapting workflow to their needs.
5) Semi-structured interviews and surveys with patients with diabetes to gather information from patients as participant-observers of clinical workflow and health IT, to understand the impact of work processes on their experience of care, and to identify enablers and barriers in clinic work processes from their perspective. During the initial observation period in each clinic, and during the final observation period in two of the clinics (early-MHT), eight patients with diabetes will be invited to participate in semi-structured interviews and to complete the Patient Activation Measure and Summary of Diabetes Self-Care Activities surveys (64 patients total). Since fewer changes are anticipated in the pre-MHT and mature-MHT clinics, patients will be interviewed at baseline only in these four clinics. Since the pre-MHT and mature-MHT clinics will not undergo changes in technology during the study period, it is anticipated that saturation of patient experiences and observations of workflow, technology use and interactions will occur during the initial observation period. Greater changes are anticipated at the early-MHT clinics as they adopt MHT, therefore, patient interviews will be conducted at these two clinics twice. The purpose of the patient interviews is to gather information from patients as participant- observers of clinical workflow and health IT, to understand the impact on their experience of care, and to identify enablers and barriers in work processes from their perspective. The interviews will address six key areas related to care coordination, including (1) general care experience; (2) patient workflow; (3) information needs; (4) barriers; (5) strategies; (6) evaluation. The Patient Activation Measure (PAM) and Summary of Diabetes Self-Care Activities (SDSCA) surveys will be used to understand patient motivation for self-care and the potential impact on care processes and workflows.
The focus of this research is anticipated to be relevant to many other settings in which health IT is used to support care coordination activities for diabetes and other chronic conditions. This focus is especially important given the cost and illness burden of diabetes. Information collected by the study will help researchers and practitioners better understand the impact of workflow and health IT in ambulatory care practices.
The lessons learned from this research may be used in a variety of ways: 1) to identify additional workflow components that ambulatory practices should consider when implementing health IT systems; 2) to identify issues to address in best practice guidelines health IT implementation; and 3) to identify issues for consideration in the design and evaluation of other health IT tools.
The study findings will be widely disseminated to health IT researchers and implementers via AHRQ's National Resource Center for Health IT Website, e-mail alerts, and conference presentations.
See any crippling methodology "generalizability" problems here? Need I enumerate?


I reported on our self-described "Lead Federal Agency" back in March: "Yet another federal public comment period announcement." See also specifically "ObamaScare Section 5405," subsection "More HH$ News." (scroll down).


No one can accuse me of being oblivious to or dismissive of the need for continual evaluation/re-evaluation of any and all processes. If health care delivery processes are not systematically improved, health care outcomes improvement will be spotty and random.

I am troubled, though, by what looks to be the prospect of federally funded, marginally scientific (to be charitable) "Plan-Study-Study-Study-Study-Study-Study-Study..."

More shortly. I just got home.

OCT 31st a.m. UPDATE

Lots of wonderfully rendered stuff. Caveat emptor on the scientific substance, though.
Reflecting on Our IT Progress
Oct 31, 2012, John D. Halamka MD, Life as a CIO Blog, re-posted

In a time of EHR naysayers, mean-spirited election year politics, and press misinterpretation (ONC and CMS do not intend to relax patient engagement provisions), it's important that we all send a unified message about our progress on the national priorities we've developed by consensus.

1.   Query-based exchange - every country in the world that I've advised (Japan, China, New Zealand, Scotland/UK, Norway, Sweden, Canada,  and Singapore)  has started with push-based exchange,replacing paper and fax machines with standards-based technology and policy.   Once "push" is done and builds confidence with stakeholders, "pull" or query-response exchange is the obvious next step.  Although there are gaps to be filled, we can and should make progress on this next phase of exchange.   The naysayers need to realize that there is a process for advancing interoperability and we'll all working as fast as we can.   Query-based exchange will be built on top of the foundation created by Meaningful Use Stage 1 and 2.

2.  Billing - although several reports have linked EHRs to billing fraud/abuse and the recent OIG survey seeks to explore the connection between EHR implementation and increased reimbursement, the real issue is that EHRs, when implemented properly, can enhance clinical documentation.  The work of the next two years as we prepare for ICD-10 is to embrace emerging natural language processing technologies and structured data entry to create highly reproducible/auditable clinical documentation that supports the billing process.  Meaningful Use Stage 1 and 2 have added content and vocabulary standards that will ensure future documentation is much more codified.

3.  Safety - some have argued that electronic health records introduce new errors and safety concerns.  Although it is true that bad software implemented badly can cause harm, the vast majority of certified EHR technology enhances workflow and reduces error.  Meaningful Use Stage 1 and 2 enhance medication accuracy and create a foundation for improved decision support.  The HealtheDecisions initiative will bring us guidelines/protocols that add substantial safety to today's EHRs.

4.  Privacy and Security - some have argued that EHRs reduce security by making records available in electronic form, possibly over internet connections.   Efforts to enhance certification of the security of EHRs, encrypt data at rest, and create guidance for EHR modules that interoperate with built in security will further protect the data that needs to be shared for care coordination and population health.

5. Innovation - some have argued that meaningful use led to the growth of a small number of vendors and dependency/lock in with those vendors.    Meaningful Use Stage 2 requires interoperability between vendors, export of data from EHRs to reduce lock in, and standards that will enable a new generation of modular "plug ins".   I'm confident that SHARP grant funded work, like the SMART initiative will lead to an ecosystem of applications from small vendors - an app store for health.

Thus, our mantra should be that Meaningful Use Stage 1 and 2 have created a foundation for query-based exchange, accurate billing, safety, security, and innovation.

Stage 3 work is already in progress and from the early thinking that I've seen (will post a blog about that in a few weeks), the trajectory of Meaningful Use will address all the naysayers concerns.
Life as a CIO Blog (John D. Halamka MD) / CC BY-NC-SA 3.0
Lots of issues. Much work to be done.

But, as JD Kleinke observes on THCB in a comment:
The operating realities of Obamacare beneath the mile-thick river of ideological spew against it are all sheer paradox: Obamacare, precisely like Romneycare, is based on previously conservative, market-based ideas about people taking responsibility for carrying private insurance – belatedly standardized to bring transparency and price competition to bear on the process – and about people getting access to it through markets corrected for distortions like medical discrimination and unaffordability by the working poor...

...If people would stop hyperventilating for a moment, they’d realize that Obamacare is nothing more or less than a violent endorsement and expansion than the status quo. How else to explain the deafening quiet from the insurers, drug companies, AMA, AHA? The only reason the Rs hate it is because it contains, thanks to their two-year sneer campaign since its passage, “Obama” in the name. The law could contain free care for all (which it certainly does not) and a cure for all cancers (nor the mandate that IPAB work to preclude finding one) and none of that would matter. The law has been turned into a political football for two sides of the American polity that seem to want to agree and cooperate on exactly nothing these days. Here in DC, scoring points rather than solving problems is the ONLY goal – and for that, we ALL suffer.

3.1 Security Components
In order to provide the security capabilities needed to enable the scenarios described in Section 2, every mobile device requires a set of security components—foundational security elements that can be leveraged by the device, OS, and applications. This section provides a concise overview of the three required security components: Roots of Trust (RoTs), an application programming interface (API) to expose the RoTs to the platform, and a Policy Enforcement Engine (PEnE). Section 4 of this document describes how these primitives will be leveraged by three new security capabilities: device integrity, isolation, and protected storage.
3.1.1 Roots of Trust (RoTs)
Roots of Trust (RoTs) are the foundation of assurance of the trustworthiness of a mobile device. As such, RoTs are security primitives composed of hardware, firmware and/or software that provide a set of trusted, security-critical functions. They must always behave in an expected manner because their misbehavior cannot be detected.
Well, okee-dokee. Hmmm... Emphasis mine.

More to come...

Sunday, October 28, 2012

Fred Trotter at Strata Rx 2012

I met Fred at Health 2.0 (I've previously reviewed his excellent book. now re-titled "Hacking Healthcare" in my July 18th post). This conference took place the week after Health 2.0 2012 SF.

Data MAKE a difference. You guys are publishers?

Cool, Fred. I had hair once too, son.

BobbyG 1976, Tuscaloosa AL,
the Zappa Years.
36 years ago.


Epatients: The hackers of the healthcare world
A quick reference for becoming an empowered patient.

I help build open source software tools that patients can use to have greater control and influence over their own healthcare (like the Direct Project and Your Doctors Advice). As as result, I’ve become quite familiar with other tools that do the same sorts of things. There is a community of patients who are deeply interested in the ways in which they can become more engaged and how they can specifically use technology to achieve this. This community calls themselves epatients. The epatient community asked me to write a short collection of resources for “becoming an epatient.”

The “e” in epatient is intentionally obscure. The initial assumption is that the “e” stands for “electronic,” as it does in “email.” But in fact, the “e” stands for “engaged” or “empowered.” Nonetheless, reference to email is intentional: The epatient community recognizes that leveraging data is a critical part of empowering a person who happens to be sick. Patients must be “electronic” to become fully “engaged.” I think of epatients as the healthcare equivalent of makers and hackers. More importantly, they are the people I have in mind when I write software...

Apropos of the foregoing:

Report of the Lucian Leape Institute Roundtable On Care Integration

A host of barriers make care integration difficult to achieve in the U.S. health care system. Alone, any one of them poses a formidable challenge; together they form a seemingly impenetrable obstacle to achieving the integration goal. While we acknowledge the difficulties they create, there are specific actions that can overcome them. In this section we discuss the most significant barriers that stand in the way of care integration. In the next, we discuss actions that could accelerate progress on the integration agenda in the face of these barriers.

Physician Autonomy

Deeply ingrained in the profession of medicine is the teaching that a physician has an individual and personal responsibility for his or her patient; this includes providing the best possible treatment and ensuring that he “does no harm” to his patient. This personal responsibility is core to a physician’s training and for most defines what it means to be a physician professional. It is also a foundational principle in the code of professional ethics for the medical profession, drives legal accountability in licensure and tort actions, and is reflected in the fee-for-service payment model for doctors (and other health professionals).
This model of the autonomous physician deciding for the passive patient informs the image of the physician that appears in popular culture (e.g., television series such as “ER” and “House”). Patients’ dependence on their physicians has been reinforced by the information asymmetry that has existed (and been protected) between the two parties. This construct was appropriate 50 years ago when most care involved a single physician supported by a handful of modestly trained professionals. Then it was important for the safety of the patient that the doctor be the “captain of the ship”; he or she was the best-trained person to do this.

But medical science and technology have advanced far beyond those days. The disease burden in our society has changed as well. Rarely now is a patient cared for by a single physician acting from his office with a small office staff.  The majority of care provided in the United States today is for chronic illness (Vogeli et al. 2007), and the proportion is likely to grow as the population ages and as acute care continues to improve. The average patient with a single chronic illness will be cared for by six to nine physicians, at multiple sites, over a prolonged period of time (Vogeli et al. 2007). Moreover, patients and their families are increasingly better informed and able to take a central role in decision making, effectively becoming “coproducers” of their own care. Especially in chronic illness care, they are their own primary caregivers, managing their medications, lifestyle changes, diets, exercise and physical therapy, as they live with their illnesses 24 hours a day, seven days a week, year round...

Lack of Expertise

The contrast between health care and other industrial sectors is striking in the paucity of production design experts involved with the people actually doing the work on a day-to-day basis. Unlike companies such as General Electric, Agilent, or Hewlett- Packard, for example, most health care systems employ few, if any, industrial design engineers. Nor do they provide extensive training or preparation in the use of the tools of production and operational design and management. One exception is the Virginia Mason Medical Center, which has committed significant resources to developing the expertise required to transform its entire management system: over the last eight years, large numbers of the Virginia Mason staff—including doctors, nurses, other clinicians and support staff, and management—have traveled to Japan to participate in a training program at the Toyota Institute and visit plants using lean meth- odologies. ThedaCare, Denver Health, and Intermountain Healthcare have prepared experts in their own domestic programs and have achieved similar improvements.

Without this expertise it is difficult to see how an industry as complex as health care delivery can hope to achieve greater care integration. A huge deficit exists both in the expertise required to undertake the initial design and transformation, and in the expertise required to measure, analyze, and learn as systems are changed. Both are required to continually improve the processes based on actual experience.

Excellent paper (pdf). I've covered these issues (and progressive leadership individuals and organizations) before multiple times. IHC, ThedaCare and Lean, the Weeds' "Medicine in Denial," etc.


The Kiss of Death for Meaningful Use Efforts

The kiss of death to an electronic health records meaningful use effort is boiling down the criteria to a checklist of to-do items for physicians. That’s the word from Jeff Loughlin, project manager at the Massachusetts eHealth Collaborative and executive director of the Regional Extension Center of New Hampshire.

“Physicians hate lists and once you think of meaningful use as a list, you are doomed to failure,” Loughlin said at the MGMA Conference in San Antonio. The program does provide qualification criteria in list format, he acknowledged, but the way to streamline adoption of meaningful use is to describe the criteria not as discrete tasks, but rather as steps that are part of any practice’s given workflow...


Would Romney kill meaningful use?
October 29, 2012 | Erin McCann, Contributing Editor

Presidential candidate Mitt Romney is no stranger to health information technology advocacy. As governor of Massachusetts, he helped spur initiatives such as the $50 million nonprofit Massachusetts eHealth Collaborative, for instance, and he signed a 2003 bill meant to enable Bay State providers to more widely adopt e-prescribing.

But some experts say Romney’s Republican platform, promoting limited federal government and increased fiscal autonomy to the states could very well put federally funded health IT initiatives at risk.

Ed Daniels, consultant for health IT firm Point-of-Care Partners, wrote that, when it comes to health IT, “Romney is likely to be more of a cheerleader than a funder.”

He surmised that if Romney were elected, eventually, “Government incentive payments for EHR adoption likely will be dropped from future budgets.”...
...Deven McGraw, director of the Health Privacy Project at the bipartisan Center for Democracy and Technology, however, argues that it could go either way if Romney were elected.

“Some folks were worried that, with the economic downturn and the need to address the deficit, that the dollars authorized by Congress for electronic health records might have a target on their back because they have an extended payout,” McGraw told Healthcare IT News. “There is money that’s promised but not yet spent, which makes it a very attractive target for a cut because nobody has those dollars yet."

As of September, $7.7 billion of that meaningful use money has been paid out to providers. As National Coordinator for Health IT Farzad Mostashari, MD, told the audience at a September HIMSS event: “Whoever qualifies, gets paid; there's no hard cap."

Government officials have pegged high estimates of EHR incentive payments at possibly exceeding $27 billion, leaving a potential $19.3 billion sitting and waiting for the providers’ race to attest.

McGraw remains hopeful the money won’t be taken back if Romney is elected – for two reasons. The first is that the benefits of EHRs are generally widely accepted by Republicans and Democrats alike. The second is that providers have already paid big money to update and implement their EHR systems.

“A whole lot of healthcare providers across the country have already made investments in anticipation that they will be reimbursed by the federal government,” she said. “It would be hard to take it back.”...
Assuming the election is not delayed owing to Hurricane Sandy, our expectations will clarify just a bit in a week.

More to come...

Hurricane Sandy

I wonder how many people are going to lose their medical records across the next few days?

But, at this point, for the many millions in harm's way (like my son and his fiance, my brother in law and his family, and my aunt and cousin), it may not be in the forefront of their concerns.


This will not be good.

Wednesday, October 24, 2012

REC Blog post number 1100111

In binary, that is.

Or, "CIII" in Roman (interesting that there's no provision for "zero" per se in the Roman enumeration system).

Post no. 103.

Number bases are arbitrary. If we had three fingers on each hand, we'd have a base 6 numbering system, in which case this would be post number "251."

Hope everyone is having a good day. Lots more upon which to reflect write.

I spent several hours logged into the live Intel "Online Innovation Summit 2012" yesterday.

Pretty nice (these will all be available in podcast format).

The Race to Reinventing Health—National Challenges to Innovation
October 23, 9:00 a.m. to 10:30 a.m. PDT

Join global thought leaders on healthcare innovation as they discuss challenges and strategies to address market forces shaping healthcare delivery in the 21st century, including a rapidly aging population, unsustainable healthcare costs, and a shortage of primary care workforce.

Big Data and Analytics in Healthcare and Life Sciences
October 23, 10:30 a.m. to 12:00 p.m. PDT

With the explosive growth of data output in healthcare, new challenges arise: downstream analytics with rapidly evolving parameters, data sources, and formats; storage, movement, and management of massive datasets and workloads; and the challenge of expressing the results and translating the latest findings directly into improving patient outcomes.

Collaborative Care: How Mobile Tools Help You Thrive in Healthcare Reform
October 23, 12:00 p.m. to 1:30 p.m. PDT

One dramatic way to transform care delivery and control costs is to look at the systemic effect of collaborative-care workflows on the system, which can dramatically lower admission and readmission, and allow patients to be treated in a variety of settings other than the hospital. How must IT systems adjust to allow for this real-time collaboration?
This tiresome Pedant heard the phrase "the data is" so many times my synapses ached.

Then I downloaded the latest ONC data on Meaningful Use attestations by EP/hospital and Vendor/Product. While sorting the data in Excel prior to running some pivot tables, I noticed something I'd never paid attention to before.

"My data has headers"
Lordy. "Resistance are futile..."


This is pretty cool.

Just a screen cap. The entire image is quite long. Linked here.


Still searching for the succinct, pithy "workflow" allusion.

Tried to find a good overhead / "birds' eye" photo of an interstate highway traffic jam. But, you get the idea. This is my Primary's office at 8:03 a.m., lol.


There is a new television show on Fox this fall called "The Mob Doctor." Its heroine, Dr. Grace Devlin, is a surgeon who, in order to help settle her brother's gambling debt, agrees to serve as a one-woman HMO for Chicago's underworld. This would include everything from tending to the wounds of the nearly-whacked to treating the strep throats of gangsters' children.

While this professional track would have its unique occupational hazards, one appealing advantage makes up for the downsides: You can bet that no one is making Dr. Devlin use an electronic medical-record system...
The full article is firewalled at The Wall Street Journal, but, you can read the comments. A quick sample:
The lifetime goal of every bureaucrat is to create the "perfect form." That is, a form that anticipates and covers every possible question or scenario. Never mind whether the form has any practical use. The job of every other bureaucrat who follows is to make sure that perfect form is filled out correctly and completely.

Then, the "perfect form" has to be completely redesigned after ICD-10 comes out. How long and complicated can a form get? We haven't seen it yet. Simplification? What simplification?

Headline I have NOT yet seen in Healthcare IT News or "Paper Charts Hacked, 500,000 Patient Records compromised."

Just wait for the arrival of the new ICD codes! They went from about 12,000 to 20 times the number of codes to improve quality. (eg things like cut on finger becomes cut on right index finger on the palm side between the 2nd and 3dr knuckle ...)

Don't forget the difference between being bit by a parrot and bit by a macaw .

I personally like "burn while water skiing".

And don't forget the important "injury due to fall out of space craft" - I've been waiting for that specific code for 30 yrs.
Some funny pushback stuff. Grossly overstated on the number of pending ICD-10 codes, but, point taken.

Dan Diamond, California Healthline Contributing Editor

The world may not be ready for a Romney presidency.

Or more specifically: world leaders may not have done enough homework.
An interesting Washington Post story this week suggested that because the foreign polls have been so bullish on President Obama -- 82% of Germans in one survey expected Obama to be re-elected -- lawmakers around the world may be scrambling to adjust to a new team of U.S. diplomats and set of policies.

Is the health sector better prepared?

Given the close race -- as of press time on Wednesday, most polls had the presidential race neck and neck -- there's been growing scrutiny of Republican health proposals. For example, the Kaiser Family Foundation and the Urban Institute on Tuesday released another report on the GOP House Budget Committee's Medicaid plan.

But there's been much less examination of the people who would steer Romney's Department of Health and Human Services and the policies they'd carry out...
Click the byline. Read all of it. Buku timely links citing the breath of interests.

We'll perhaps -- perhaps -- have a bit of clarity in less than two weeks. I've already voted. Wish that would stop the ad nauseum TV commercials and the tree-killing crap wedged in my front screen door.


Indeed. Nice post. I was there at Health 2.0 SF as well (still trying to catch up with my observations). Took particular interest in the Health Law 2.0 pre-conference track.

Federal Register/Vol. 77, No. 203/Friday, October 19
Abstract: ONC seeks approval to collect key data from a relatively small sample of clinical laboratories nationwide for the Evaluation of the State Health Information Exchange Cooperative Agreement Program. The National Survey on Health Information Exchange in Clinical Laboratories will assess and evaluate the electronic transfer of health information from clinical laboratories to ordering physicians. It will focus on two key measures: (1) Percentage of laboratory facilities that are able to send structured lab results electronically to ordering physicians and (2) percentage of lab results that are currently being sent electronically in coded format to ordering physicians.
Sounds simple enough.

"1,489 burden hours. Estimated, annualized"

My question to the email contacts in the FR announcement: "Shouldn't this have been a responsibility of the state HIE Cooperative Grant Awardees? What are they doing with all that money?"

FierceEMR article here.

Patient I.T. Engagement in Stage 2 is Policy Gone Awry
By Robert DeFazio, OCT 24, 2012

During a presentation at the MGMA Conference, Travis Broome, a health insurance specialist at the Centers for Medicare and Medicaid Services, responded to the worries of practice administrators who insisted their patients are not interested in using patient portals necessary to meet Stage 2 meaningful use patient access measures. Broome said practices would have to push the use of portals.

I ask Mr. Broome, is this meaningful use or meaningful coercion? ...

...This is medical policy gone terribly awry. The HHS Secretary and her policy advisors should change the requirement such that it lays out what should constitute the minimum expected functionality of a patient portal without at the same time prescribing any specific percentage of users.

Demanding patients, whom neither HHS regulates nor physicians control, to use portals and simultaneously holding the threat of failing meaningful use tests over the heads of physicians for not succeeding as social networkers is not only bad policy; it is also amazingly unintelligent and high-handed.
Ouch. What do you think?


In the Mail section:
[Nicholas] Lemann’s article includes a quotation from Clayton Christensen, a professor at Harvard Business School, that speaks volumes about the Republican Party’s and Romney’s failure to connect with the working poor: “People who run against him [Romney] are liberal in the sense that they vote for legislation that takes money out of one person’s pocket and puts it in another person’s. . . . They don’t get it. They don’t have any idea of what life is like at the bottom of the pyramid.” As a doctor who cares for many indigent children, I believe that I “get it” as well as Romney, Christensen, and President Obama do. I support legislation that “takes money out of one person’s pocket” so that a profoundly disabled child on a home ventilator can have the equipment and care she needs to survive. I am in awe of the unbelievable dedication of the parents and families of sick kids, and the continual grinding exhaustion and frustration they experience. I see how close to the edge our system forces them to live, and I can’t imagine what they will do if the Romney-Ryan team eviscerates Medicaid. The idea that these families are “takers” offends me; they give far more to the world than I do, and, with all due respect, I suspect that they give more than most private-equity executives or business-school professors. What is most telling about the quotation, however, is the hidden assumption that decisions about how best to help those at “the bottom of the pyramid” should be settled among policy élites. Surely, those who live at the bottom of the pyramid “get it” better than anyone else.

David W. Roberson, M.D.
West Roxbury, Mass.
"...takes money out of one person’s pocket and puts it in another person’s"

Otherwise Socialistically known as "insurance."

Google "RomneyCare."

It's a red flag that this "Clayton Christensen, a professor at Harvard Business School" was not readily emailable (hedged behind a form). As Forbes put it, "[T]he great discoverer of the disease of disruptive innovation."


More to come...

Saturday, October 20, 2012

Stayin' with the numbers: REC Brew 102

Runnin' with a riff a bit longer. Post no. 102. The Power of Photoshop Compels me, The Power of Photoshop Compels me, The Power of Photoshop Compels me...

Post number 102. Lots to update and discuss this weekend.
Mostashari: Paper records are great ... if you're Harry Potter
Health IT coordinator talks to CHIME members about accountable care, national patient identifiers, EMR certification and more
October 18, 2012 | By Gienna Shaw

I'm optimistic. I think we're going to do it by tapping into innovation. We're going to create disruptive innovation … evolutionary innovation. And we're going to do it through the one thing known to create reliably faster, better and cheaper [healthcare], which is technology," he said. "The idea that we would bring the same brilliance, the same power, that has transformed everything else and bring that to healthcare."
Technology is just a tool, he said, but what a tool it is, he added. "Data," he said. "Wow! I Love data."

On paper records

Once you close a paper file it's dead. "You can't use it for anything. You can't move it, you can't learn from it," Mostashari said.

"In a Muggle world, the world we live in, the provider can't go into the room of paper charts and flourish their wand and say 'All the patients with diabetes!' and the charts fly out and hover in the air. 'All those who didn't come back to see me, over here!' Send in an owl. We can't do that on paper. But that is the essence of population health management."
Gotta love the guy.

I Photoshop quickie. I can do better. It'd be funny to put other ONC execs' faces in as well.

More to come. Gotta go vote.

Done. I'm back. a quick rant in the comments on THCB before heading out to a wounded Veteran benefit.
BobbyG says:
October 20, 2012 at 11:45 am
“Finally, individuals who insist that corporations should be beacons of social progress are bound to be disappointed”
Straw man.
The aggregate moral purpose of markets should properly be to advance the human condition, net (which includes not fouling the nest) -– maddeningly difficult to achieve ongoing as it may be. Markets properly exist to serve humanity, not the other way around. That this requires rational regulation ought be self-evident. That such is a never-ending pain in the ass ought also be self-evident.
If you disavow that, you are disavowing our system of law. It has been a long, painful climb up out of the Tooth and Claw muck.
See Gresham’s Dynamic, for one thing. A Winners vs Losers economy will not sustain. How many times must we re-learn that lesson?
Corollary: Not all markets are equally morally consequential. Markets for cheap trinkets and crass entertainments can come and go without appreciable socioeconomic/moral impact. The “markets” in health care or other life necessities are quite another matter at core.
We continue to live through the adverse upshot of an inadequately regulated financial sector.
Short memories are a bane. They simply re-enable the rapacious.
I, for one, will continue to insist that corporations be beacons of social progress, notwithstanding that I will be guaranteed of my numerous disappointments. Settling for a net win/win would suffice for me. Declaring “stymie” in the face of the difficulties of the requisite hard work ahead is no excuse for making excuses.

"I use the EMR every day, and I am old enough to have trained and practiced when everything was on paper. While overall, I am happy to have electronic records, there is a problem: The EMR is trying to serve too many masters. The needs of these various masters are different, and sometimes they are incompatible, even hostile to one another."
Christopher Johnson, MD, "The EMR and the Case of the Disappearing Patient"

That is so true, and comprises the fundamental problem HIT must confront.


apropos of nothing. Just some the cool stuff you find on Twitter.


Sir! May I have another, Sir?!

At HealthInsight, we're the "health improvement" people. Saw this in the kitchen at work the other day.

Can I get an a1c test with those?
Preparing IT for Mobile Forensic Investigations
By Thor Olavsrud, 19-Oct-2012

If your IT security team must comply with regulations like PCI-DSS or HIPAA, you need to know who accesses your data and what they do with it, even if they're using a mobile device to do it. But performing forensic investigations on mobile devices is trickier than it is on PCs.

As mobile devices proliferate in the enterprise, whether corporate-owned or part of a bring-your-own-device (BYOD) strategy, security organizations need to ensure they're prepared for the unique challenges of mobile forensic investigations.

This is especially true of organizations subject to compliance with regulations like PCI-DSS or HIPAA, but any organization could find itself in trouble if it can't get its hands on emails and SMS messages during an ediscovery process.

"If a company faces litigation or some other incident, do they have the capabilities to get the answers that these devices potentially hold inside them, whether through insourcing or outsourcing? That preparation is often an afterthought," says David Nardoni, a director in Pricewaterhousecooper's Forensic Services practice. "It has to be part of the implementation of your mobile policy."...
Good article. PCI-DSS refers to "Payment Card Industry Data Security Standard."
 See Requirements and Security Assessment Procedures Version 2.0 (pdf).
PCI DSS represents a minimum set of control objectives which may be enhanced by local, regional and sector laws and regulations. Additionally, legislation or regulatory requirements may require specific protection of personally identifiable information or other data elements (for example, cardholder name), or define an entity’s disclosure practices related to consumer information. Examples include legislation related to consumer data protection, privacy, identity theft, or data security. PCI DSS does not supersede local or regional laws, government regulations, or other legal requirements.
Interesting article on the topic of Mobile Forensics here:
by kstrzempka | in iPhone Forensics | October 3, 2012

The release of iOS 5 came with many new features, one of which was iMessage.  iMessage allows for sending text, photos, videos, group messages, and more over a cellular or Wi-Fi network from an iOS device (i.e. iPhone, Mac, iPad). From a user’s perspective, there isn’t a major difference from the looks of an iMessage compared to a standard text. Using iMessage, the user can see when another is typing, and the message appears in a blue text bubble instead of green.

From a forensic analyst’s standpoint, iMessages are stored in the same database as a standard SMS message; however, the format of the record is very different...
Zero percent unemployment rate in the InfoSec sector as far as the eye can see, IMO.


Regional Extension Centers Strive Toward a Sustainable Future
By Kurt Andrews, PhD (pdf)

With a charter that was boldly going where nobody had gone before and limited federal funding through 2014, it was unclear at the creation of regional extension centers (RECs) whether they could succeed and create a sustainable future. Will they do it? With just less than 20 months to go in the RECs’ funding lifecycle, the signs are pointing in the right direction...

RECs recently announced the creation of an REC-specific trade association, the Association of Regional Centers for Health Information Technology (ARCH-IT), which was formed in June 2012. Executive Director David Bergman is a Point-of-Care Partners (POCP) alumnus. (Learn more about the Association, which will soon have its website available at

ARCH-IT’s Bergman remains optimistic about RECs’ future, despite the speed bumps in the road ahead. He believes the providers’ needs and use cases would clearly support RECs’ long-term sustainability...
Were it all of "20 months." It's effectively more like 10, for the reasons I've addressed previously. And, ARCH-IT, well, they have their work cut out for them.

This same POCP consulting outfit has another interesting article circulating:
EHRs and the 2012 Presidential Elections
By Ed Daniels, MSIE (pdf)

It is impossible to know how each of the two presidential candidates would impact the electronic health record (EHR) industry if elected. However, that knowledge would be valuable to all of us who develop market, sell, implement and utilize EHRs. That knowledge would also be of interest to us as patients, whose records are stored in EHRs, and to our physicians who benefit from EHR use. Since we cannot know how these candidates will behave once elected, the best we can do is speculate based on available information.

According to KateAckerman, managing editor of  iHealthBeat, “Given the bipartisanship surrounding health IT for years, it's no surprise that both presidential candidates back the use of IT to improve health care.” A wild card for both candidates is the looming fiscal cliff to which Congress will attend after the election. A lot of what happens depends on the makeup of the Congress, especially since the senate composition is too close to call, according to some pundits. Clearly, some expenditures will be cut. Will the meaningful use (MU) incentives survive? Ackerman’s article reminds us that the MU incentive programs for EHR adoption were created under the Health Information Technology for Economic and Clinical Health Act (HITECH). That legislation is separate from the Affordable Care Act (ACA), which opponents often call Obamacare. Because of the statutory separation, it will be “very difficult to end the incentive program" even if the ACA is repealed or modified, according to the vice president of government relations for the Healthcare Information and Management Systems Society (HIMSS). The meaningful use program is classified as an entitlement, so Congress will have to pass legislation to end or reduce the program. It might be easier to just call it quits at stage 3, which is as far as HITECH goes.

At a high level, we can assume that President Obama, if reelected, will continue to pursue his current approach to EHRs. There is no evidence that he believes any major changes are required. His administration put in place significant, high-dollar programs to promote EHR standards and adoption. If a Republican house is preserved and a Republican senate elected, President Obama may find some of his EHR programs reduced due to the broad impact of budget reductions at the federal level...

It is safe to say that a Romney administration will find a way to limit the billions of dollars of federal spending now going directly to guide development of specific EHR features as well as motivate adoption. More of that is likely to be left to states, payers and private sector...
This is a nice article. Good side-by-side table Obama-vs-Romney comparative table at the conclusion.

Meaningful Use funding aside, I would conclude it to be the safest of bets to predict that there will be no more federal REC money forthcoming, no matter who wins the Presidency.

I take no joy in saying that, either.

We'll have a bit more HIT path forward clarity in 15 days. 

More to come, after the Giants-Cardinals Game 7...

UPDATE: Wow! 9-0 skunk to win the Pennant. Fear the Beard.


Click for programme

ONC seeks approval to collect key data from a relatively small sample of clinical laboratories nationwide for the Evaluation of the State Health Information Exchange Cooperative Agreement Program. The National Survey on Health Information Exchange in Clinical Laboratories will assess and evaluate the electronic transfer of health information from clinical laboratories to ordering physicians. It will focus on two key measures: (1) Percentage of laboratory facilities that are able to send structured lab results electronically to ordering physicians and (2) percentage of lab results that are currently being sent electronically in coded format to ordering physicians.

Need and Proposed Use of the Information: A key goal of the State Health Information Exchange Cooperative Agreement Program is to promote the electronic exchange of structured test results from clinical laboratories to healthcare providers. ONC will use these survey findings to develop a comprehensive understanding of the baseline level of laboratory information exchange in order to inform program activities to promote laboratory information exchange and provide more targeted assistance to states and territories in developing their laboratory information exchange strategies.
Interesting. "1,489 burden hours." Priced at $??? per hour, subbed out to ??? Beltway contractor? (rather than, say, contract mods for the RECs already working this turf?) Stay tuned.


Well, this is interesting.

AirStrip files lawsuit against mVisum for patent infringement
October 22, 2012 | By Greg Slabodkin, FierceMobileHealth
The battle between mHealth providers is heating up. San Antonio-based AirStrip Technologies last week announced that it filed a lawsuit in Federal District Court for the Southern District of New York, arguing that mVisum violated its patented intellectual property rights. The alleged violation involves an "industry-leading" method for remote monitoring of patient medical data on smartphones such as Apple's iPhone, tablets such as Apple's iPad, and other mobile devices.

In its legal complaint for patent infringement, AirStrip argued that its "revolutionary" AppPoint software was the "first FDA-cleared healthcare application for Apple devices to appear in the App Store," and now is found in more than 400 hospitals in the U.S. and internationally...

Safe to say, I think, that there will be a proliferation of this kind of litigation in coming years.

More to come...