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Thursday, October 1, 2015

Federal FY 2016. What will it bring for Health IT and Healthcare?

First, two items,

Well, no federal shutdown this time. Boehner's resignation deprived the GOP hardliners of the leverage they'd have needed to throw sand in the budget resolution gears over defunding Planned Parenthood. They've essentially kicked the can down the road until mid-December, when the next stand-off will ensue. At that time the national debt limit will be front and center once again, and the melodrama will ramp back up. I have a curt, dispositive opinion on that cynical charade.

I'll just glad it's been avoided this time, so some of my federal peeps will be able to make it to Health 2.0 2015.

Swell email notice I got from the Hyatt:
Dear Robert,

Thank you for choosing Hyatt Regency Santa Clara during the Health 2.0 Conference!

Please take a moment to review the information below as it may affect your travel time and travel conditions to and from the hotel

The week of your conference, the San Francisco 49ers will be playing the Green Bay Packers at Levi's Stadium on Sunday, October 4, 2015 at 1:25pm.

As you are travelling to our hotel, please be aware that heavy traffic and delays are anticipated on the major thoroughfares leading to and from the stadium, including Highways 101, 237, 880, Lawrence Expressway, Great America Parkway and San Tomas Expressway, as a result of the event. Peak travel times are estimated between 10:00am - 1:00pm and 3:00pm - 7:00pm.

If you are arriving to the hotel on Sunday, October 4, 2015, expect delays due to the temporary closure of Tasman Drive, which is the street adjacent to the hotel. Please allow additional time getting to the hotel.

When you arrive at the hotel, our hotel staff will direct you to our front drive to assist you with your check-in.

If you are currently parked on the Hotel property and plan to leave and return within this time period, you will need a Hyatt Parking Pass, which is available at the Front Desk.

Please note that check-in time is 3:00PM and check-out is 12:00PM. Due to our sold-out capacity on Saturday, October 3rd, Sunday, October 4th, and Monday, October 5th, we will not be able to accomodate Early Check-in requests.  In the event that you arrive earlier than 3:00PM, we will have luggage storage provided for you to utilize while you wait to check into your room.
I'll be leaving the house at about 7:30 a.m. Parking will still probably be a hassle.

Then, on Monday, Tuesday, and Wednesday, I'll have to bail out at about 11 a.m. to run up the 680 to Pleasant Hill for my daily IMRT tx (I'm now in the 4th week of nine). Should be back at Health 2.0 by about 2:30 or so. Not what I'd envisioned. I'm starting to get quite tired every day mid-day now, which I knew was to be expected. Gonna have to suck it up next week.

Time to fire up the cameras and let 'em rip. Joe Flower will be keynoting on Sunday morning at 10. Gotta be there for that. See my review of his new book in my recent post "The Future of Health Futurism."

UCSF's Dr. Bob Wachter will be on hand.

See my review of his book in my post "Obama Administration Report Slams Digital Health Records."

I'm also gonna be on the lookout for salient discussions on "Leadership" in the health care space. My prior post "What exactly is 'Leadership,' anyway?" got a lot of interest, including over on LinkedIn (where I pimped it assiduously).

I will also be on the lookout for substantive discussion on the issue of chronic "fragmentation" in health care. See my post The U.S. healthcare "system" in one word: "shards."

Also, per my prior post:

Speaking of Health IT "Leadership,"


PDF copy here (50 pages). When I'm pressed for time and have too much contending stuff to read, many times I'll do a preliminary keyword search of high-priority terms and phrases to get a sense of relative emphasis, and scan a few excerpts prior to subsequently devoting time to close front-to-back study. A quick selective rank-ordered tally here:
  1. "Standards" - 42
  2. "Value" - 29
  3. "Interoperability" - 26
  4. "exchange" - 20
  5. "EHR"  - 18
  6. "mobile" - 13
  7. "usability" - 9
  8. "telehealth" and "seamless" (a tie) - 8
  9. "patient-centered" - 6
  10. "performance" - 4
  11. "governance" - 2
  12. "portal" - 1
  13. "leadership, API(s), HL7, HL-7, FHIR, use case(s), ACO, PCMH" - 0
Interesting. Particularly #13. Goose eggs on all of those, including "leadership"?

From the ONC report:
Modernizing and redesigning the U.S. health and wellness information, communications, and technology infrastructure is vital for advancing the health and well-being of individuals and communities across the nation. In today’s connected society, a variety of sources, platforms, and settings generate electronic health information that can inform health goals, behaviors, and decisions. These information sources extend well beyond traditional health care services to create a more expansive, continual pool of salient information. These sources and information types include self-generated information collected through an individual’s mobile device, and non-clinical information collected by communities, including air and water quality from work and physical environments, potential toxin exposure, and availability of transportation and social services. To unlock the full power of information to improve individual health and well-being, essential electronic health information must be available when and where it matters most. 
Improving the secure availability and use of pertinent health information allows individuals to take ownership of their health, partner with their health care providers and others on care preferences and decisions, and reach their health and quality of life goals. It bolsters the delivery of health care and long- term services and supports, allows communities to reduce health disparities, and improves public health agencies’ ability to detect, track, manage, and prevent illness outbreaks and individual harm. Information also fuels research and innovation, spurring advancements in scientific discovery. As the information and technology demands continue to evolve, opportunities for the federal government exist to create pathways for the private sector to innovate and to design programs and policies that do not impede the marketplace’s progress. It is imperative for government to address this new electronic health information and health IT paradigm to improve the health of the nation.
Empowering individuals to make healthy choices can improve their quality and longevity of life. Information is central to setting and accomplishing individual and systemic goals and improvement plans; however, information alone – even when electronically generated and shared – cannot improve the nation’s health. It will take the collective efforts of many stakeholders using electronic health information in meaningful and effective ways, alone and in partnership with one another, to help achieve the nation’s full health potential.
An individual can take many steps to improve his or her health, including lifestyle and wellness choices, actively managing his or her health care, and receiving necessary immunizations, preventive care, and long-term services and supports. Engaged individuals are more likely to be proactive in practicing wellness, prevention, and disease management behaviors. However, health care providers and health insurers offered fewer than three in ten individuals electronic or online access to their medical record in 2013.

Individuals and caregivers often want to increase their care engagement and health management, but many challenges and deficiencies make it difficult for them to play a proactive role and respond to the information and resources available to them...
 Can't disagree with any of that. So, cutting to the chase, ONC is going to "advance," "foster," "enhance," and "transform" stuff. Is that tantamount to "leadership"?

I first came to Health IT deployment in March of 2005 when I left my bank risk management job (taking a 23% pay cut) to do more socially beneficial work, returning for my second of three tenures with HealthInsight when the federal DOQ-IT initiative was launched. DOQ-IT was a CMS 8SoW baby-steps precursor to the 2010 (now much-maligned) Meaningful Use program, which comprised my third tenure. My first stint at HealthInsight was during 1993-1995, wherein I served as a Medicare acute care hospitalization outcomes analyst (coding in Stata and SAS) and LAN administrator.

I am always struck by the extent to which these episodic HHS reports and white papers and "strategic plans" keep re-plowing the same ground. To be fair, though, read most EHR marketing literature today, and it's almost verbatim to that of the glowing pitches of 10 years ago during the onset of DOQ-IT.

Dunno. Read the ONC Plan for yourself.


The GAO chimes in on "Interoperability." (29 pg. PDF)

Electronic health record (EHR) interoperability is viewed by many health care stakeholders as a necessary step toward transforming health care into a system that can achieve goals of improved quality, efficiency, and patient safety. EHR interoperability refers to the ability of EHR systems to exchange electronic health information with other systems and process the information without special effort on the part of the user, such as a health care provider. When EHR systems are interoperable, information can be exchanged—sent from one provider to another—and then seamlessly integrated into the receiving provider’s EHR system, allowing the provider to use that health information to inform clinical care.

The Department of Health and Human Services’ (HHS) Office of the National Coordinator for Health Information Technology (ONC) is charged with promoting the adoption and use of health information technology by the Health Information Technology for Economic and Clinical Health (HITECH) Act, part of the American Recovery and Reinvestment Act. ONC has stated that EHR interoperability is key to its vision of enabling every individual and his or her health care providers to access the health information they need in a useful electronic format when and how they need it. Although ONC has reported nationwide progress on the extent to which providers can exchange health information among different data systems and organizations, it has also reported that interoperability remains limited due to, among other things, electronic health information not being sufficiently structured or standardized, a lack of financial motives, and misinterpretation of existing laws governing the sharing of health information...
"Without special effort on the part of the user." That's straight out of the IEEE definition of "interoperability." One of my ongoing concerns is that we're essentially stripping that clause out of the definition.
We identified nonfederal organizations that have ongoing initiatives that are working to facilitate electronic health record (EHR) interoperability. The 18 initiatives we selected for our work are listed below,
  • Argonaut Project
  • California Association of Health Information Exchanges (CAHIE)
  • Carequality
  • Center for Medical Interoperability (C4MI)
  • CommonWell Health Alliance
  • ConCert by Healthcare Information and Management Systems Society (HIMSS)
  • eHealth Exchange
  • eHealth Initiative (eHI)
  • Electronic Healthcare Network Accreditation Commission (EHNAC)
  • Healthbridge
  • Healthcare Services Platform Consortium (HSPC)
  • Identity Ecosystem Steering Group (IDESG) Healthcare Committee)
  • Integrating the Healthcare Enterprise (IHE) USA
  • Kansas Health Information Network (KHIN)
  • National Association for Trusted Exchange (NATE)
  • Open ID Health Relationship Trust (HEART) Working Group
  • Statewide Health Information Network of New York (SHIN-NY)
  • Substitutable Medical Applications and Reusable Technologies (SMART) on Fast Healthcare Interoperability Resources (FHIR)
Interesting. Be nice if they could come to agree on "Standard Data."

A couple of GAO report conclusions:
1. EHR interoperability would move forward once providers saw a value in their systems becoming interoperable. Six initiative representatives said that improvements to EHR systems—such as enhancements that improve providers’ workflow or clinical decision-making—are needed to increase the extent to which an EHR system, and the information contained within it, is a valuable tool for health care providers. Six initiative representatives noted that reforms that tie payment to quality of care rather than number of services provided will incentivize sharing of information across providers to improve efficiency.

2. Changes to CMS’s Medicare and Medicaid EHR Incentive Programs would also help move nationwide interoperability forward. While 8 initiative representatives we spoke with told us that the EHR Incentive Programs have increased adoption of EHRs, representatives from 5 initiatives suggested pausing or stopping the programs. Representatives from 10 of the initiatives noted that efforts to meet the programs’ requirements divert resources and attention from other efforts to enable interoperability. For example, some initiative representatives explained that the EHR programs’ criteria require EHR vendors to incorporate messaging capabilities into EHR systems, but this capability generally does not enable interoperability at this time. Representatives from 10 of the initiatives said that the criteria currently used to certify EHR systems under the EHR Incentive Programs are not sufficient for achieving interoperability, and representatives from 3 initiatives suggested amending the criteria to focus on testing systems’ ability to interoperate.

"[T]he criteria currently used to certify EHR systems under the EHR Incentive Programs are not sufficient for achieving interoperability."
Indeed. For one thing, I have long complained that one thing ONC should have demanded was that EHR vendors submit their data dictionaries as part of the certification process, so that they could study the relative extent of data standardization and obtain a clearer picture of the work yet to be done. Our chronic state of HIT "interoperababble" is getting quite old. I remain skeptical that a proliferation of APIs will be an interop panacea.

Concluding point #1 above goes to "incentives." Profitable data "opacity" and "vendor lock" remain prevailing private market incentives.

Welcome to ICD-10
Oct 1, 2015

Today, the U.S. health care system moves to the International Classification of Diseases, 10th Revision – ICD-10. We’ve tested and retested our systems in anticipation of this day, and we’re ready to accept properly coded ICD-10 claims.

The change to ICD-10 allows you to capture more details about the health status of  your patients and sets the stage for improved patient care and public health surveillance across our country. ICD-10 will help move the nation’s health care system to better, smarter care...

This will certainly bear watching.

But, wait! There's more!
Pecked By A Chicken? Now There’s A Medical Code for That

If you’re struck by an orca, sucked into a jet engine, or having relationship problems with your in-laws, fear not: Your doctor now has a medical diagnosis code for that.

Today U.S. doctors, hospitals and health insurers must start using the ICD-10, a vast new set of alphanumeric codes for describing diseases and injuries in unprecedented detail.

The transition, mandated by the federal government, has been called American health care’s Y2K moment, because the codes haven’t been updated in 36 years. Doctors and hospitals are on high alert since the arcane letters and digits are key to how health care providers get paid. If they don’t use the right codes, down to the decimal, they may not be paid sufficiently – or at all.

For months, healthcare insiders have been venting their frustrations with the changeover, posting Halloween-themed ICD-10 office decor on social media and mocking some of the wackier codes. Among the targets: W61.33 (pecked by a chicken), Y08.01 (assault by hockey stick) and R46.1 (bizarre personal appearance).

Not to mention W56.22xA – “struck by orca” – which became the title of an illustrated book of infamous ICD-10 codes that’s sold nearly 10,000 copies, said its editor, Niko Skievaski of Madison, Wis...
in other news, by way of Dr. Jerome Carter's always-excellent EHR Science,
Inspired EHRs:
Designing for Clinicians

Our goal in writing this book is to inspire useful and usable Electronic Health Record (EHR) interface design by providing clinical scenarios and insights with examples of interactive designs, guided by basic design principles.

Illustrative, Not Prescriptive

While meaningful use criteria influenced the choice of the book topics, we and our supporters (California HealthCare Foundation and SHARP-C Project) want this book to be clinically relevant, illustrative, and inspirational —but not prescriptive. We hope our design examples will inspire our readers to improve their own EHR designs.

This book is written for anyone who develops and implements health IT applications, but particularly for electronic health record (EHR) vendor teams who want to learn more about human factors and design. Designers who want to learn about the needs of EHR users, medical informatics students, and EHR users who want to learn more about design principles might also benefit from reading this book.


Clinical focus: This book focuses on ambulatory adult care. Our examples especially emphasize the needs of primary care practitioners.
EHR functionality focus: Our design examples seek to address five specific areas: medication list, medication reconciliation, allergy list, e-prescribing and drug alerts.
We hope that future books will address other clinical needs and the many other elements that EHR designs require to be useful and usable, so they can be carefully implemented and seamlessly integrated into healthcare organizations...
Bring a Snicker's, you're gonna be a while.

That's all for now, I gotta go get nuked.

I'm back. From NPR's "Here and Now," "How to Stay Sharp As You Age."
Is mental decline an inevitable part of aging? Our brains do shrink as we get older, but new research shows it does not have to have to go hand-in-hand with a decrease in cognitive ability. In fact, it’s possible to enhance existing brain pathways and even create new ones as we age. New concepts like neuroplasticity demonstrate that changes in behavior, environment, thinking, and emotions and health can all affect the way our brains change...

The Misery of a Doctor's First Days
For many new physicians, residency brings fatigue, emotional stress, and self-doubt, affecting their ability to take care of themselves and their patients. Is there a way to fix it?

One night in July—the night before her first day of work—a new doctor picked at a container of sushi in her apartment on a sleepy street in Brooklyn. She tried to swallow a few bites as she chatted on the phone with her best friend from medical school, who was also marking the eve of his first day as a working physician. “Break a leg,” she said. “But not really.”

There wasn’t any street noise to keep her up as she tried to go to sleep early for her 5:00 a.m. start—but even in the silence, heavy with midsummer humidity, she couldn’t drift off. For two months, since she’d graduated medical school, her body had registered her mounting stress leading up to her first day in the hospital. She was plagued by insomnia. Food made her nauseated, except plain donuts, which she ordered twice a day from the diner at the end of her block. She’d eat them while studying diagnoses and procedures that she’d learned in school and long since forgotten, crumbs piling up in the crease of her textbook. In the months between graduating and starting work, she lost more than 15 pounds...

When they graduate from medical school, newly minted physicians are prepared to recall minute details about a litany of illnesses—but not necessarily confident managing the symptoms. In his memoir The Real Doctor Will See You Shortly: A Physician’s First Year, Matt McCarthy describes the “tectonic shift” from laboratories to hospital life: Throughout much of his rotation in general surgery at Massachusetts General Hospital, where he practiced suturing banana peels back together in his free moments, McCarthy felt unprepared to deal with the onslaught of diseased bodies.

If he had been asked to “recite pages from a journal article on kidney chemistry or coagulation cascades, I could’ve put on quite a show,” he writes. “But I hadn’t learned much of the practical business of keeping people alive, skills like drawing blood or putting in a urinary catheter.”...
Recall my April post "Nurses and doctors in the trenches" wherein I reviewed Dr. McCarthy's book.

More to come...

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