Please note: This post by the HIT Standards Committee’s Implementation Workgroup is now closed for comment. Monitor this blog for more posts from the FACA committees and its workgroups as issues develop. Also, please visit the Health IT Buzz Blog to join other Health IT related conversations.
Today, the Health IT Standards Committee within the Department of Health and Human Services will begin an unprecedented effort to get the public’s view on how our work might “pull forward” the benefits of healthcare information technology (IT). Specifically, we’re interested in uncovering new strategies to accelerate the adoption of health IT standards. This effort began with the passage of the American Recovery and Reinvestment Act of 2009, calling for recommendations on standards to promote safe, secure, healthcare information exchange.
“Standards” are really the guardians of quality, consistency, and interoperability. Without thoughtful, clear and uniform standards, we cannot enable the seamless and secure exchange of electronic health information (or the benefits that accrue to providers and patients from such protected exchanges).
So, while the exploration of technical standards may seem mundane to some, it is foundational to electronic health records (EHRs) and electronic health information exchange more broadly. In other words, it’s worth paying some attention to, and voicing your opinions.
Our process continues with a public hearing today in Washington, DC, accessible via phone and webcast at http://healthit.hhs.gov/portal/server.pt. We are convening four panels of experts with on-the-ground experience in interoperability standards – providers, quality stakeholders, health IT vendors, and a group with lessons drawn outside of healthcare. Thanks to HIT Standards Committee member Judy Murphy for her leadership on this effort.
The public hearing draws to a close this afternoon but we will continue the conversation through an Online Forum over the next two weeks. Thanks to Committee Member Cris Ross for his leadership on this effort. Given the breadth of interests, we have arranged a series of Committee Member blog posts to begin the dialogue, starting with HIT Standards Committee Vice-Chair John Halamka’s summary of our work to date, which will post on Friday. We will concurrently enable ongoing discussion threads on the following topics:
1) Proposed Standards (General Discussion)
2) Interoperability
3) Vocabularies
4) Privacy
5) Security
6) Quality
7) Implementation Case Studies (Your Story – the good, bad and in-between)
We have also enabled a “voting” feature on submissions to allow you – the public – an opportunity to emphasize points raised in a given post. Our goal is to harness the shared wisdom of our community to inform the work of the HIT Standards Committee in the weeks and months ahead.
The tight schedule of this process is designed to ensure that your ideas inform the HIT Standards Committee at its November 19th meeting. However, your ongoing feedback on our efforts is also encouraged via written submission or public comment at any of the subsequent monthly meetings of the HIT Standards Committee.
The process of accelerating the adoption of health IT standards will not end this week, this month, or this year. This is an ongoing effort, and your participation will continue to be essential to its success.
– Aneesh Chopra, U.S. Chief Technology Officer
Tags: FACA, Federal Advisory Committee Act, health IT, HIT Standards Committee
Please accept the following observations from Dr. Robert Carlson, MD, Chief Information Officer of Marshfield Clinic:
Marshfield Clinic is the largest private group medical practice in Wisconsin and one of the largest in the United States, with nearly 800 physicians representing more than 80 different medical specialties, 6,490 additional employees, and more than 40 locations in 35 Wisconsin communities. The primary service area of Marshfield Clinic is predominantly rural with 70 percent of patients being cared for in rural areas. Most sites are primary care centers located in HPSA’s, with three larger centers in urban areas of less than 150,000 people. The largest center, the main Marshfield campus, is located in a rural area, yet houses the majority of specialists and services. Marshfield Clinic’s mission is to serve patients through accessible, high-quality health care, research, and education.
Marshfield Clinic has been a pioneer in developing and using integrated computer technology for patient care for almost 20 years. A detailed electronic medical record was in widespread use by the early 1990s. On April 6, 1994, Marshfield Clinic implemented a provider electronic signature, making the electronic medical record the official medical record. Created by collaboration between the information systems professionals and physicians of Marshfield Clinic, the electronic medical record delivers critical medical information whenever and wherever it is needed for high quality, efficient patient care. Coded information is moved to a data warehouse where Marshfield Clinic researchers conduct landmark population-based studies. We have also recently commercialized our EMR and our internally developed system – developed “by physicians, for physicians” – is commercially available as CattailsMD.
On behalf of all, we applaud your and the HIT Standards an Policy Committee’s work on the crucial issue of defining “meaningful use” of HIT. This endeavor will shape how health care is delivered and paid for for generations to come. As you finalize your work on the meaningful use criteria, please consider the following input/questions based off of the draft meaningful use documents currently available:
• Regarding required computer-based entry by providers of orders (medication, laboratory, procedure, diagnostic imaging, immunization, and referral), a concern is that the physician needs to see the order and sign off on the order. However, the actual physical entry of the order in workflow should not be placed upon providers to complete this task. Physicians need to sign off on the order, but not do the actual physical ordering of the test. Recommended goals should foster design of an EHR to be such that activities are done at the right place, at the right time, by the right person. In this situation, the physician is not the right person to do the physical entry of the order.
• Regarding the 2011 measures regarding use of high-risk medications (e.g. BEERS criteria in the elderly). The question is is this a point of care decision support tool or is this a report that would be generated? Is the defined capability to be a report that would be generated indicating the number of patients on a particular medication of concern, or the capacity to alert the use of high-risk medications at point of care?
• Regarding the percent of orders for high cost imaging services with specific structured indications recorded, we feel more clarification is needed. For example, do you need the diagnostic code of the encounter? Currently that is not available.
• Regarding percentage of all patients with access to personal health information electronically and percentage of all patients with access to patient-specific educational resources, we again feel there is need for further definition. For example, are metrics on patient portals adequate to meet measure regarding patients having access to their personal health information electronically?
• Regarding the percentage of patients with access to patient-specific educational resources, what are those resources, and by patient specific, does it need to be access out of a broader library of available topics or topics that are actually pushed to the patient based on their given condition, i.e. diabetes?
• Regarding percent of encounters for which clinical summaries were provided, this, too, needs further definition. What is considered a clinical summary? What are the data elements?
• Regarding retrieval and action on electronic prescription filled data where med reconciliation was performed, clarification is needed in terms of what will be required of hospitals. Will hospitals be required to send the medications for which patients were prescribed at the time of discharge, or is this medication reconciliation when the patient comes into the office and the provider verifies with the patient what medication they are on and how it is that they are taking that medication?
• Regarding the measure for “implemented ability to exchange health information with external clinical entity” (specifically lab, care summary, and medication lists), the measure for percent of transitions in care for which summary care record is shared (example electronic paper, e-fax) need further definitions in terms of what is meant by transitions.
• Finally, we feel full compliance with HIPAA and conducting a security risk assessment needs further definition.
We again thank you and all for all of your important work on this crucial issue. We would also like to offer the expertise of the professionals at the Marshfield Clinic should there be further need or opportunity for us to testify at committee hearings or assist/advise you or the Committees in any way. We look forward to continuing to work with you and engage in the process going forward.
Thank you.
Robert A. Carlson, MD
Chief Information Officer and Director, Applied Sciences
Marshfield Clinic
Agree or Disagree:
13 
8 (+5)
We wasted a ridiculous amount of money purchasing and training to use a traditional EMR. We had a huge decrease in productivity. Even worse is that EMR notes are almost completely useless. They contain only a fraction of the information of a dictated note. Much of what is there has only the appearance of being meaningful and often has no actual basis in reality. These notes do not transmit any of the subtlties of the patients condidtion. In the end we had to discard our EMR for a total loss. (This was a “brand name” highly recommended system and was not cheap.)
When we went to SRS (a hybred system) training time was 10 minutes per doctor. The first day of use the doctors saw full schedules of patients. We now have increased productivity, and the quality of the notes and information in the chart is improved, not degraded. The hybred SRS system needs to be CCHIT certified.
Agree or Disagree:
15 
9 (+6)
I am a memeber of a 12 man 18 provider cardiology group in Wausau, WI. We have been very pleased with our hybrind EMR. We were able to implement it with very littel pracitce or patient disruption. We did not have to cut back on our schedules and this allowed full patient access throughout the implementation phase. Our SRS populates the EPIC program at our hospital so all our notes and test are available when neccessary to the ER and inpatient services. The ease of use resulted in great provider acceptance and adoption. The ease of access has afforded great patient service and safety form any site. Hybrid EMR’s need to be accepted and CCHIT certified
Agree or Disagree:
16 
8 (+8)
I am a huge fan of hybrid EMR (SRS). I firmly believe that a hybrid EMR should be CCHIT certified. A true EMR product did not work for our office because it took too much time to document a visit requiring less patients to be seen which is not good patient care. It also takes longer for a patient to be seen and patients are not happy with this because their time is valuable also. A hybrid EMR is so similar to a full EMR but a lot of the normal fashions a physician operates under today allows them to continue in that same fashion which is very important as a lot of physicians, especially older ones, do not like change.
Agree or Disagree:
17 
9 (+8)
After extensive evaluation and testing we choose to bypass the unsuccessful traditional EMR and to implement a Hybrid EMR. Following a very easy two month installation and a very short training period for our providers, the system was in place and working as intended. Our providers love the easy access to patient information and the efficient flow of information and messages through the system. The system paid for itself within the first year. The Hybrid EMR did not decreased our provider’s productivity ….. and it really does contribute to better patient care. This is the sort of system on which our tax dollars should be spent.
Agree or Disagree:
19 
10 (+9)
Part II of Rules Learned in Working with Data
11) Data is dirty. That is the nature of data. It does become more evident when you (9) sunshine the data.
12) Keep data in its most granular form possible. That is the richest trove. Standardization and abstraction too early removes content and therefore removes value. You can always form data molecules out of data atoms, and data organelles out of data molecules; it is impossible to go in the other direction
13) It is more important to get the data than for the data to be in a standardized or canonical form. Consider a “throw it over the wall” model of data where any transformation (if necessary)of data into a standardized form is done at the receiving end instead of the sending end (I know this be heresy).
14) There is no such thing as collecting too much data. There is such a thing as viewing too much data. You never know down the line which data elements are going to be needed to answer tomorrow’s questions.
15) Everything has unintended consequences. Anticipate them.
16) Content is king. It is more important to get new data , potentially of new types, into the data cauldron than it is to pretty up the data that is already there.
17) Less is more. Not only does insisting on completeness sometimes take so much time that nothing ever gets finished, but when everything is treated equally, the important can get hidden by the unimportant. From a patient’s perspective, receiving a list of 15 side effects of a medication has much less impact than getting a list of only the top 3. The mind can pay attention to only so many things at once before it gets overwhelmed.
18) The most interesting data action occurs at the middle level, not at the individual patient level and not at the total population level. All the patterns that provide insight are patterns occurring among cohorts selected on some combination of conditions.
19) Value accrues from data by repurposing the same piece of data in multiple different venues. So, for example, a single atom of data generated during a patient encounter (eg. serum glucose value, time spent waiting to see the physician) should be able to be used in at least 5 different ways:
a. clinical care of the individual patient
b. answering questions about populations to provide understanding and insight (ie filtering
c. facilitating workflow
• organizing tasks
• triggering alerts
• engaging decision support
d. creating dashboards (situational awareness)
e. conducting clinical research
Agree or Disagree:
15 
7 (+8)
Part I
Permit me to share some simple rules that I learned from building, along with my colleague and partner Craig Feied, an information platform that is active use in hospitals today. I think these rules may be of value to the process of shaping an information strategy in healthcare. (Many of these ideas grew out of the work that Craig and I did together; if they are of help to anyone, credit goes equally to the two of us; if there are errors or misconceptions in the material below, that is at my doorstep only)
One preliminary point— organizations often speak of an IT Strategy or an IT Roadmap. I think that unconsciously and inadvertently puts the emphasis on the wrong entity: the “T”. The focus should be on the “I”; the data and information and not the apparatus that delivers it. We would be better off thinking about and talking about an I Strategy and an I Roadmap.
Here are the simple rules. They may sound trite, but one metarule that I would add is “all truths are simple.”
1) The difference between zero and one is a lot greater than the difference between one and ten, ie don’t build a skyscraper when what you need is an A frame in order to get out of the rain (credit to an unnamed colleague for this last image)
2) Don’t build one off solutions to solve a specific problem. Build a general information platform that can be used to answer not only today’s questions (including the specific problem that you wanted to solve), but also to answer questions that were not thought of at the time the platform was designed.
3) Assiduously follow the 80/20 rule: 80% of the benefit occurs with the first 20% of effort or with 20% of the content (Actually the rule could be rephrased as the 90/20 rule or the 75/20 rule, since there is no reason that the two numbers need to sum to 100). Much of the adverse patient events that occur in hospitals could be eliminated if more assiduous attention was paid to the “lowly” vital signs. Willie Sutton well knew the 80/20 rule. That’s why what he robbed were banks.
4) Corollary to #3: Simple things can have large effects. The magnitude of the intervention has little relationship to the magnitude of the benefit
5) Always ask: what is the value? Is this going to help make care safer, better, faster, or less expensive. We are too often locked into the HIS categories of today: clinical documentation, CPOE, etc. without remembering that the only reason to move our HIS in a specific direction is so that the care of patients is improved.
6) Avoid monolithiasis. Build modularly. Leave yourself multiple chances for success or failure
7) Build incrementally. Test and retool frequently. Forge your system in the crucible of real experience
9) Sunshine the data. People selforganize their behavior in the right direction
10) Keep feedback loops as tight as possible, All systems work better with tight feedback. If the feedback in healthcare can be made realtime, the possibility exists to affect care on this encounter and not just in future encounters.
Agree or Disagree:
15 
7 (+8)
Dear Sir,
I went into orthopedics because the specialty treats patients of all ages with a diverse group of problems. We do trauma, congenital deformities, systemic diseases like lupus and RA, sports injuries, dislocations, arthritis, spinal deformities, and more. We have operations that involve almost every part of the body.
Orthopedics is incredibly diverse and completely different from other medical specialties. For that reason, it needs an orthopedic-specific EMR. And the definition for “meaningful use” should be different for orthopedics than it is for other specialties.
Meaningful use for orthopedics should include:
1. Ability to manage images (xrays, MRIs, arthroscopy images, etc.), including making the images accessible to outside providers and having the ability to easily acquire outside images.
2. Full participation in electronic prescribing and medication reconciliation.
3. Full participation in national registries for implanted medical devices.
4. Making available to other providers a narrative record of the orthopedic evaluation and treatment plan.
5. Ability to fetch, meaningfully display and manipulate all the data made available by other healthcare providers over the network.
Meaningful use for orthopedics should not include:
1. Structured data which is highly observer-dependent such as range-of-motion measurements, amount of swelling, etc. This type of data is “garbage in, garbage out.”
2. Templated notes which are very difficult to interpret and mainly designed to achieve higher levels reimbursement. Some providers send us 3 page notes which are obviously computer-generated templates and yield very little meaningful information. We look at the bottom to the free-text area to see what really happened during the encounter.
I believe that someday there will be a perfect orthopedic EMR software. It will have a different data entry form for each ICD-9 code, perhaps depending also on the age of the patient. For post-operative patients there will be different data entry forms for each procedure CPT code or combination of codes, with one for early and one for late post-op visits. When that day comes, the definition of meaningful use for orthopedics should include the structured data elements. Until then please do not penalize orthopedic surgeons for not using a product that doesn’t exist.
If meaningful use for orthopedic surgery is developed with the five points that I suggest above, the $40,000 federal stimulus will be sufficient reward to move the specialty into the digital age. The ability to exchange images will improve care and eliminate needless duplication of expensive studies. The electronic prescribing will save lives and reduce narcotic abuse. The participation of orthopedic surgeons in national device registries will identify inferior devices and treatments. And the exchange of office records will improve medical care coordination dramatically.
Please do not force orthopedic surgery into the one-size-fits-all meaningful use requirement. Look at each specialty separately, decide how that specialty could contribute to the improvement of healthcare through information sharing, and design the meaningful use requirement for that specialty accordingly.
How will you prevent physicians from claiming their stimulus under the specialty program with the least-stringent meaningful use requirement? Require them to submit a copy of their board certification for the specialty. Medicare may have other means of classifying physician specialties. Do not rely on self-designation or the AMA Masterfile.
Thanks for considering my suggestions.
Hadley Callaway, MD
Raleigh Orthopaedic Clinic
Past President, North Carolina Medical Society
Agree or Disagree:
14 
7 (+7)
I went into orthopedics because the specialty treats patients of all ages with a diverse group of problems. We do trauma, congenital deformities, systemic diseases like lupus and RA, sports injuries, dislocations, arthritis, spinal deformities, and more. We have operations that involve almost every part of the body.
Orthopedics is incredibly diverse and completely different from other medical specialties. For that reason, it needs an orthopedic-specific EMR. And the definition for “meaningful use” should be different for orthopedics than it is for other specialties.
Meaningful use for orthopedics should include:
1. Ability to manage images (xrays, MRIs, arthroscopy images, etc.), including making the images accessible to outside providers and having the ability to easily acquire outside images.
2. Full participation in electronic prescribing and medication reconciliation.
3. Full participation in national registries for implanted medical devices.
4. Making available to other providers a narrative record of the orthopedic evaluation and treatment plan.
5. Ability to fetch, meaningfully display and manipulate all the data made available by other healthcare providers over the network.
Meaningful use for orthopedics should not include:
1. Structured data which is highly observer-dependent such as range-of-motion measurements, amount of swelling, etc. This type of data is “garbage in, garbage out.”
2. Templated notes which are very difficult to interpret and mainly designed to achieve higher levels reimbursement. Some providers send us 3 page notes which are obviously computer-generated templates and yield very little meaningful information. We look at the bottom to the free-text area to see what really happened during the encounter.
I believe that someday there will be a perfect orthopedic EMR software. It will have a different data entry form for each ICD-9 code, perhaps depending also on the age of the patient. For post-operative patients there will be different data entry forms for each procedure CPT code or combination of codes, with one for early and one for late post-op visits. When that day comes, the definition of meaningful use for orthopedics should include the structured data elements. Until then please do not penalize orthopedic surgeons for not using a product that doesn’t exist.
If meaningful use for orthopedic surgery is developed with the five points that I suggest above, the $40,000 federal stimulus will be sufficient reward to move the specialty into the digital age. The ability to exchange images will improve care and eliminate needless duplication of expensive studies. The electronic prescribing will save lives and reduce narcotic abuse. The participation of orthopedic surgeons in national device registries will identify inferior devices and treatments. And the exchange of office records will improve medical care coordination dramatically.
Please do not force orthopedic surgery into the one-size-fits-all meaningful use requirement. Look at each specialty separately, decide how that specialty could contribute to the improvement of healthcare through information sharing, and design the meaningful use requirement for that specialty accordingly.
How will you prevent physicians from claiming their stimulus under the specialty program with the least-stringent meaningful use requirement? Require them to submit a copy of their board certification for the specialty. Medicare may have other means of classifying physician specialties. Do not rely on self-designation or the AMA Masterfile.
Thanks for considering my suggestions.
Hadley Callaway, MD
Raleigh Orthopaedic Clinic
Past President, North Carolina Medical Society
Hot debate. What do you think?
11 
8 (+3)
Our decision to not purchase a traditional EHR was made because the systems were expensive and required learning a propritary software logic, which has proven to be the downfall of many, if not all, of the systems except for simple document storage devices (hybrid EMRs) like SRS.
It is vital that an EHR offer the ability to, without exception, prevent government agencies from accessing the data. One should be able to quickly open a chart and prescribe meds with few steps. One should also have the ability to easily correct documents, with history documenting the correction/alteration. A handheld device would be helpful.
Hot debate. What do you think?
12 
9 (+3)
Yes, most of the software that can do this requires a steep learning curve, and is also fairly expensive to implement. The problem with a system like SRS is the vulnerability for accessing the data.
Agree or Disagree:
12 
7 (+5)