We are pleased to announce that on March 8th, the Implementation Workgroup of the Health IT Standards Committee will hold a public hearing on “Implementation Starter Kit: Lessons and Resources to Accelerate Adoption” to help providers achieve meaningful use by, in part, surfacing examples of effective meaningful use implementation preparation.
As background, the Standards and Certification Interim Final Rule (IFR) was released on December 31st, 2009, along with a Notice of Proposed Rulemaking on Meaningful Use. You can find both of these documents, and other useful information about the rules, here: http://healthit.hhs.gov/standardsandcertification.
To prepare for the March 8th hearing, we are asking you to post questions and comments about implementation opportunities and challenges you are facing today and for which you would either like to share or would welcome support. We want the hearings to be directly relevant to your needs and to learn from the panelists how we might better serve the industry as we prepare for the Committee’s work.
We also are looking for success stories. Some organizations have been engaging in “meaningful use” for some time, and while the IFR is new, the standards embedded in it are not. If you have implementation success stories where you have found innovative ways to address the requirements, we want to know about them, especially if you think they could be useful to others.
Please submit your comment or question about the IFR below. Your comments and questions will help form the agenda for the on-going work of the Implementation Workgroup. In particular, we will use your questions to help generate our agenda for March 8, and we will ask our expert panels to comment on as many of your issues as possible.
We also want to be clear that comments on this blog are not a substitute for official feedback on the regulations. We urge interested parties to also submit comments on the regulations, and the appropriate place to do that is on the Regulations.gov website before March 15, 2010.
Although any comment or question is welcome, we are particularly interested in questions or comments about the four categories of standards:
- Vocabulary Standards (i.e., standardized nomenclatures and code sets used to describe clinical problems and procedures, medications, labs and allergies);
- Content Exchange Standards (i.e., standards used to share clinical information such as clinical summaries, prescriptions, and structured electronic documents);
- Transport Standards (i.e., standards used to establish a common, predictable, secure communication protocol between systems); and
- Privacy and Security Standards (e.g., authentication, access control, transmission security) which relate to and span across all of the other types of standards.
We expect this blog to continue beyond the comment period on the Interim Final Rule. The next phase of work for the Implementation Workgroup will be to provide useful guidance and patterns for implementation of the 2011 standards, and to receive input relating to the 2013 standards that are yet to be fully defined. This Workgroup’s particular emphasis is on facilitating effective and efficient implementation of meaningful use standards, and we hope this forum and our other public activities will be a place where success stories are highlighted, resources are shared, and problems avoided. Your active participation is an important component to our mutual success in achieving meaningful use.
Thank you for your contribution!
– Aneesh Chopra, Chair, Implementation Workgroup
Tags: FACA
In regards to the following I will address #3:
1. Vocabulary Standards (i.e., standardized nomenclatures and code sets used to describe clinical problems and procedures, medications, labs and allergies);
2. Content Exchange Standards (i.e., standards used to share clinical information such as clinical summaries, prescriptions, and structured electronic documents);
3. Transport Standards (i.e., standards used to establish a common, predictable, secure communication protocol between systems); and
4. Privacy and Security Standards (e.g., authentication, access control, transmission security) which relate to and span across all of the other types of standards.
Transport standards are without a doubt one of the most important things to consider. If this problem is solved then the basics of linking the data and associating it with key terms is possible. I would like to see there be a centralized location with specific security allow the “data pool” to be accessed.
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Children are a diverse and complex group. Their physiology, metabolism, size, development and special legal, educational and social needs result in unique vulnerabilities and special requirements that must be considered when planning and implementing EMRs. In children (unlike in adults) the difference between two consecutive measurements (like weight and height, or developmental milestones) are as important or more important than the actual measurement. Children and adolescents also include many different subgroups with different medical needs. It is easy to recognize that children are not just little adults when you picture a 180-lbs adolescent and a 2-lbs premature infant. Their activities, nutrition, anticipated development, preventive care needs, privacy and confidentiality, name or family history changes, anticipatory guidance, metabolism, response to medications, and their risks for specific infections could not be more different.
The different stages of growth, development, and socialization of childhood require different Meaningful Use criteria. The Notice of Proposed Rule Making recognizes that Meaningful Use criteria for an orthopedic surgeon should be different from for an internist. But these two physicians have more in common in their daily practice than a Neonatologist and an Adolescent Medicine physician. Meaningful Use criteria for such a diverse patient population with so many needs that change over time must be developed carefully. The American Academy of Pediatrics suggests that it be done with the following principles in mind:
Meaningful Use and Quality measures must be tailored to the scope of pediatric practice, and to specific patient populations. A pediatrician specializing in the treatment of obesity should be able to select quality reporting measures that reflect the nature of her practice. Reporting and retrieving newborn screening data and tracking follow-up should be quality measures for physicians who care for newborns. Adolescents are in a critical stage of their life, where not all sensitive information is shared with their parents. Meaningful Use in this age group must acknowledge the need for privacy and support the ability of adolescents to determine when and how parents or guardians have access to their clinical information.
Rule 1: Meaningful Use criteria and quality measures must be tailored to the scope of practice.
Any Meaningful Use criterion should be based on evidence that its implementation will lead to improvement in quality of care. Additionally, tested, valid quality measures should be available so that it can be determined whether goals are actually being achieved.
Rule 2: All Meaningful Use criteria must be based on valid quality measures.
The American Academy of Pediatrics advocates primary care patient centered medical home as a model of delivering primary care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective. The goal of the Medical Home includes a community based system focused on a family-centered partnership and the provision of high-quality, developmentally appropriate, health care services that continue uninterrupted as the individual moves along and within systems of services and from adolescence to adulthood.
Rule 3: Meaningful Use MUST encourage and endorse the Patient Centered Medical Homes.
Meaningful use legislation will be more likely to make a positive impact on child health if pediatricians are able to participate in the incentive program. Approximately 46% of pediatricians are forced to limit their Medicaid panel to below the 20% threshold in order to stay in business.. These pediatricians may have financial difficulties in purchasing EHRs. Pediatricians generally do not care for those with Medicare, either. Thus, a significant proportion of pediatricians will be excluded from eligibility from the ARRA incentive program. We urge that Children’s Health Insurance Program (CHIP) and uninsured patients be included in the 20% calculation. Additionally, future ONCHIT initiatives should include the recognition that further dissemination of EHRs in pediatric practices that do not meet the Medicaid threshold could be limited because they are left out of ARRA incentives.
Rule 4: Meaningful use must mean that no pediatrician is left behind.
Unlike the Meaningful Use program for adult patients that will be designed and structured by the federal government though CMS, the incentive programs tied to Medical incentives are shaped and implemented by the state and Territorial Medicaid programs. The risk of generating 57 different programs and 57 different definitions of Meaningful Use for children is high. This would discourage HIT vendors from implementing Meaningful Use criteria for children, because the potential buyers for each measure may be limited to one or two states. In order to be successful in pediatrics, meaningful use criteria must be standardized and harmonized across states and Territories.
Rule 5: Meaningful Use must mean the same thing in every Medicaid program.
Meaningful Use has been divided into stages, and stage one requires the physician to use an EHR that contains all the required elements. Failure to comply in even one category will lead to a failure to qualify for incentives. However, many smaller practices and hospitals will face challenges and obstacles that may make 100% compliance with all measures impossible. To generate the most benefit for children, the American Academy of Pediatrics believes it is in the best interest of children to support and encourage both full and partial implementation by physicians to qualify for full or partial participation in the incentive process.
Rule 6: Meaningful Use regulation should include incentives for partial implementation.
Meaningful Use is part of the 2009 American Recovery and Reinvestment Act. One goal of this stimulus measure is to get money into the economy as fast as possible. ONCHIT’s Meaningful Use does so, at the same time advancing HIT in medicine in a dramatic way. Clearly, regulation done under such enormous time pressure has opportunities for improvement. The American Academy of Pediatrics supports the goals of Meaningful Use rules, and looks forward to collaborating with CMS and the Office of National Coordinator to improve on the details.
Medical Director, Child Health Informatics Center
American Academy of Pediatrics
Hot debate. What do you think?
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We need an easy way to identify that the patient is the patient (unique ID or some national matching algorithm). Without a national solution, each region will have their own method that must be replicated and will waste dollar. In addition to wasting dollars the quality may not be the same so people will begin to not trust the sharing of the data if it makes mistakes.
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It is difficult to think about implementing HIT/EMR/EHR when we have been unable to secure a proper computer operating system and infrastructure. First, we need help in doing that. Does anybody know if some of these funds can be allocated to upgrading our operating system so we are not operating in the dark ages? If we become at risk of viruses, hackers, etc., due to outdated operating systems, how can we build secure apps on top of that? Can anybody point me to some specific text in this package where we could possibly justify upgrading our operating systems first and get reimbursed?
Hot debate. What do you think?
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Many (most?), of the work flows are semi-manual or paper based. These work-flows evolved over the years (ages ?), to solve the problems which occurred, and new opportunities that came up. These were made piece-meal, and often in a knee jerk reaction to the situation. The work-flows kept getting fatter and fatter, layer upon extra layer, esp. when the earlier work-flow was unable to solve the problem, another layer,procedure was added, and so-on. Computers only added to the confusion by easing some of the tasks.
However I feel that health care , in the 21st Century, needs to look at he complete Health Care supply chain, on a life-time, and life cycle view (as against small silo driven and optimized views), to see what the process/work-flows should be. Benchmark them, and standardize them to a few “Best Practices”. These best practices can form the basis of a future software, and standards, CCHIT etc. Then choosing the software/package, becomes easier, as you have to see the work-flows for which it has been designed (or to which it can be configured/modified easily), Also an assessment should be made if the new (To-be ) process required is really needed. or is it a hang-over of past practices. It is easier to asses work-flows by non-IT folks. business analysis tools, RACI Analysis etc are available to analyze work-flows, than it is for providers and administrators to assess the pros-cons of different packages. Besides they can own and contribute to the change management which is essential for the success of an EHR.
These are not rocket science, but practical knowledge that ha been learn t by other industries in the past, like automobiles, manufacturing, supply chain, CRM etc. Health Care needs such a wide reference work-flow model.
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The Healthcare Information and Management Systems Society (HIMSS) Nicholas E. Davies Award Program provides the nation’s largest collection of first-hand accounts of the vision, leadership, technology and management required to achieve successful EHR implementation. Since its inception in 1994, 65 awards have been received across the four award categories: Organizational Davies Award: Initiated in 1994, 27 healthcare organizations recognized; Ambulatory Care Davies Award: Initiated in 2003, 19 practices recognized; Public Health Davies Award: Initiated in 2004, 13 public health entities recognized; Community Health Organization Award: Launched in 2008, six community health organizations recognized.
With its objectives to 1) Promote the vision of EHR systems through concrete examples, 2) Understand and share documented value of EHR systems, 3) Provide visibility and recognition for high-impact EHR system, and 4) Share successful EHR implementation strategies, the Davies Awards program not only requires a solid implementation, it requires the applicant to demonstrate through its application and onsite evaluation by HIMSS staff and Committee members:
· Patient care efficiencies achieved through seamless integration across the continuum of care
· Clinical decision support within the EHR systems in real time to make patient care decisions, to meet quality, efficiency and safety goals (e.g., medication reconciliation, decreased average length of stay)
· Demonstration that the system is integral to achieving the organization’s strategic objective
· Demonstration that all major clinical areas are using the EHR, through setting, measuring, and achieving clinical, financial, and operational objectives
· The ability to mine data to produce information for informed and proactive clinical decision making
· Cost savings and return on investment (hard and soft)
The application itself is a tool that provides an introspective self-assessment, valuable for planning an EHR implementation. The evaluation process assesses the real-world experience of applicants, requiring information of how barriers were overcome and what lessons learned were applied, to continuously evolve the system. These personal stories, substantiated by metrics of change and improvement, distinguish this program, as an essential learning vehicle.
The Award winning applications are posted at http://www.himss.org/davies as well as other resources including fact sheets and white paper series that provide metrics that show value derived from the system.
A program of case studies, not an Awards program, is the HIMSS/ASQ Stories of Success call for case studies, that highlights how health IT is leveraged to fulfill National Patient sSafety Goals of The Joint Commission and national recommendations of the National Priorities Partnership.
A listing of the case studies selected, and six of sixteen posted case studies can be accessed at http://www.himss.org/storiesofsuccess
Hot debate. What do you think?
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It is difficult to think about implementing HIT/EMR/EHR when we have been unable to secure a proper computer operating system and infrastructure. First, we need help in doing that. Does anybody know if some of these funds can be allocated to upgrading our operating system so we are not operating in the dark ages? If we become at risk of viruses, hackers, etc., due to outdated operating systems, how can we build secure apps on top of that? Can anybody point me to some specific text in this package where we could possibly justify upgrading our operating systems first and get reimbursed?
Hot debate. What do you think?
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First, I could not agree with Dr. Fishman more. Preparation, not selection, should be the primary focus for this massive change management upon which we, the whole of American healthcare society, are embarking.
Second, while there is so much which needs addressed within the confines of this global system change we are undertaking (we are truly in the throes of labor, suffering the birth pangs as we birth this giant new digital healthcare baby – for which there is no epidural, I might add,) that limiting the discussion here is not only wise, but necessary. Thus, to address your requested focus of “four categories of standards,” specifically number “2. Content Exchange Standards,” I suggest one component, one approach which, in my humble opinion, might solve one small, but important, piece of this giant puzzle.
Standardization of Views for Laboratory and Radiology Reporting
“Meaningful Views” is a grand conglomerate term which encompasses graphical user interfaces (GUIs) and workflow efficiencies and the minimization of “clicky-clicks.” Meaningful views are something we all seek, every day, whether via digital dazzlery or paper and pen.
Consider the ultimate goal of medical information: to lead to better heath. My goal, as a physician, is to help my patients lead better quality lives via better health choices and illness management optimization. To accomplish this goal, I need to: obtain data; aggregate, assimilate, and evaluate that data; add interpretive value to that data; and deliver the data’s meaning and true usefulness to the patient. Whether it needs to come from the patient, from a lab test or radiology exam, or from a textbook, professor, colleague, or website, the data I need to digest must somehow be “viewed” in order to be shared and used.
While auditory “viewings” of data are important, more and more in our modern world we are turning to visual information sharing portals. Televisions, faxes, lab/radiology printouts, computer screens – these are increasingly diminishing the verbal-auditory transfer of information.
The exponential growth rate of medical knowledge has long ago exceeded the mental capacity of mere mortals. Thus, how data is presented has become increasingly pressing. We need data views that facilitate our data comprehension. If we were not mere mortals – and perhaps the ultimate goal of all this techno-data-collaboration is to allow this – we could share knowledge via some form of Vulcan mind meld or Borgian collective consciousness. Until that time, in order for us to share the information we seek or need, the presentation of that data must improve.
We all only have so much time in a day. We need data delivery which is as fast as possible, as efficient as possible, and as easy to assimilate as possible, because we have a lot of things we need to do with that data. Personally, I also want to get home to see my family on occasion. (OK, I also want to have time to catch the latest Mythbusters.)
I want data “views” that make sense. I want data views where I have to do as little as possible to assimilate said data. I want views that allow me to do the things I really want to do, not views that require me to alter what I do in order to accommodate the viewing. If I have to learn how to view the data, if I have to work to visualize the data because it comes in a difficult format, if I have to constantly seek the data I need because it comes in non-standard views, then the data viewing becomes a barrier to my goals.
When I seek data from a lab report or from a radiology report or from the exam notes of a previous physician, you know where most of my time is spent? Yep. Looking for the data I need. Why? Because the “view” is either non-standard, sub-standard, or, sometimes, flat out crappy.
I recently learned of an initiative to provide cross-platform standardization of laboratory data. This means that whenever I look at a lab report, from whichever institution or provider or EMR or HIE, the data is presented in a regular, logical, and consistent format. The “view” is optimized. Time is spent in understanding the data, not in finding the data. (If you’ve ever had a new lab reporting system thrust upon you where you had to relearn where to look for lab data in the new system’s report forms, you’ll understand.) If you can easily see it, you can use it. If you can easily see it, you won’t unnecessarily repeat it. If you can easily see it, you can make meaning from it. (You can see this solution at http://www.diagnosticinformationsystem.com/index.html . It can reportedly reduce “views” by a whopping 80%!)
Meaningful use, in my humble opinion, should always revolve about what helps us doctors help patients. Help me spend less time looking for what I need, help me focus less upon data entry functions and clicky-clicks, help me make better decisions for helping more people faster, help me get home to see my wife, sons, and Survivor more often – that is meaningful use for us grunts in the trenches. This standardized look for lab reports, one form of “meaningful views,” would be a great step in that direction.
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As a FT practicing physician (currently ER , primary care in the past) I have worked in many different settings, and have a broad ‘trench’ level view of HIT. As a member of the PDF Healthcare committee, and exploring software design, I have obtained another very different view of HIT. Unfortunately, these two views are very disconnected. When I am delivering care, I need products that HELP rather than hinder my efforts. When I see grants awarded, these are obtained by organizations who know how to write for grants. When I see money directed toward HIT, this money will go to organizations who understand ‘the system’ of how to obtain such money (that is, large vendors whose main business is generating money with sophisticated sales, marketing and lobbying activities rather building innovative, useful products). What I DON’T see is enough support for things such as PDF Healthcare. The following is a statement put together by the PDF Healthcare Committee to get the word out:
·Despite the growing (albeit slow) acceptance and use of electronic medical records, there remains a continued need to print electronic documents to paper.
·Despite the important need to securely exchange “structured” electronic medical record data between providers, patients and payers, there is an important need to include attachments, which consist of “unstructured” data provided on paper, in graphic or video file formats, as diagnostic images, or as text data.
For more than four years, the PDF Healthcare Committee has been promoting healthcare information technology (HIT) interoperability “from the roots” by means of the PDF document format. PDF is a globally-accepted and used document file format as well as an international, open standard (ISO 32000-1, Document management – Portable Document Format – PDF 1.7). PDF is recognized worldwide as the most reliable, flexible, and feature-rich format for information exchange because it manages all information formats, including structured data, text, graphics, x-rays, and video that are used in the healthcare industry.
PDF Healthcare is NOT another proposed standard for healthcare information interoperability NOR does it replace existing standards. PDF Healthcare is an intersection of the PDF standard and the Internet’s eXtensible Markup Language (XML) standard for moving and sharing data. This allows healthcare providers to offer any existing or future standardized healthcare data set with PDF Healthcare in response to record requests and exchanges — with the electronic system receiving the data negotiating for the standardized data set that makes the most sense at the time.
The PDF Healthcare Committee believes that interoperability must start with tools such as PDF that are widely-available and simple for people to use at the point of healthcare delivery and that a “bridge” approach such as PDF Healthcare must be realized when transitioning from the paper world to the digital world. Any healthcare provider, patient, or payer can save a healthcare document to a PDF file, easily print it out if they still operate using paper, or manage it digitally.
The PDF Healthcare Committee is a voluntary group of HIT industry vendors, consultants, and thought leaders. The PDF Healthcare effort is sponsored by the AIIM (Association of Information and Image Management) and ASTM International (American Society for Testing and Materials) standards development organizations. More information about PDF Healthcare and the Committee can be found at: http://www.aiim.org/standards/article.aspx?ID=31832
PDF Healthcare is number one on my list of inexpensive, modern technologies that need to be nutured and supported for us to move forward with digitizing healthcare.
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The future of healthcare has been alive and well for years in central Massachusetts.
Fallon Clinic, a 250-physician multispecialty group practice, over the past 18 years developed interfaces to 5 regional hospitals, a reference lab, an imaging center, a Quality Data Center, and a health plan. These interfaces pass discrete test results as well textual documents directly into Fallon Clinic’s EHR in a seamless manner. For instance mammograms performed at one of the interfaced hospitals will appear on the imaging tab in the EHR right next to imaging studies done at other facilities. This mammogram also automatically satisfies health maintenance reminders. Similarly, claims data from the health plan for a Hemoglobin A1C done outside of Fallon Clinic’s interfaced systems appears on the lab tab next to other labs performed on that patient, and satisfies disease management reminders and Quality Data Center reports as well. Claims from visits to an Emergency Rooms for a laceration while a patient is away on vacation creates an ER Encounter in our EHR and automatically updates the patient’s tetanus immunization status. For the past 18 years, Fallon Clinic has similarly been loading medication claims data into the patient’s medication list where it is possible to view medication compliance and the number of refills remaining on a patient’s prescription, regardless of prescriber or the pharmacy that they used to fill it.
Significant surgical procedures and diagnoses from billing and claims are reloaded automatically back into the EHR to populate the Past Surgical Hx and Past Medical Hx respectively. This, and the fact that 15 years of historical notes, test results, medications, allergies, and immunizations were loaded into Fallon Clinics EHR when it went paperless 3 years ago, have led to the extraordinarily successful implementation of the Epic EHR. As a result of this electronic “abstracting”, it appeared to the user when the system went live, as if the EHR had been in use for 15 years, with encounters from 1992 showing the transcribed notes, billing diagnoses, prescriptions, and test results all linked together.
Patients have access to their Epic EHR using a tethered PHR where they automatically receive their test results, have instant access to a linked medical encyclopedia, and can send secure emails to their Fallon Clinic physicians.
Fallon Clinic continues to advance healthcare with SAFEHealth.org, a live and sustainable federated Health Information Exchange written by the Fallon Clinic IT department, designed to simplify the patient consent process and to integrate clinical data directly into other EHRs.
Fallon Clinic has been able to provide exceptionally high quality care to their patients as a result of this Health Information Technology. For instance, in 2009 Fallon Clinic exceeded the 90th percentile nationally for 22 of the 36 Commercial HEDIS Quality Measures for which comparisons are available, and is the benchmark for the state of Massachusetts in 8 of these. At the same time Fallon Clinic has a reputation for providing highly efficient, cost effective care, to a large degree as a result of health information technology. And since SAFEHealth went live in June of 2009, other healthcare providers are now experiencing the same incredible capabilities that physicians at Fallon Clinic have enjoyed for years: only having to look in their own EHR in order to know everything about their patients.
The future is here today, and it’s wonderful!
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