Needless to say, the site does provide a wealth of information, though you may have to dig to find what is most important to you.  The site may also become prone to being dated, so be careful and double check other sources for more current info.  For example, the section on certification of EHRs stated that certification rules will be released in “late spring/early summer” – well they are already out, having been released on June 18th.  Hopefully, HHS, CMS and ONC can work more closely going forward to insure that information on this new, and what may become an important site, is truly current.

In launching this site, CMS is trying to get ahead of the curve and likely onslaught of requests for information once the final meaningful use rules are released. While this website states that these rules will be released, again, “in late spring/early summer,” we are now placing our bets that these rules will be released at 4:55pm on July 3rd, unless of course someone in the administration decides to postpone such an announcement until the opportune moment comes along to generate some positive press for what is currently an embattled administration.

Winners

Consultants: At 556 pages, very few physicians and hospitals will take the time to read the complete meaningful use rules, rather hiring consultants to guide them in mapping out a strategy to adopt and implement a certified EHR to meet these requirements in the tight time-frame allowed.  Hospitals and large private practices will have the resources to hire such consultants, small practices will not, instead relying on the yet to be formed statewide extension centers.

Payers: Demonstrating meaningful use will require electronic eligibility checking and claims submission for 80% of all patient visits.  This will greatly simplify payers cost burden for payers who must currently contend with eligibility checking by phone and mountains of paper claims submissions from providers.

Large, Established EHR/EMR Vendors: These vendors have the resources and political clout to insure their apps will meet certification requirements.  They will meet such requirements either through internal development or acquisitions.  In some cases, partnerships will also be used to meet smaller, niche requirements of meaningful use.  Big boys with an established presence include: AllScripts, Cerner, Eclipsys, Epic, GE, McKesson, NextGen, Siemens, etc.

Revenue Cycle Management (RCM) Vendors: Core to most RCM vendors solutions is the ability to perform electronic eligibility checking and e-claims submission.  As this is now a core requirement for incentive payment, these vendors will see a boom in business. Smaller, independent vendors such as MedAssets and SSI will likely be acquired.  Large vendors, such as Emdeon, may expand their offerings into core EMR functionality similar to what athenahealth has done with the introduction of athenaclinicals.  Companies such as RelayHealth should also see a bump up in business as providers look to address this requirement.

Medication Checking Reconciliation & eRx Apps: A significant amount of attention is being paid to addressing medication errors and e-Prescribing (eRx) in Stage 1 of the meaningful use rules.  The HITECH Act legislation specifically calls out eRx as part of meaningful use and CMS has been promoting/encouraging adoption as well so this is a no-brainer.  The big winner here is SureScripts.  Medication/formulary reconciliation is also called for in Stage 1, something that the Joint Commission has been advocating since 2005.  Several eRx and EMR apps have embedded this functionality in their solutions.  Lastly, physicians and hospitals will be required to do drug-drug, drug-allergy and drug-formulary checking.  Companies such as First Data and Thompson as well as Cerner’s Multum solution should do well in addressing this requirement.  There are also a plethora of smaller companies, such as enhancedMD, Epocrates, Medscape, etc. that may benefit, through partnerships with or acquisitions by larger HIT firms.

M&A Firms and Small, Innovative Software Companies:: Stage 1 is asking for a lot of functionality that simply does not exist in many EHR/EMR solutions.  Larger, more established EHR/EMR companies will not have enough time to build out all the functionality required and will either seek partnerships or acquire smaller, niche vendors such as those mentioned previously (our bet is we’ll see more acquisitions than partnerships).  Due to the strong demand for niche applications to fill gaps in their solution portfolios to meet Stage 1 requirements, these EHR/EMR vendors will likely pay premium dollars for the best-in-class apps.  Small, innovative software vendors and the M&A firms that represent them will do well over the next few years.

The first document, at 136 pgs, titled: Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology is targeted at EHR vendors and those who wish to develop their own EHR platform.  This document lays out what a “certified EHR” will be as the original legislation of ARRA’s HITECH Act specifically states that incentives payments will go to those providers and hospitals who “meaningfully use certified EHR technology.”  This document does not specify any single organization (e.g. CCHIT) that will be responsible for certifying EHRs, but does provide some provisions for grandfathering those EHRs/EMRs that have previously received certification from CCHIT.

The second document at 556 pgs titled: Medicare and Medicaid Programs; Electronic Health Record Incentive Program addresses the meaningful use criteria that providers and hospitals will be required to meet to receive reimbursement for EHR adoption and use.  Hint, if you wish to begin reviewing this document, start on pg 103, Table 2.  Table 2 provides a fairly clear picture of exactly what CMS will be seeking in the meaningful use of EHRs.  In a quick cursory review CMS is keeping the bar fairly high for how physicians will use an EHR within their practice or hospital with a focus on quality reporting, CPOE, e-Prescribing and the like.  They have also maintained the right of citizens to obtain a digital copy of their medical records.  An area where they pulled back significantly is on information exchange for care coordination.  Somewhat surprising in that this was one of the key requirements written into the original ARRA legislation.  But then again not so surprising as frankly, the infrastructure (health information exchanges, HIEs) is simply not there to support such exchange of information.  A long road ahead on that front.

In Closing…

As I am on vacation and today is a powder day here in the Rockies, I will come back to this at a later date after I have had some time to review and digest these two documents.  First thought though that comes to mind is that the only initial winners here will be the consultants as few doctors have the time or inclination to pour over the 556pgs of the incentive program.  Heck, in my own brief encounters with many doctors, most have only the most cursory knowledge of the HITECH Act and that knowledge is most often full of inaccuracies.  Hopefully, those regional extension centers that HHS will be funding will go live in the very near future as there is a tremendous amount of education that needs to occur to insure this program’s future success.

Speaking of which, CMS submitted its meaningful use rules for regulatory review on Christmas Eve.  Titled EHR Incentives Program (CMS-0033-P), we can expect final rules released for public review and comment in very near future.  Incentive payment schedule: hospitals may begin receiving reimbursement payments by 10/01/2010.  For physician practices, reimbursement payments begin on 01/01/11.  Of course, reimbursement is dependent on demonstration of meaningful use of a certified EHR  and we still do not know what “certified EHR” is.  Long road ahead folks – we’ll do our best to provide clarity as it evolves.

Next week, I’ll return to a more normal state of research and writing or this site.

Until then, may all enjoy the time they spend with their family over these holidays and wishing god health to you and yours for the New Year.

Unlike other aspects of the Stimulus package that were whittled down to get the required votes for passage, all things HIT came through relatively unscathed. What’s in store:

$17.2B in CMS incentives for physicians & hospitals to adopt a “certified EHR”. This is a boon to legacy EHR vendors as they will claim “certified” status via previous CCHIT certification.  Unfortunately, this language is likely to be a disaster for any innovative vendor.  No matter how much wiggle room the legislative language has as to what actually is a certified EHR (they leave it up to NIST & ONC to define), the bottom-line is that any certification process is cumbersome, time consuming and rarely, if ever, keeps pace with technology developments.  We’ve said it before and will say it again, this is extremely problematic.

Money distributed through CMS will be tiered, e.g., first year physician gets $15k, 2nd, $12k, etc.  If that physician gets started quickly (by 2010) they can reap some $41K. If they drag their feet and start a couple of years later, they’ll get a total of $24k.  A similar tiered model is also established for hospitals.  All of this is laid out in Division B of the Bill beginning on page 480.

To get reimbursement, a physician or hospital has to demonstrate that:

The certified EHR is “used in a meaningful manner”, they reference eRx.  They must be able to demonstrate the certified EHR “is connected n a manner that provides for electronic exchange of health information to improve quality of care such as care coordination.” Lastly, they must demonstrate that the certified EHR can also provide reporting on “clinical quality measures.”  Fine attributes to promote but see no reason why it must be done with a certified EHR.  Why not simply state that the physician/hospital must be able to demonstrate such activities?  You don’t need a “certified EHR” you need technology that can get the job done.

Flipping over to Division A, beginning on page 286 (real pain going back and forth between these two documents – do they do this on purpose?) we find the language that lays out how a certified EHR will be defined.  ONC will turn over $20M to NIST who will go forth and define the test standards ad implementation specifications and testing infrastructure for a certified EHR.  There on page 332, Division A we also find the language regarding the testing that NST will manage…

may include a program to accredit independent, non-Federal labs to perform testing

While they do not spell out CCHIT, sure sounds like that is who they are referring to.

An interesting little piece found on page 488 of Division B is the requirement that HHS do a study and produce a report on “Availability of Open Source HIT Systems.”  Odd to have such a study and can only think it is a pet project of someone in the VA looking to keep VistA alive or someone like Sun Microsystems looking to further substantiate the open source CONNECT NHIN they developed.

$2B for the Office of the National Coordinator (ONC). An absolutely huge amount of money of which 15% ($300M) is going directly to RHIOs/HIEs.  The nominal money spent to date, via grants for RHIOs, has been a waste.  Let’s hope this time that no money is distributed until a RHIO can provide a detailed business plan and revenue model that will make them self-sustaining within a given time frame, say 3yrs.

A significant portion of that $2B will go to establish a network of HIT Research Centers.  There will be one main Center, a number of regional Centers and HIT Extension Centers at the State level.  For State Centers a tiered funding model is also used with State having to provide matching funds that increase over time. These Centers will be established to gather lessons learned in best practices for adopting, deploying and using HIT in a clincal setting.  These Centers, in the short-term, may also be used for training HIT professionals.  Good idea, if they can keep these Centers focused and delivering value at the local level.  Agricultural Extension Services have been doing this for years with mixed success, hopefully they can learn from them.

It should also be noted that Congress has also given ONC the authority (Division A pg 322) to “develop and provide a qualified EHR unless determined that the needs and demands of providers are being substantially and adequately met through the marketplace”

Plenty more to look at in this Bill, but believe the above hits the high points, though we reserve the right to come back and add to it as we uncover more items of interest.

Concluding Thoughts

When we first wrote about HR 1, we were very concerned with the terminology for “certified EHR”.  That concern only increased upon reading very similar language in the Senate version.  It was pretty much a foregone conclusion that we were going to get stuck with that dreaded “certified” albatross, which has indeed occurred.  At this point, the best we can hope for is that insightful minds will take full advantage of the loose language in the HITECH Act and craft a definition and implementation program for certified EHR that promotes innovation, rather than hinders it.  Unfortunately, with the rush to do something, anything to get the economy on track, haste may make waste.  Congress has given ONC until Dec. 31, 2009 to “adopt an initial set of stnadards and implementation specifications” for certified EHRs.  Let us all pray that they use that time wisely.

While these legacy HIT vendors celebrate there will be many a small, innovative HIT vendor wondering what the heck does “qualified” or “certified” EHR mean as the legislation will only provide incentive payments to those physicians and hospitals that adopt a “certified EHR.”

CMS PHR Demo Launches in AZ & UT

First, CMS announced the launch of the trial PHR program for Medicare members in AZ and UT.  Beneficiaries can chose a PHR that fits their specific needs and have it pre-populated with up to two years of claims data. Within these states, Medicare beneficiaries will have the opportunity to pick from four different PHRs to use:

• Google Health: The big boy in the group, but arguably the one with the least features in their core PHR product.
• HealthTrio: These were the ones that performed the CMS PHR trial in South Carolina.
• NoMoreClipboard: They had the best interoperabilty capabilities of any PHR vendor in our May 2008 iPHR Rpt.
• PassportMD: Based out of Florida, they offer a solution with high-touch service features.

Now that this is live, will be interesting to see just what the adoption rate is among the elderly. We’re not holding our breath. Note, previous posts for more background on the CMS demo can be found here and here.

My Family Health Portrait Gets Upgrade

And out of the Surgeon General’s office we have an announcement that they have updated the My Family Health Portrait (MFHP) service.  While others are calling MFHP a PHR, it really doesn’t even come close.

MFHP does only one thing: It allows the consumer to enter various diseases contracted by various family members that a physician may later review to understand potential predispositions to diseases based on that family history.  No, it will not store your list of meds.  No, it will not have a list of your allergies, or advanced directives, or claims data, or clinical data or anything else that may often be found in most PHRs. MFHP provides only one service, a secure place to record one’s family disease history and then share it.

What many may not realize is that in fact, virtually all reputable PHRs in the market today already provide this capability to their customers, so it does seem a bit odd that the Surgeon General would go to all this trouble.  However, there may be a silver lining here in that MFHP may provide a convenient stepping stone for consumers to become comfortable with entering health information online that can later be used with their physician. In this case a consumer is entering information with a trusted source, it is the Surgeon General after all, and the data being entered is not necessarily specific to them – more inferential and thus may not be viewed as sensitive.  Having taken this initial step,and become comforatble with it, might the next step of the consumer be to use a more robust and complete service to record, store and access their complete health profile, ala a PHR or even one of the consumer Health Clouds from Google, Microsoft or Dossia?

First released as a downloadable app in Nov. 2004, the Surgeon General’s office quickly migrated MFHP to a Web-based service in Nov. 2005, and there it sat for three plus years with little visibility (I never heard of it) and attracted roughly 25K who created a family health portrait.

On Jan. 12, 2009, following guidance from AHIC, a new version of MFHP was released.  According to the website, the new version is:

1. Standards-based: Leveraging work done by the American Health Information Community (AHIC), both technical and core data standards have been built into the FHH 2.0 design. This means an increase in interoperability and a diminished learning curve for consumers, practitioners and researchers. They are using HL7 Family History Model, LOINC, SNOMED-CT and HL7 Vocabulary.  Wonder why not CCR?
2. Shareable: Information can be electronically shared by the consumer with family members and healthcare providers. This new feature allows consumers to collaborate with family electronically to develop a more robust family health history record. Somewhat surprised that this was not a feature of the original Web-based version.
3. EHR-Ready: Version 2.0 produces xml files that can be easily integrated into existing EHRs with little customization or IT support needed. Its as simple as copying an electronic file from one location into a new system. Obviously, since they are already using HL7.  Big question is, will a doctor actually import this into their EMR.  Also, do the Health Clouds today already have the data architecture/data elements in place to accept this data, let alone the plethora of PHR vendors?
4. Customizable: The tool can be downloaded for adoption under an organization’s own brand. It is intended to be easily adaptable into patient care portals, thus allowing healthcare organizations to promote family health history taking under their own brand, use it within their own secure environment, and contribute to comprehensive “one-stop-shopping” online patient service portal.  We like this feature as it will enable providers to readily adopt MFHP, for very little $$$, rather than re-invent the wheel.

Since the announcement went out on Jan. 13th, those responsible have reported to us that they are already running into server capacity issues.  Looks like there is a demand, or at least interest in this type of service.  Checking back in 6 months will prove whether or not there is sustaining interest or this is just a flash in the pan.

CMS & Nordian (CMS’s private administrator for that region who will oversee the project) received a total of 44 proposals.  Of the 44 submitted, 17 met the criteria for deep review and consideration.  Of those 17 , only 4 made the final cut.

Congratulations final four!

So, putting on our pundit and forecasting hat, here is what we see coming from Obama’s new administration:

The oft-quoted $10B a year investment in HIT will not materialize, in the near-term.  There is a small problem down on Wall Street that has extended across the country, heck the world, that will consume most available resources.  During the second half of his term, Obama may begin opening up the spigots and direct some significant funding towards healthcare IT but that will only occur if more pressing financial issues are brought under control.

Tighten budgets will put strain on all healthcare stakeholders.  This will lead to no one willing to give up their stake for the better good. Such committees as AHIC will be impotent in their ability to move anything significant forward.

Federal funding of RHIOs will continue, but at a lower level.  Limited resources and a lack of RHIOs that have actually succeeded (become self-sustaining) will force the Feds to reassess such funding, despite Kolodner’s loud protestations.

While being a strong supporter of Obama (worked local voting booth for the primary election), not convinced that throwing money at the HIT adoption problem is sound policy.  Such approaches tend to be top-heavy, too perscriptive, and despite the best of intentions, mis-aligned with true market needs.

Where the government can play a much more important and significant role is in the restructuring of programs it already funds (CMS), crafting incentive policies that create market forces to drive HIT adoption.  For example, the CMS program to push eRx, first with a carrot, later with a stick, makes a whole lot of sense.

Now, if we could only get legislation changed to allow CMS to support telehealth (new technology with clear benefits) or funding in support of PHR demonstrations, then we would be getting somewhere.

Thus, though I cringe at reporting these developments, report I must as they are important and will influence the market and its direction.

Today, received notice (caution PDF) that CCHIT has completed the draft certification criteria for PHRs.  They have set up a website, really nothing more than a Blog, where they will post the draft criteria on Sept. 29th for a a 30-day comment period.  They will also be hosting a Town Hall teleconference on October 10th to solicit feedback as well.

CCHIT is really hoping for consumer input(s) to the process and it will be interesting to see just how much consumer input they receive.  My hunch: It will be quite small as the vast majority of consumers either do not know what a PHR is and if they do, really are not engage at this level of discussion.

The first, by Carol Diamond (Markle Foundation) and Clay Shirky (Prof. at NYU) provides a thoughtful analysis on why the current government focus on standards and certification processes for HIT may be misguided and ultimately could hinder long-term adoption of HIT. Their argument is basically that current technology standards initiatives supported by the government are to prescriptive (limiting flexibility to respond to real market needs) while government policies addressing information use are sorely lacking.

Of the three papers, this one was by far my favorite. Thoughtful, well reasoned analysis that reflects many of my own beliefs. If you only have time to read only one, this is it. Where I do differ with the authors is their lack of attention to addressing the business case for HIT adoption. They touch upon it but do not drill down on it. This is the crux of the biscuit. Frankly, there are few incentives for any physician to adopt HIT (with the exception of revenue cycle mgmt), and plenty of disincentives not to. When there is a way for physicans to either clearly make money or save money via adoption of HIT, it will occur. Now what’s so hard about understanding that?

The second paper by HHS executive Robert Kolodner, et. al., attempts to defend the direction that has been taken at HHS to promote HIT adoption with an almost point-counterpoint style of writing in response to the Diamond-Shirky paper. Kolodner defends the direction that the government has taken stating that EMR adoption is accelerating as a result of government actions. He also goes on to state that information policies are very difficult to reach consensus on, a process that often lags advances in the technology itself.

This paper comes off as a defensive (not too surprising), though it begins by stating they fully agree with Diamond-Shirky that HIT will not solve the many ills that plague our healthcare system. Kolodner et. al., make several valid points where HHS initiatives have helped, but take far too much credit for EMR adoption. Little if any EMR adoption, to date, can be directly attributed to the feds, unless of course they paid for it in full through a grant. Rather, EMR adoption is occurring and accelerating for the simple reason that it makes economic sense for the adopting entity (and one can not ignore that part of that economic sense is that the solutions are getting cheaper and easier to deploy and support). Increasingly, physician practices of all sizes will have an economic justification for adopting HIT which has little to do with any government initiatives, except for that massive payer CMS, who has one hell of a carrot/stick to use if necessary. For example, the carrot today and the stick tomorrow for adopting eRx solutions that CMS has put in place. Next up, how about CMS reimbursement for eConsults?

And finally, I strongly disagree that information policies often move to slow in relation to technology advances. The trouble with this statement is that properly constructed policies, that provide frameworks (guardrails and sign posts) are useful and can be agreed upon without hindering technology development, adoption and use. Where we get in trouble is when we make such policies prescriptive.

The last paper by David Kibbe and Curtis McLaughlin takes a dig at the current processes and players that are recruited for various government led HIT initiatives. They argue that various committees, be they for standards or policies, are dominated by the old guard of the healthcare sector and fail to bring in outside players, such as new, Web-based solution providers. This has resulted in glacial, often reluctant advances in standards development, a continuation of the status quo and the lack of new perspectives/views to solve many of the seemingly intractable problems in the healthcare sector.

My least favorite of the three papers, this one is reminiscent of the many articles and papers I read in the late 90′s (the dot com era) where proponents loudly pontificated about how the Internet changes everything. For example, they state:

Over the past six years, expert panels and policy analysts have often ignored the analogy driving the public’s high expectations for health IT: namely, their experiences with Web-based applications in information-intensive activities such as banking, travel, finance, education, music, and interpersonal communication.

Simply ain’t so. Sure, there is a very small portion of the populace that may agree with the above statement and there have been plenty of public surveys that basically support this statement as well. But in my own informal discussions with consumers at almost every chance I get, very few really care – they simply are not engaged at the same level with the healthcare sector as they are with their music, their finances or their friends on Facebook. For most of us (the 80% that do not have a chronic health condition), healthcare is episodic, we worry about it when we have to and forget about it the rest of the time. This will change in time as the baby boomer generation moves into elder age and the multitude of health issues that will accompany them which they will need to manage, but it isn’t now (though we would be wise to prepare for it and Google, Microsoft and others are doing just that). The only exception to that statement is the increasing use of incentives by payers and employers to encourage healthy behaviors. But even here, there is most often a financial motive.

As in the case of Google, Microsoft and others, changes will occur when the end user sees value in that change. Quality, price and transparency, sure I’ll want to see that when I’m pulling out my credit card to purchase a healthcare service that is not covered. Ease of engagement with the healthcare system, yes I’ll want that to and my doctor better be prepared to work with me by communicating electronically. When healthcare stakeholders see more and more consumers like me, they will adopt the technologies necessary to engage me and retain me as their customer. It will be in their best financial interests to do so.

As I commented over on Matthew Holt’s blog (which by the way is where I first caught wind of these papers, thanks Matthew!), this whole problem of HIT adoption, value, standards, certifications, etc. can easily be boiled down into one simple thing, it is a supply chain problem. Suggest this industry start looking at manufacturing to better understand how they overcame many similar problems as well as where even in manufacturing, they still struggle today.