EHR Interoperability

Reforming the Military Health System – CNAS

Posted by timmreardon on 02/23/2015

Posted in: Data Science, EHR Interoperability, Global Standards, Health Care Costs, Health Care Economics, Health IT adoption, Health Outcomes, Healthcare Delivery, Healthcare Informatics, Innovation, Integrated Electronic Health Records, Military Health System Reform, Mobile Healthcare, National Health IT System, Patient Centered Medical Home, Patient Portals, Primary Care, Quadruple Aim, Quality Measures, U.S. Air Force Medicine, U.S. Army Medicine, U.S. Navy Medicine, Veterans Affairs. Leave a comment

Article link: http://www.cnas.org/reforming-the-military-health-system#.VOs6o8k5C03

Report link: https://healthcarereimagined.net/wp-content/uploads/2015/02/reforming-dod-healthcare_021015.pdf

By Heather Caspi | February 19, 2015 DOD EHR Choice

What’s in an EHR? As the Department of Defense prepares to select a new electronic health record system, some are advocating that it go with an open-source solution—not just to benefit of the DOD but to use the $11-billion program to benefit the healthcare industry at large.

Why it matters to the DOD

In a new report released by the Center for New American Security titled “Reforming the Military Health System,” the authors argue that the selection of a closed, proprietary system would trap the DOD into vendor lock, health data isolation and a long-term contract with technology that will age rather than evolve.

Co-author Stephen L. Ondra, a former senior advisor for health information in the White House Office of Science and Technology Policy, tells Healthcare Dive that an open-source solution could more easily adapt to meet future modernization and interoperability needs, and could more creatively be tailored to the DOD’s requirements.

Ondra says most commercial EHR systems are developed around the fee-for-service revenue cycle, a model that is not particularly relevant to the DOD and its healthcare system. He says an EHR for the DOD should be focused on the clinical care management aspect of these programs, which would require lengthy and expensive modification.

He argues that a proprietary system would be inadequate as it would leave the DOD with a single vendor’s solutions. “You don’t have some of the creativity and innovation that an open source system would have because you’re limited to a single vendor’s view and skills,” Ondra says.

In addition, he notes, proprietary systems have less incentive to provide interoperability solutions because their business model aims to lock people into using that particular system.

“I think the commercial systems are very good at what they do,” Ondra said. However, “they are not ideally designed for efficiency and enhancement of care delivery, and I think the DOD can do better with an open source system both in the near-term, and more importantly in the long-term, because of the type of innovation and creativity that can more quickly come into these systems.”

Why it matters to everyone

Whoever gets that $11-billion award is going to have a lot of money to develop EHR technology—and whether they are serving an open or closed solution will determine whether the innovations remain stovepiped from the rest of the industry, notes report author Peter L. Levin, a former chief technology officer at the Department of Veterans Affairs.

“If the DOD were to choose to go with a closed, proprietary system, it has the potential of stifling innovation in the rest of the industry,” Levin says. “If they go with an openly-architected, standard space and modular system, then really in a very simple way, they are spreading the innovation resources around.”

“Instead of concentrating it all in one place and letting that vendor own all of the innovation, they’ll be able to nourish and support the various components that comprise these complicated enterprise resource platforms in a way that will not only be beneficial to the DOD and the country in the long run, but will tremendously benefit the country and other kinds of innovations now,” Levin said.

Levin adds that the same arguments for the DOD to select an open-source EHR system apply to private healthcare systems as well. He asks consumers to imagine if they could only talk to people with same phone carrier, or only go to gas stations for their particular make of car.

He argues that private hospitals and private payers have been unwittingly supporting the continued isolation and segmentation of the commercial solutions.

“Healthcare suffers tremendously in terms of cost and outcome because of these isolated systems,” he says, “and that’s just as true for the private sector as it is for the public sector.”

Ondra adds that the DOD’s choice will set an example from which both open and closed source providers could learn.

“I think that a major government contract would send the message that the current systems, as good as they are, are not fully meeting the needs of clinical care in a way that is efficient for the provider,” he says.

“Going to an open source for the DOD gives the opportunity to have rapid development of things that are more helpful to care delivery, more efficient for the provider, because the customer then is the deliverer of care, and not the finance department of a care delivery system,” Ondra said.

Article link: http://www.healthcaredive.com/news/how-the-dods-choice-of-ehr-will-impact-providers/366180/

The Office of the National Coordinator for Health IT has released for public comment its shared nationwide roadmap for interoperability.

The roadmap’s goal is to provide steps to be taken in both the private and public sectors to create an interoperable health IT ecosystem over the next 10 years, according to ONC.

One of the main focuses on the roadmap is to enable “a majority of individuals and providers across the care continuum to send, receive, find and use a common set of electronic clinical information at the nationwide level by the end of 2017.”

In addition, the roadmap is also linked with President Barack Obama’s recently announcement Precision Medicine Initiative, which aims to increase the use of personalized information in healthcare, ONC announced.

“HHS is working to achieve a better healthcare system with healthier patients, but to do that, we need to ensure that information is available both to consumers and their doctors,” HHS Secretary Sylvia M. Burwell said in the announcement. “Great progress has been made to digitize the care experience, and now it’s time to free up this data so patients and providers can securely access their health information when and where they need it.”

Along with the roadmap, ONC also released a draft of 2015 Interoperability Advisory Standards, which “represents ONC’s assessment of the best available standards and implementation specifications for clinical health information interoperability as of December 2014.”

The roadmap is garnering praise from industry leaders, including from the College of Healthcare Information Management Executives. CHIME said in an annocement that is “welcomes” the Interoperability Standards Advisory today as part of the roadmap.

“This is a much-needed playbook for each and every health IT professional,” CHIME President and CEO Russell P. Branzell said in the announcement. “Now, healthcare providers and health IT developers have a single source of truth, with an extensible process to align clinical standards towards improved interoperability, efficiency and patient safety. While we have made great strides as a nation to improve EHR adoption, we must pivot towards true interoperability based on clear, defined and enforceable standards.”

The draft road map stems from, and is a more robust version of, a vision paper published in June by ONC. The ultimate goal of ONC in developing the road map is to build a continuous learning health system. The interoperability roadmap is also part of the ONC’s overarching Federal Health IT Strategic Plan, which spans from 2015 to 2020.

“As a draft, this roadmap needs the input from knowledgeable, engaged stakeholders and, in particular, areas where important actions or milestones may be missing,” according to ONC.

To learn more:
– here’s the roadmap (.pdf)
– check out the Interoperability Advisory Standards (.pdf)
– read the announcement

Article link: http://www.fiercehealthit.com/story/onc-unveils-interoperability-roadmap-public-comment/2015-01-30?spMailingID=11587394&spUserID=Mjg0MDEwMzE2MzkS1&spJobID=424244809&spReportId=NDI0MjQ0ODA5S0

Compiled by Neil Versel, Contributing Writer

While health providers praise the ONC’s interoperability vision, they’re demanding increased standardization and an accelerated roadmap to achieve the Triple Aim.

Interoperability was supposed to be a centerpiece of Stage 2 of the Meaningful Use (MU) EHR incentive program, but hospitals and physicians practices nationwide are finding out just how hard it is to achieve that goal. Through the end of August, a mere 25 hospitals and 1,277 eligible professionals had attested to Stage 2 on the Medicare side of the program, according to CMS.

A KLAS Enterprises report, released in October, found that although 82 percent of the 220 providers interviewed thought that they were at least “moderately successful” with interoperability, a mere 6 percent said they were at an “advanced” level. And just 20 percent were “optimistic” about health IT vendors’ efforts to collaborate on interoperability.

In the same week, the Office of the National Coordinator for Health Information Technology submitted its annual report to Congress, highlighting some of the problems. “Electronic health information is not yet sufficiently standardized to allow seamless interoperability, as it is still inconsistently expressed through technical and medical vocabulary, structure, and format, thereby limiting the potential uses of the information to improve health and care,” the report said.

Days later, ONC released an update of its proposed 10-year roadmap to interoperability, a document that will be finalized in 2015. Like the earlier draft, this version put interoperability front and center on the office’s three-year agenda, while harnessing this information to improve care and lower cost was part of the sixyear plan. This effectively pushes a main goal of Stage 2 into the third stage of MU, which will not start before 2017, and suggests that the bulk of the nation’s healthcare providers won’t achieve the “Triple Aim” until after the incentive money is gone.

Building Interoperability Around APIs

ONC’s Health IT Policy Committee and Health IT Standards Committee also approved recommendations from a task force of an independent scientific advisory group known as JASON (not an acronym, but a reference to a character in Greek mythology) to build interoperability around application programming interfaces (APIs). Together, the moves have gotten mixed reviews.

“Credit to ONC for the vision,” said Russell Branzell, CEO of the College of Healthcare Information Management Executives (CHIME). “We just need to find a way to do it faster than a 10-year plan.”

Branzell wondered how hospitals are supposed to balance the longer-term vision for interoperability with an MU timeline that penalizes noncompliant providers starting in 2015. “There still are some pieces fundamentally missing,” Branzell said.

He believes there should be “clearly enforceable standards” for patient matching, as well as “specific data standards that are enforceable down to the nomenclature number.” Not having standards — standards that are kept current — adds to the complexity of health information exchange by offering too many choices that are not always compatible with each other, according to Branzell.

The CHIME chief continued, calling patient matching “the cornerstone of not only effective patient exchange but also patient safety.” He would like at least a standardized patient matching requirement, if not a national patient identifier; a national ID has been politically taboo since at least 1998, even though the original 1996 HIPAA statute called for one.

Branzell praised the API strategy, while also indicating he was a proponent of the Fast Healthcare Interoperability Resources (FHIR) standard for data exchange, something created by Health Level 7 International. (Branzell is a member of the HL7 advisory board.)

The API idea is proving popular at the policy level. At a Washington, D.C. healthcare conference put on by U.S. News & World Report in October, Micky Tripathi, founding president and CEO of the Massachusetts eHealth Collaborative; Jennifer Covich Bordenick, CEO of eHealth Initiative; and Steven Posnack, director of ONC’s Office of Standards and Technology, all spoke in favor of greater availability of APIs in healthcare. After all, it has become common for facilitating interoperability in so many other industries.

“Kendall Square [in Cambridge, MA] and Silicon Valley are laughing at us,” said Tripathi.

Tripathi mentioned other interoperability vehicles, including secure messaging following Direct Project protocols, point-to-point query and retrieve — usually by organizations using the same EHR vendor — and record aggregation with data normalization. Central repositories, he said, “are the dinosaurs that are going to go away.”

Later, at the same event, then-National Health IT Coordinator Dr. Karen DeSalvo, said that EHRs would have limited impact on the quality of care in the absence of greater interoperability.

In the real world of healthcare, providers are getting creative, though some still want more clarity from Washington or from the health IT industry. Gulfport (MS) Memorial Hospital replaced its legacy EHR with a Cerner system that went live in June. Three months later, CIO Gene Thomas said that his most difficult task was migrating data to Cerner.

“This could have been avoided if all vendors had been told to adhere to the same formats,” Thomas said. “The lack of standards in healthcare is a problem.”

Addressing HIE Via Common Vendor Platforms Memorial Health System in Springfield, IL approached interoperability in what CIO Dr. David Graham called a “reverse way,” with private practices bringing data to the organization’s primary care group. Like so many other providers, Memorial is building a health information exchange among nearby organizations that have a common vendor, in this case, Allscripts Healthcare Solutions.

Memorial has been rolling out the Allscripts TouchWorks EHR at its own clinics this year and is installing an Allscripts interoperability platform called FollowMyHealth. The precursor of FollowMyHealth, called Jardogs, was incubated at the Springfield Clinic, a partner of Memorial Health System, prior to Allscripts acquiring the technology in early 2013.

Another partner, the Southern Illinois University School of Medicine, also is transitioning to TouchWorks for ambulatory clinics, Graham said. “We are competing practices using the same database and the same instance of TouchWorks,” he said.

Memorial also collaborates with a federally qualified health center (FQHC). When that safety-net facility refers patients to the Springfield Clinic or the SIU School of Medicine, information from a NextGen Healthcare Information Systems EHR flows into a common portal that care managers can access to reach out to high-risk patients, Graham said.

“The other benefit of it is that then you can put that data in front of the physician,” Graham said.

It’s not full interoperability, but it’s a start.

Adding Mobility To The Interoperability Equation

A much larger healthcare system, San Francisco-based Dignity Health, has made interoperability a major component of a massive IT program. Dignity Health, formerly known as Catholic Healthcare West, was the launch customer for AirStrip One, a product from San Antonio-based AirStrip Technologies that delivers data from EHRs, patient monitors, and medical devices to clinicians on their mobile phones and tablets. Dignity also made an unspecified investment in AirStrip in August.

“We’re fairly early with AirStrip One,” said Dr. Davin Lundquist, Dignity’s CMIO for population health. In the fourth quarter of 2014, the multistate health system was implementing the product in the Central Coast region of California. “In parallel with this, we are exploring care management, video visits, and other ways to engage patients,” Lundquist said. “You need to come at it from lots of angles.”

AirStrip OB, an obstetrics module, is in nearly every one of Dignity Health’s hospitals, and the health system also has begun using AirStrip’s cardiology product. “What we are envisioning is that we will get AirStrip in the hands of all of our physicians,” said Lundquist, a family physician in Camarillo, CA, who practices about one day a week. He expects to have secure clinician messaging within the apps as well.

There are a lot of physicians to reach. Dignity Health has approximately 1,200 employed physicians and 2,000 to 3,000 “clinically integrated” aligned physicians among its total medical staff of more than 10,000, according to Lundquist. “Our health system, like many others, relies on independent physicians to support our work,” he said.

Meanwhile, Dignity is about two-thirds of the way through migrating its hospitals to a Cerner EHR from an older system. Dignity Health Medical Foundation in California and several practices in the Phoenix area all run an Allscripts EHR, though Lundquist said there is “some variability” among those Allscripts installations.

Dignity has built a private health information exchange on the MobileMD platform, technology that Siemens bought in 2011 and now is in the process of selling to Cerner as part of the latter’s $1.3 billion acquisition of Siemens’ health IT business. More than 7,000 physicians across all of Dignity’s markets are connected, according to Lundquist. “In most cases, that allows them to access hospital information,” he said.

However, most of the data flow is one-way, though some employed physicians do have bidirectional exchange with Dignity Health hospitals. According to Lundquist, this is more a legal issue than a technical one. “Who owns it? Does it become part of the [patient’s] legal record? Do you become an HIO?” he wonders.

Dignity Health’s system connects with many national, standard HIE connections and exchanges data with the UC-Davis Medical Center and, according to Lundquist, is exploring a relationship with UC-San Francisco. He expects Dignity to participate in some fashion in California’s statewide HIE known as the California Integrated Data Exchange, or Cal INDEX.

Physicians seem to welcome the efforts, as long as HIE fits workflow and makes practitioners more efficient. “I haven’t seen any resistance from physicians when we give them data,” Lundquist said.

Eventually, he would like to push alerts to clinicians to encourage early interventions with high-risk patients. “There needs to be a benefit to the doctor and the patient for them to do something outside their traditional workflow,” Lundquist said.

“Obviously, it’s important to integrate as much clinical data as possible,” said Lundquist, who reports to both the CIO and to physician integration team leaders. That is easier with employed doctors than with independent physicians, who have all sorts of EHRs at various levels of implementation and sophistication. “Some small vendors don’t even have strong CCD outputs yet,” Lundquist said, referring to the Continuity of Care Document format required in Meaningful Use Stage 1. (Stage 2 replaces CCD with an HL7 standard called the Consolidated Clinical Document Architecture.)

The Best Is Yet To Come

Stage 1, which about 90 percent of hospitals and 70 percent of individual clinicians in the U.S. have met, was about getting EHRs in place. With that in mind, CHIME’s Branzell is optimistic. “We have a lot of exchange going on in a lot of places that wasn’t there 4 to 5 years ago,” he said.

“We’re building a house. We’ve got a beautiful foundation now,” Branzell said. “But you can’t live in a foundation.” Right now, the nation’s healthcare organizations are “just starting to put up the walls,” he added.

“Huge gains in efficiency and safety were not supposed to come until post-Stage 3,” Branzell said. That will be in about 2020, or the sixth year of ONC’s new 10-year vision. “It’s not all doom and gloom,” Branzell said.

Article link: http://www.healthitoutcomes.com/doc/the-ongoing-health-it-interoperability-struggle-0001?sectionCode=Articles&templateCode=Single&user=2423280&source=nl:42136&utm_source=et_6231164&utm_medium=email&utm_campaign=HCIT_2015-01-15&utm_term=0009EE33-ABCE-4D02-9B3C-4F32FFAA82BE&utm_content=The%2bOngoing%2bHealth%2bIT%2bInteroperability%2bStruggle

by Margalit Gur-Arie 12/15/2014

The distinguished JASON group of anonymous scientists and academics that provides consulting services to the U.S. government on matters of defense science and technology, just published a sequel to the 2013 best seller, “A Robust Health Data Infrastructure”. The new report is titled “Data for Individual Health”, and it has two purposes. The first and foremost purpose is to backtrack on the searing criticism leveled at government efforts to promote health information technology, which evoked much angst and indignation earlier this year. The second purpose is to expound upon the exact nature of personal data required to feed the robust infrastructure laid out in the first JASON report, complete with illustrations and examples of breakthrough benefits to humanity, such as helping city planners design bicycle paths. Yes, bicycle paths. And if you didn’t know that the number one health care problem in this country is the layout of bicycle paths, then you are a Luddite, and luckily your generation will soon be dead.

After dutifully observing that only a tiny percentage of Americans use medical services of any kind, JASON is informing us that the government agencies that funded its work “specifically” asked the group “to address how to bridge, on the national scale, to a system focused on health of individuals rather than care of individuals” [italics in the original]. It seems that the overdetermined triple aim of health care reform, better health for populations, better care for individuals, at lower per capita costs, is finally being reformulated into a solvable optimization problem by removing the unprofitable constraints on caring for the sick.

As was the case with the previous JASON report, the group was briefed by a diverse array of researchers and technology experts, including the great new hope of health, our most beloved, innovative, tax evading, and slave labor supported, Apple Inc. The content of briefing sessions is not available to mere mortals, but one in particular is rather enlightening in its title: “Disrupting the Status Quo: Putting Healthy People First”. Never since the dawn of medicine, from Hippocrates, to Florence Nightingale, to Mother Teresa and today’s Doctors Without Borders, have we experienced greater disruption in the status quo.

Similar to the first JASON report, the second offering is chockfull of technical recommendations for the “collection, assimilation, and exchange” of quantifiable “data streams” emanating from living things, whether in traditional medical surroundings or as people go about living their healthy lives. There is nothing earth shattering in the JASON findings or recommendations, but some finer points may be worth mentioning anyway.

Phenotypes – After providing us with a crash course in genomic sequencing and the workings of RNA and other protein molecules in the first report, JASON argued that the “biomedical research community will be a major consumer of data from an interoperable health data infrastructure”, hence the government “should solicit input from the biomedical research community to ensure that the health data infrastructure meets the needs of researchers”. In the second installment, JASON is reiterating its obviously very strong interest in genotype-phenotype relationships and their assimilation into the IT system they are recommending we build. Luckily, some of the JASON briefers happened to hail from academic centers renowned for grant funded genomic research in general, and efforts to “develop algorithms and methods to convert EHR data into meaningful phenotypes” in particular.

In Vivo – I have to admit that compared to run of the mill interoperability papers, which deal with unconscious patients in the ER, or people irritated by having to fill out paper forms, the JASON report is much more interesting. Here is another supercool futuristic development that we absolutely must consider when creating an IT infrastructure to collect data for health related research, which is essentially the main concern of the JASON group. It seems that the Defense Advanced Research Projects Agency (DARPA) is working on in vivo nanoplatforms. Something about “ultra-small scaffolds inserted directly into the body” and “fluorescent nanospheres that are functionalized to detect biomarkers of interest”. The purpose seems to be “continuous physiological monitoring for the warfighter”. We do of course want to support our troops, so these cute little nanites must also be part of our robust health data infrastructure.

FHIR – In this report JASON is taking an unequivocal stand behind a new HL7 standard for clinical information exchange, the Fast Healthcare Interoperability Resources (FHIR), which is actually pretty neat, and has been in development for approximately three years. FHIR is envisioned as a replacement for the C-CDA, which replaced the CCD, which replaced the CCR, which replaced an array of HL7 2.x messages. JASON is recommending that government “policies should make it advantageous for one or more leading EHR vendors to be the first to propose such standards”. Lo and behold, two days after the JASON report was published, a group of leading vendors and institutions, several of which briefed JASON, and some who are helping the government implement JASON’s recommendation, launched the Argonaut Project for precisely this “advantageous” purpose.

FDA – For some reason the JASON report is engaging in a lengthy and strangely passionate litigation of the 23andMe (a DNA analysis service) tiff with the Food and Drug Administration (FDA) from a year or so ago, concluding with a recommendation that the FDA should take a “more nuanced approach” to its regulation of apps that could be construed as “practicing medicine”. The FDA regulatory authority over medical software has been in the crosshairs of corporate lobbyists (tech, pharma, telecom, etc.) for a couple of years now, with a variety of bipartisan deregulation bills introduced, or almost introduced, unsuccessfully in Congress. Coincidentally, two days after the publication of the JASON report, Senators Bennet (D-CO) and Hatch (R-UT) introduced the MEDTECH Act, the most serious attempt so far to restrain the FDA’s regulatory abilities.

Non-profits – JASON is recommending that non-profit organizations, either those that are disease specific or general in nature, “should be encouraged to assess their goals with respect to health data streams, and to provide “stamps of approval” for applications (apps) and other consumer tools”. In other words non-profit organizations should leverage the trust of their communities to monetize their members’ health data. JASON also recommends that private foundations should help the government by creating cash prizes to entice entire communities into participation in data wellness games. This is brilliant thinking, which leads me to hypothesize that at least one of the JASON members must be a Nobel laureate in marketing.

In this era of “transparency”, where every dollar from every pharmaceutical company or government agency, paid to every doctor and hospital, comes under relentless public scrutiny, why should JASON be exempt? Shouldn’t the JASON reports be accompanied by full disclosures of conflict of interest, both for JASON members and the various briefers whose pet projects populate every page of every report? Where is the media when a group of secretive researchers and private corporations are steering almost 20% of our economy towards endeavors immediately beneficial first and foremost to themselves?

When you read the JASON reports back to back, you are left with the impression that the group’s overarching goal is to create an international distributed repository of genetic materials tied to individual, environmental, behavioral and disease specific manifestations for all people on this planet. There is no doubt in my mind that a structure of this type and magnitude can facilitate an infinite number of perhaps beneficial research projects, and maybe even an IPO here and there. But if taxpayers are expected to fund the infrastructure for such expansive research, shouldn’t they be asked, or at the very least clearly informed?

And why rob the President of the United States of a legacy-defining “We choose to go to the moon” speech? It could go something like this: My fellow Americans, by 2025 every American will have his or her DNA collected and catalogued, and by 2025 every movement and every breath of every American man woman and child will be associated with their genomic sample, launching the grandest experiment in the history of mankind. From the ashes of the Great American Experiment, we will bring you more than freedom, more than liberty and more than a futile pursuit of happiness. We will bring you, Health. Download it for free from iTunes today.

In 1802, Thomas Jefferson wrote in a letter to David Hall: “We have no interests nor passions different from those of our fellow citizens. We have the same object: the success of representative government. Nor are we acting for ourselves alone, but for the whole human race. The event of our experiment is to show whether man can be trusted with self-government. The eyes of suffering humanity are fixed on us with anxiety as their only hope, and on such a theatre, for such a cause, we must suppress all smaller passions and local considerations.” Whatever.

Article link: http://hitconsultant.net/2014/12/15/jason-report-the-great-american-experiment/

The following is a guest blog post by Carrie Yasemin Paykoc, Senior Instructional Designer / Research Analyst at The Breakaway Group (A Xerox Company). Check out all of the blog posts in the Breakaway Thinking series.
Carrie Yasemin Paykoc

With 2014 coming to a close, there is a natural tendency to reflect on the accomplishments of the year. We gauge our annual successes through comparison with expected outcomes, industry standards, and satisfaction with the work done. To continue momentum and improve outcomes in the coming years we look for fresh ideas. For example, healthcare organizations can compare their efforts with similar types of organizations both locally and abroad. In the United States, looking beyond our existing borders toward the international community can provide valuable insight. Many other nations such as the UK, are further down the path of providing national healthcare and adopting electronic health records. In fact, the National Health Service (NHS) of UK has started plans to allow access of Electronic Health Records (EHR) on Smartphones through approved health apps. Although healthcare industry standards appear to be in constant flux, these valuable international lessons can help local healthcare leaders develop strategies for 2015 and beyond.

By the year 2024, the Office of the National Coordinator (ONC) aims to improve population health through the interoperable exchange of health information, and the utilization of research and evidence-based medicine. These bold and inspiring goals are outlined in their 10 Year Vision to Achieve Interoperable Health IT Infrastructure, also known as ONC’s interoperability road map. This document provides initial guidance on how the US will lay the foundation for EHR adoption and interoperable Healthcare Information Technology (HIT) systems. ONC has also issued the Federal Health IT Strategic Plan 2015-2020. This strategy aims to improve national interoperability, patient engagement, and expansion of IT into long-term care and mental health. Achieving these audacious goals seems quite challenging but a necessary step in improving population health.

EHR Adoption in UK
The US is not alone in their EHR adoption and interoperability goals. Many nations in our international community are years ahead of the US in terms of EHR implementation and utilization. Just across the Atlantic Ocean, the United Kingdom has already begun addressing opportunities and challenges with EHR adoption and interoperability. In their latest proposal the NHS has outlined their future vision for personalized health care in 2020. This proposal discusses the UK’s strategy for integrating HIT systems into a national system in a meaningful way. This language is quite similar to Meaningful Use and ONC’s interoperability roadmap in the United States. With such HIT parallels much could be learned from the UK as the US progresses toward interoperability.

The UK began their national EHR journey in the 1990s with incentivizing the implementation of EHR systems. Although approximately 96 percent of all general provider practices use EHRs in the UK, only a small percentage of practices have adopted their systems. Clinicians in the UK are slow to share records electronically with patients or with their nation’s central database, the Spine.

Collaborative Approach
In the NHS’s Five Year Forward View they attempt to address these issues and provide guidance on how health organization can achieve EHR adoption with constrained resources. One of the strongest themes in the address is the need for a collaborative approach. The EHRs in the UK were procured centrally as part of their initial national IT strategy. Despite the variety of HIT systems, this top-down approach caused some resentment among the local regions and clinics. So although these HIT systems are implemented, clinicians have been slow to adopt the systems to their full potential. (Sarah P Slight, et al. (2014). A qualitative study to identify the cost categories associated with electronic health record implementation in the UK. JAMIA, 21:e226-e231) To overcome this resistance, the NHS must follow their recommendations and work collaboratively with clinical leadership at the local level to empower technology adoption and ownership. Overcoming resistance to change takes time, especially on such a large national scale.

Standard Education Approach
Before the UK can achieve adoption and interoperability, standardization must occur. Variation in system use and associated quality outcomes can cause further issues. EHR selection was largely controlled by the government, whereas local regions and clinics took varied approaches to implementing and educating their staff. “Letting a thousand flowers bloom” is often the analogy used when referring to the UK’s initial EHR strategy. Each hospital and clinic had the autonomy of deciding on their own training strategy which consisted of one-on-one training, classroom training, mass training, or a combination of training methods. They struggled to back-fill positions to allow clinicians time to learn the new system. This process was also expensive. At one hospital £750 000 (over $1.1 million US) was spent to back-fill clinical staff at one hospital to allow for attendance to training sessions. This expensive and varied approach to training makes it difficult to ensure proficient system use, end-user knowledge and confidence, and consistent data entry. In the US we also must address issues of consistency in our training to increase end-user proficiency levels. Otherwise the data being entered and shared is of little value.

One way to ensure consistent training and education is to develop a role-based education plan that provides only the details that clinicians need to know to perform their workflow. This strategy is more cost-effective and quickly builds end-user knowledge and confidence. In turn, as end-user knowledge and confidence builds, end users are more likely to adopt new technologies. Additionally, as staff and systems change, plans must address how to re-engage and educate clinicians on the latest workflows and templates to ensure standardized data entry. If the goal is to connect and share health information (interoperability), clinicians must follow best-practice workflows in order to capture consistent data. One way to bridge this gap is through standardized role-based education.

Conclusion
Whether in the US or UK, adopting HIT systems require a comprehensive IT strategy that includes engaged leadership, qualitative and quantitative metrics, education and training, and a commitment to sustain the overall effort. Although the structure of health care systems in the US and UK are different, many lessons can be learned and shared about implementing and adopting HIT systems. The US can further research benefits and challenges associated with the Spine, UK’s central database as the country moves toward interoperability. Whereas the UK can learn from education and change management approaches utilized in US healthcare organizations with higher levels of EHR adoption. Regardless of the continent, improving population health by harnessing available technologies is the ultimate goal of health IT. As 2015 and beyond approaches, collaborate with your stakeholders both locally and abroad to obtain fresh ideas and ensure your healthcare organization moves toward EHR adoption.

Xerox is a sponsor of the Breakaway Thinking series of blog posts.

Article link: http://www.emrandhipaa.com/guest/2014/12/17/the-future-of-electronic-health-records-in-the-us-lessons-learned-from-the-uk-breakaway-thinking/

12/1/2014
By: Health.mil Staff

We just completed a remarkable first year in the Defense Health Agency.

In December, you will all be receiving our first Annual Report on what we have accomplished, and where we are headed in 2015. But let me give you a preview of what I consider the principal takeaways from our first year.

Unity of Effort is critical. Our successes in year 1 are directly attributable to your ability to bring people together on behalf of our broader purpose in military medicine. We put a new system of decision-making for the Military Health System (MHS) in place. And it ensured engagement at every level – the Office of the Secretary of Defense, the service secretaries, the Joint Chiefs, the service Surgeons General and all of their staffs. To some, the MHSER, the SMMAC, the MDAG, the MOG, BOG, and MPOG are an alphabet soup of bureaucracy. But not to me, and hopefully not to you. These committees are the machinery that allows us to tee up, vet and make sound decisions on the future of this vital system of care. Together.

The business of building consensus is not easy – but the payoffs are enormous. And, so for the many initiatives that we introduced this year, we succeeded when the hard work of building trust, ensuring transparency and skillful execution were sustained.

And the inverse is also true, when unity of effort was lacking, when the processes became slow or bogged down – sometimes on substantive policy issues, sometimes on minutiae, and sometimes on simple misunderstanding – we fell short of our goals. But, if we had nothing but successes this year, I think it would be a sign that we were not challenging ourselves enough. Perseverance matters. We will pick it up in 2015.

Success is not only measured in dollars saved. I am as pleased as anyone that we saved $250 million in 2014, which was $250 million more than we projected! This was supposed to be a building year, creating the infrastructure and hiring staff. But through aggressive action by leaders at all levels, we also provided the department and the taxpayer with a return on investment. Yet, equally important to saving dollars is the long-term work of creating common clinical and business processes.

Let me give you one example of an area where no money has yet been saved, but tremendous progress has been made: creating a common cost accounting structure for the MHS. This has been “behind the scenes” work by an often unheralded team of budget and financial management experts. They are positioning the MHS for the long-game.

In the coming years, we will look back at the work of 2014 – across all of our domains – and we will recognize this was the beginning of a process that genuinely allows us to compare performance in a meaningful way across the system of care. Not just counting dollars and cents, but utilization, outcomes, quality, safety and access to care. Not every success has a price tag on it, but they are all valued.

2014 was a down payment on a bigger promise. It has been a transformational year. At the same time that we stood up the DHA, which required a tremendous amount of energy and intellect in its own right, we have also played an indispensable role in the Secretary of Defense’s “Review of the Military Health System” and in implementing the action plan that followed it. We have an important role to play – in creating, maintaining and communicating a Performance Management System as well as a broad mandate for ensuring greater transparency to the public.

Now, add in the deployment of thousands of service members to West Africa in support of the larger federal response to the Ebola outbreak, along with the deployment of service members to Iraq to confront the threats from ISIS, and you have a sense of why having a “Medically Ready Force…Ready Medical Force” is more than a mere slogan; it is a perpetual promise in our combat support agency role.

In such a world, our customers – the services and the combatant commanders – need a system that ensures their medical logistics needs are met. They need medical facilities that are designed, built and sustained for 21st century medicine. They need a pharmacy system that can deliver vaccines, therapeutics and other medicines that prevent disease when possible, and treat disease when needed, which is often immediately. They need a health system in which private sector providers complement our direct care system and reach every corner of the globe where our service members and families live and work. They expect the care that we provide in Afghanistan, Iraq, Liberia, South Korea or the South Pacific to be captured, shared and available worldwide to our medical teams through a functioning Electronic Health Record. They need a global public health system that monitors the environment and disease threats anywhere in the word. They demand a medical research and development system that never stops the search for better ways of addressing the myriad of threats and disease and injuries we face in this unique line of business. They need us to educate and train thousands of new recruits and experienced professionals. They need a procurement system that can respond in a timely manner with high quality products and services. And they need us to properly budget, oversee and account for all of these things. And they need leading, joint institutions for health care delivery – and they are right here in the National Capital Region.

And they need the DHA.

And we have a deep moral and personal obligation to ensure that their needs are met.

I know that many of you were double and triple-tasked to manage the avalanche of requests for policy reviews, data calls, and briefings. But it all had a purpose. In Dr. Woodson’s words, we are building a better, stronger, more relevant MHS. I can see the concepts that were just words a year ago beginning to take root. This has been an extraordinary year of progress. And, yet, our work has just begun. So, let’s keep our sleeves rolled-up and let’s keep our unity of effort focus … we’re burning daylight as we speak!

Article link: http://www.health.mil/News/Articles/2014/12/01/Robb-Leadership-Message

Why EHRs require continual modification – Government Health IT

Posted by timmreardon on 01/05/2015

Posted in: Big Data, Blue Button, Data Science, EHR Interoperability, Global Standards, Health Care Costs, Health Care Economics, Health IT adoption, Health Outcomes, Healthcare Delivery, Innovation, Integrated Electronic Health Records, National Health IT System, Quadruple Aim, Quality Measures. Leave a comment

December 29, 2014 | Government Health IT Staff

Inpatient Electronic Health Records (EHRs) are not optimized to support delivery of quality and safety initiatives and, as a result, providers must be prepared to devote time and effort to continually modify them as they are implemented.

That’s according to a new study published in Electronic Data Methods for which researchers monitored the use of an EHR at three hospitals within Baylor Scott & White Health (BSWH), the largest not-for-profit health care system in Texas and one of the largest systems in the U.S. The researchers focused on treatment of delirium, a common problem for ICU patients addressed through the care processes of daily awakening and breathing trials, formal delirium screening, and early mobility — collectively known as the “ABCDE bundle.”

The study showed that, to effectively use the EHR, the hospitals’ health care delivery system had to modify its inpatient EHR to accelerate the implementation and evaluation of ABCDE bundle deployment as a safety and quality initiative. The researchers worked with clinical and technical experts, including doctors, nurses and support staff at the hospitals to create structured data fields for documentation and to identify where these fields should be placed within the EHR to streamline staff workflow.

They found that modifying the EHRs to support ABCDE bundle deployment was a “complex and time-consuming process,” the researchers wrote. “These shortcomings prevented the delivery of efficient care and our ability to assess the potential benefits of this quality improvement initiative.”

The EHR was not structured in a manner “that facilitated interdisciplinary care coordination among the range of providers in the ICU including nurses, physicians, and respiratory, physical, and occupational therapists,” the researchers wrote. The EHR also failed to allow for documentation of patient eligibility for processes of care in the ICU, such as those contained in the ABCDE bundle, the report said.

The health workers were able to customize the EHR documentation fields to support of ABCDE bundle deployment by assembling a team of IT personnel and clinical experts to identify the bundle data elements to be added to the EHR, to streamline EHR documentation in support of staff workflow, and to make these data accessible to providers. A tab in the EHR Patient Viewer was created to allow clinicians to view in one place the performance of bundle for individual patients.

The researchers said the difficulties in adapting to the EHR in the case study “are generalizable to other healthcare settings and conditions.”

“Tailoring the EHR to accelerate adoption of the ABCDE bundle was a challenging, time-consuming, and resource-intensive process, but we learned many valuable lessons that can facilitate the implementation of future quality improvement projects involving EHR modifications,” the researchers wrote.

They cited the need to gain buy-in from senior leadership at the beginning of the project as crucial to ensure that EHR modifications can be prioritized and resourced properly. With competing demands for time, health systems need to set timeline expectations and provide ongoing training to staff on proper use of the new EHR documentation fields.

The researchers said health care systems are currently challenged to find efficient ways to modify the EHR, and successful implementation is currently dependent on an ability to modify EHRs to meet emerging care delivery and quality improvement needs.

“Many out-of-the-box EHRs are poorly designed for the delivery of clinical care and often do not include good documentation templates and decision-support tools for specific conditions,” the report concluded. “Continual modification and optimization of these systems is needed to meet the needs of providers and, more importantly, of the patients.”

Article link: http://www.govhealthit.com/news/why-ehrs-require-continual-modification

James C. Salwitz, MD | Tech | November 1, 2014

A 57-year-old doctor I know is retiring to teach at a local junior college. He is respected, enjoys practicing medicine and is beloved by his patients; therefore, I was surprised. While he is frustrated by the complexity of health insurance, tired by the long hours and angered by defensive medicine, the final straw is that he can not stand the world of the EMR.

As an electronic medical record junkie, I would quit if I had to practice without a computerized information system. These programs are a dramatic improvement over the paper and pen way of keeping records. Still, I understand the onerous problems. Data entry is clumsy, painful and takes hours. Information is stored in a nearly random manner, not much better than papers tossed into a cardboard box. Every EMR program is different and none share vital patient data. Training is lousy, access is non-intuitive, support is spotty, costs are high and any gains seem to be countered by poorly timed system crashes.

Unhappy to lose a physician from our medical community, I find myself musing about what has gone wrong with a critical technology that has such shining potential. Computer systems fly giant aircraft around the world without incident, handle trillions of dollars of financial trade without a penny lost and allow hundreds of millions to tweet, Facebook or blog. Why is medical IT so bad?

The major problem with EMRs, as they are conceived and as they presently exist, is that they are round pegs in square holes. They are designed to gather and store information; shiny electronic file cabinets, and they are built around the primary function of billing; grinding out ICD-9 and CPT codes. That would be fine if that was what doctors actually do with their time and if making money was the primary goal of practicing medicine. However, surprise, surprise, what doctors really do is treat patients. EMRs often hinder, not assist, the giving of medical care.

A physician’s normal function is to interface between objective biology and the complexity of each human life. Often called “the art” of medicine, it is the act of bridging science to individual reality. Ask questions; test; collect information. Attempt to organize by creating of a list of possibilities, a differential diagnosis. Assimilate, screen and sift that data until you reach a final diagnosis. Then, implement therapy using science and the results of research, with compassion, patience and the skill of a teacher.

A functional electronic health delivery system would assist in this systematic decision process, actively participating in the query and analysis, adding scientific knowledge and observations based on state-of-the art recommendations. Help the doctor build the differential. Recommend testing or therapeutic alternatives. The EMR should be aligned with the doctor’s goals, which are the patient’s health.

The GPS in my car is first rate. Data input is verbal and flawless. It tells speed, direction, and continuously adjusts recommendations based on my progress and traffic impediments. It even throws in alerts about the weather. In other words, the GPS not only stores data, it tells me what to do with it, and is constantly updated by events far beyond my windshield, which I have not yet considered. Someday soon, that GPS will actually drive my car.

A health computational system should have, at a minimum, the functionality of that GPS. Easy data entry and access. Flawless expanding storage. Clear output. Actionable recommendations and observations, based not only on the patient, but on the science of medicine. An EMR should be updated continuously by clinical information such as labs, vital signs and tests, as well as the most recent scientific discoveries, even if they are made halfway around the world, delivering at the bedside the vast resources of big data. Help me care for the patient by complementing my work.

As the practice of medicine becomes logarithmically more complex with the expanding potential of genomic or personalized medicine, advanced information technology will be vital. No doctor will be able to assimilate an individual patient’s genome and thousands of actionable variables into a differential diagnosis or comprehensive treatment. The key will be real-time EMR support.

To date no one has taken the potential or complexity of EMRs seriously. The assumption is that these systems can be built by cottage industries, with the result that there are hundreds of rudimentary programs, all grossly inadequate. The average GPS is far more functional.

This slowly expanding area of IT research is called translational bioinformatics, but there have been relatively few dollars invested by the NIH in the basic science. Data input remains primitive. We have no backbone on which to create a national network to maintain and track individual records. There is no integration with decision making software or connection to research troves. Medicine relies on the doctor to connect the myriad dots, even as he or she is up at midnight, typing elementary progress notes into elementary office systems.

Doctors need and desire help in taking care of their patients, but instead they have a tool designed for secretaries and insurance auditors. We must readdress the goals of clinical IT to improve, empower and give medical care. The future of our patients and the future of health, depend on it. No amount of frustration and burned out physicians will force patient lives into slots built for dollars.

James C. Salwitz is an oncologist who blogs at Sunrise Rounds.

Image credit: Shutterstock.com

Article link: http://www.kevinmd.com/blog/2014/11/medical-bad.html

Monday, December 8, 2014

Integrating unique device identifiers into electronic health record systems could improve medical device safety and make recall efforts easier, according to a Brookings Institution report released Friday, Politico’s “Morning eHealth” reports (Gold, “Morning eHealth,” Politico, 12/8).

Background

In July 2012, FDA released a proposed rule to create a UDI system to track medical devices. Such a system would allow FDA officials to electronically track medical tools and promptly recall any devices that could jeopardize patient safety.

FDA in September 2012 issued a report that outlined the agency’s approach to improving its post-market surveillance system for medical devices, including the creation of a UDI system (iHealthBeat, 9/3).

Details of Report

The report aims to advise providers on how to adopt and integrate UDIs to improve patient safety, research and analytics, according to EHR Intelligence.

Specifically, the report outlines key steps to integrating UDIs into:
•Provider systems;
•Administrative transactions; and
•Patient-directed tools.

The report focuses on high-risk devices, but the authors note that all medical devices affecting patient care can benefit from tracking UDIs.

The report states, “Recording UDIs at the point of care in EHRs and in claims data could significantly enhance the nation’s ability to conduct medical device safety surveillance and manage recalls.”

In addition, the authors write that using UDIs could help to:
•Determine devices’ long-term quality and performance;
•Efficiently identify and communicate device safety concerns;
•Improve reimbursement transparency;
•Make supply chain processes more efficient and accurate; and
•Streamline premarket device approval.

Recommendations

In the report, the authors recommend:
•Conducting studies to showcase the benefits of UDI use;
•Including UDIs in claims details for high-risk, implantable devices;
•Incorporating UDIs into EHR systems and personal health records;
•Increasing outreach about UDIs through collaborations between advocacy groups, FDA and providers; and
•Using UDIs across supply chain, clinical and revenue cycle processes to obtain the highest return on investment.

The authors also recommend including UDIs in Stage 3 requirements of the meaningful use program. Under the 2009 economic stimulus package, health care providers who demonstrate meaningful use of certified EHRs can qualify for Medicaid and Medicare incentive payments (Bresnick, EHR Intelligence, 12/5).

Article link: http://www.ihealthbeat.org/articles/2014/12/8/report-providers-should-integrate-unique-device-identifiers-into-ehrs

healthcarereimagined

Envisioning healthcare for the 21st century

Reforming the Military Health System – CNAS

How the DOD’s choice of EHR will impact providers

Why it matters to the DOD

Why it matters to everyone

ONC unveils Interoperability Roadmap for public comment – Fierce Health IT

The Ongoing Health IT Interoperability Struggle – Health IT Outcomes

Building Interoperability Around APIs

Adding Mobility To The Interoperability Equation

The Best Is Yet To Come

JASON Report: The Great American Experiment – iHealthBeat

The Future of Electronic Health Records in the US: Lessons Learned from the UK – Breakaway Thinking

Message from Lt. Gen. (Dr.) Douglas J. Robb – A Year in Military Health – Health.mil

Why EHRs require continual modification – Government Health IT

Why is medical IT so bad? – KevinMD

Report: Providers Should Integrate Unique Device Identifiers Into EHRs – iHealthBeat

Search site

Recent Posts

Categories

Archives

Tags

Upcoming Events