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Monday Morning Update 8/17/09

August 16, 2009 News 19 Comments

michigan

From Don Money: “Re: West Michigan HIE article.” Here’s the link, but you have to be a subscriber (the reader sent me a PDF). The Grand Rapids Business Journal covers an HIE created by three hospitals, all of which are using technology from the former Novo Innovations (now Medicity). Medicity’s Robert Connely: “It’s not designed to create the next generation of applications. It’s designed mostly to solve work and save tons of money, and that’s the reason they’re willing to pay for it.” The hospitals’ HIE is replacing the community-based model advocated by Alliance for Health, which found providers unwilling to pay third-party usage fees. Trinity Health will use the Medicity approach for all 45 of its hospitals, according to the article. Medicity says its technology and business models can be adapted to any connectivity scenario: a hospital-owned HIE servicing its doctors, a RHIO/HIE with third-party governance, and (as in this case) a RHIO/HIE without third-party governance.

From Stan Pacifica: “Re: PROMIS pain scale. This is an adaptive testing methodology that contains 120 items in the item bank, but far fewer than 120 are used to assess pain.” That makes sense, although the reporter specifically said “asks patients 120 pain-specific questions, as well as hundreds more that probe the physical and mental effects of pain.”  

Here’s the layoff letter from Philips Healthcare, citing lower profitability and “risk of further deterioration in several of our markets.” The usual “simpler, leaner, more flexible organization” mantra is recited, oddly enough by the same CEO who originally oversaw its regrettable transformation to more complex, fatter, and more rigid organization in the first place. He’s making $2.5 million a year for 20-20 business vision, which would value it at $5 million if it worked in foresight and not just in hindsight.

cert

It’s clear from Friday’s excellent recommendations to HHS by the Certification and Adoption Workgroup of the HIT Policy Committee that they want major changes made to EHR certification. Some of the high points:

  • HHS certification (notice they didn’t call it CCHIT certification) is not intended to be a seal of approval.
  • A new certification process should be developed that focuses on Meaningful Use rather than specific functionality points (that change will let specialty EMR vendors certify their products).
  • Certification should include all privacy and security policies that are in ARRA and HIPAA.
  • New highly detailed interoperability and data exchange specs should be created.
  • “Test harnesses” should be created so that providers can test their own software.
  • Multiple certification organizations should be allowed, with NIST accrediting them.
  • ONC should define certification criteria, not the organizations performing the certification testing.
  • Certification criteria will be updated no more frequently than once every two years and certification should be good for four years.
  • “Lock down” requirements should be eliminated to level the playing field for open source systems.
  • Since Meaningful Use definition is imminent, HHS should create a preliminary certification that would be valid through 2011.
  • Interesting quotes: “There has been criticism that CCHIT is too closely aligned with HIMSS or with vendors. While we did not see any evidence that vendors were exerting undue influence on CCHIT, we also understand that the appearance of a conflict is important to address … Most vendors advocated for a minimal approach to certification, complaining that CCHIT has ‘hijacked their development effort’ and that they are developing features/functions that nobody will use.”

The takeaway: if the recommendations are accepted, CCHIT’s role will be diminished and shared with other certification bodies, none of which will be allowed to create certification criteria; certification will move away from a detailed product design to focus instead of how EHR products are used; and CCHIT cannot shake its reputation for being controlled by a few big vendors and HIMSS. It’s pretty clear that CCHIT may well have an ongoing role in the government’s HIT policies, but not at the level of influence it has enjoyed until now. Finally, someone says no to HIMSS.

The Colorado Hospital Association and the Colorado Behavioral Healthcare Council select Qwest Communications to provide broadband services to create one of the largest health information networks in the country, connecting 400 providers and supporting telemedicine initiatives. The Colorado Telehealth Network will focus on rural areas, giving them 100-megabit connectivity via Qwest’s fiber-optic network.

Ross Koppel pointed out that hospitals probably can’t sign software vendor contracts containing non-disclosure language without running afoul of the Joint Commission’s accreditation requirements, which require hospitals and providers to share information about known patient safety risks. Here’s my challenge to you providers: send me a copy (scanned or copied and pasted) of the non-disclosure language in your contracts and the vendor involved. I’d like to run some of them here anonymously (nothing but the wording and the vendor) so new customers will recognize those terms and insist they be removed.

Recondo Technology announces EligibilityPlus, a SaaS insurance eligibility application. I mentioned the defunct (well, acquired by Sybase, which is pretty much the same thing) New Era of Networks the other day and, what do you know, founder Rick Adam is now chairman and CEO of Recondo. It’s a small world, this healthcare IT stuff.

A Florida medical magazine covers the history of EMR vendor DoctorsPartner, which says its PM offering was Best in KLAS 2007 and its EMR #2.

A London Times article compares US healthcare to the NHS, quoting a patient who moved from Britain to the US. “Every time you go for any treatment here, they want to see your insurance card and check every detail they have about you and that is wearisome. But I’ve had some terrific treatment. There are all sorts of things you have to be aware of: some treatments you part-pay for and you have to choose a doctor who is approved by your insurer. But it’s not all about money here. The doctors are doctors – they really want to help you.” Another insightful comment from a UK cancer patient who sought treatment here: “Most doctors in Britain, if they’ve worked overseas, will admit that somewhere like America has the best of the best. What it doesn’t have is the breadth of coverage. Ours is an equitable, morally cogent way of doing things. But looking at the amount and quality of research into my cancer, there was a clear difference between Britain and the United States.”

cropp

A pharmacist who didn’t catch a technician’s IV mixing mistake that killed a child at Rainbow Babies & Children’s Hospital (OH) is sentenced to six months in jail for involuntary manslaughter, to be followed by six months of house arrest, three years of probation, a $5,000 fine, and 400 hours of community service. His pharmacy license was also revoked. It appears from the newspaper’s description that the technician mixing the chemo IV used sodium chloride concentrate 23.4% instead of sodium chloride 0.9%, related to the fact that the hospital’s computer system had been down for some time. The tech was charged, but not indicted. I don’t know that putting healthcare providers in jail for making an honest mistake is a good idea, especially if you want to keep enough providers providing.

E-mail me.

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Currently there are "19 comments" on this Article:

  1. As exhilarating as are the recommendations you highlight from HHS by the Certification and Adoption Workgroup of the HIT Policy Committee (tremendous, really), the jailing of a healthcare provider for a, albeit devastatingly tragic, medical mistake leads to a much darker feeling. Another rollercoaster overview of our digihealth world, Mr. H. Thanks, I think…

  2. The writer speaks kindly describing acts of no-saying toward CCHIT; however, that does not change the events leading up to equilabration by the work group. CCHIT is very much involved with the vendor community and will undoubtedly be pitching vendor interests, whether or not they are the only certifying body in this space or are surrounded, outflanked or trumped by entities garnering stakeholder respect. It’s refreshing to note some agreement with the writer here, that stakeholder interests are now suddenly much bigger than the vendor group, EHRVA, that HIMSS founded and represents.

    A timely reminder of the Institute of Medicines report, “A New Health System for the 21st Century” provides a handy looking glass for examining the development of EHR products and certification of those products. If it were not so important to the vendors to have their hands on the certification process, they simply would not be there operating through HIMSS’ President and CEO, Steve Harry Lieber, who continues as their man at the helm of CCHIT. And while Harry may resign in the near future, it is very likely he will be succeeded by another who will work just as hard to tilt the playing field in a direction that prospers vendors. The same vendors who are prospering from certification now.

    Back to the IOM (for hopefully more then a millisecond of thought), the report has six aims; Safety, Effective, Patient centered, Timely, Efficient, Equitable. The six aims should be at the core of any certification process as part of the ongoing sea change unless, that is, there is disagreement as to the current state–a sea change is at hand?

  3. It is a little more than attractive for a provider to buy a vendor product that includes non disclosure clauses from a defensive medicine point of view. It protects the vendor, and it protects the provider. This reality is counter current to modern patient safety theory, which includes a climate of non-punitive expectations for reporting. So let’s be honest about this.

  4. “7. CCHIT has been criticized because it both sets certification criteria and does the testing (certifying) of vendor systems.”

    My responses to this comment:
    1. There is still no lab in which CCHIT does their testing. They pay their vendors (EHRVA) to do the testing. They are certifying each other’s products. Where is the underwriter’s laboratory? Where is the legal record of certification, the processes, the documentation, the artifacts of certification–where will they be held? Who will keep them? Who will pay for this repository?

    2. That is not the only criticism. Another serious criticism is that CCHIT started inside the beltway, and still exerts its influence inside the beltway. CCHIT is aided by its parent organization, HIMSS, in exerting influence inside the beltway, with the intent to profit.

    3. Why doesn’t CCHIT require the vendors to remove all non-disclosure clauses on their products? Specifically, the clauses that relate to “malfunctions” or “events that damage patient outcomes”? Because that would be going against the vendors.

  5. Regarding CCHIT, it’s interesting to read the letter dated 8/11/2009 from CCHIT to the HIT Policy and Standards Committees (http://cts.vresp.com/c/?CertificationCommiss/ce91fdbb23/65369ed25b/5ff37a7eca).

    CCHIT sets forth new certification criteria that are needed for EHRs to meet the proposed meaningful use requirements. I counted 88 criteria for ambulatory EHRs which is down from the nearly 500 items required for 2009 certification.

    I feel sorry for those EHR companies that went on a wild goose chase to meet the nearly 500 requirements only to find out that more than 80% of them are no longer necessary – not to mention the physicians that paid for these features.

    Still, no mention of usability as a requirement.

    Moving from nearly 500 requirements down to 88 is a good start, but there is still a long way to go. The meaningful use requirements as proposed are a non-starter for most private practicing physicians and need to be greatly reduced, lest we have a failed government program on our hands.

    The proposed meaningful use matrix is a must read for every physician (http://healthit.hhs.gov/portal/server.pt/gateway/PTARGS_0_10741_876940_0_0_18/Meaningful%20Use%20Matrix%2007162009.pdf).

  6. Can anybody show me the part of any bill going through the house or senate that offers a single payer, NHS like system? Of course the people making comparisons to the NHS are not being dishonest, they just don’t understand that it’s not even on the table. But Mr. HISTalk? Surely he should know better?

    On another note, any article taking individual accounts over statistics are also not being dishonest. The U.S has a slim advantage over cancer outcomes. Obviously a large part of that is the socialized medicine practiced in the V.A, Medicare and Medicaid.

  7. Two things for blah:

    1) The health care bill that passed the House included a government insurance option, as well as legislation preventing individuals from buying private insurance under many circumstances. The reasonable concern of many is that this government insurance plan will compete unfairly with the private insurers, eventually growing into a de facto single-payer insurer. And once there is a monopoly payer out there, is any practitioner really self-employed? Or are they now working directly for the only game in town (the government), whether or not their business is superficially independent?

    This weekend Obama seems to have taken this off his agenda, so we’ll see where things go next.

    2) The US has a large advantage over many parts of Europe in cancer survival rates, with UK near-worst. See here: http://www.telegraph.co.uk/news/uknews/1560849/UK-cancer-survival-rate-lowest-in-Europe.html

    My personal experience with cancer treatment in the UK vs the US supports these statistics, incidentally.

  8. As I noted in my comments to Dr. Koppel last week, OpenVista EHR contracts from Medsphere Systems, do not, I repeat, do not contain any non-disclosure language.
    (OpenVista is the commercialized version of the VA’s VistA, EHR)

  9. RE: Honest mistakes, I agree jail does not sound like the best step. Maybe you have seen and commented on the story in The Atlantic already, but when the author’s father died from preventable hospital acquired infection, it led him to a wide ranging analysis of health care delivery and government that spreads blame to all of us for supporting (each in our own way) the status quo at every step of the equation. Will be interesting to see if anyone in the administration or Congress responds and the rhetoric used either to co-opt the message or cast him as one-of-those stirring the rabble. Still, it cannot be denied, wash your hands and checklists remain the hardest sell in all of (U.S.) health care and proposed government reforms are political theatre in need of a better script. http://www.theatlantic.com/doc/200909/health-care

  10. Re non-disclosure contract terms, be careful about publishing ANY vendor contract language. While every vendor strives to sign “standard” agreements, every agreement is subject to negotiation and tweaking standard language. It’s likely that whatever you publish will have been tweaked and that the vendor will recognize it and know exactly which of their customers sent it to you. The customer will be in hot water for sharing confidential info…not sure what kind of trouble you might be in for making it public. While everyone wants to know who you are, not sure we want to see your face in the news!

  11. Two things for House.

    1) So what your saying is your speculate that the secret plan is for a public option to become single payer? Apart from it being pure speculation, it’s a little paranoid. fact still remains there are no plans for an NHS like system. Full stop. Opponents of the bill are using the comparison to make a false statement that we are heading for a socialized system. You know it and I know it.

    2) You need to read this study, to see the flaws in the article you quoted. And also understand that all U.S cancer survival rates are estimated. There are no hard statistic as there are in Europe. The study also only covered 11 States.

    http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(05)71700-1/fulltext

  12. Comments back to blah:

    1) The plan for single-payer isn’t so secret. Obama advocated it in 2003, and Barney Frank also stated his views more recently. So I’m neither speculating nor paranoid.

    http://www.youtube.com/watch?v=fpAyan1fXCE
    http://www.youtube.com/watch?v=QLm9t9j-qKM

    2) Maybe the cancer study has flaws, although without a subscription to The Lancet, I can’t read your link. The point is that your original claim turns out to be pure speculation, unless you can back the claim with some evidence. (You claimed that “the U.S has a slim advantage over cancer outcomes. Obviously a large part of that is the socialized medicine practiced in the V.A, Medicare and Medicaid.”)

    3) And my final point is that, lost in all the discussion right now, Medicaid and Medicare are already on an unsustainable trajectory from a cost point of view. Putting more people into a government plan would seem a really bad idea until we figure out how to limit the cost of we’ve already promised. http://cboblog.cbo.gov/?p=328

  13. The HHS approach to the “meaningful use question” is an interesting one to follow. The efforts of many dedicated, involved people have been working this issue. As a result, since February and the signing of the ARRA HITECH act, FOUR major shifts seem to be evolving as the end game starts to come into focus:

    1) The shift in control from CCHIT to HHS (via the ONC). The HIT Policy Committee has realized that it is not good process to have the same group DEFINE what certification is, AND do the testing/credentialing. The certification has become “excessively detailed” along product function lines and group recommended simplifying this with a phased-in set of requirements. The industry credential will become “HHS Certification”. The “CCHIT” credential will no longer be meaningful. The CCHIT list of criteria will be pared back by as much as 80% by HHS. Too bad so much CCHIT-generated development took place.

    2) The shift of focus from vendor to practitioner. “Certification” of vendor products was all that CCHIT focused on. “CCHIT” produced an ever-growing, detailed set of specs (nearly 500 of them) that VENDORS had to comply 100% with—remarkably in line with what a lot of the largest vendors had already developed. CCHIT had no metrics for “usability”, and no warranties or “incentives” for providers. Now, the burden shifts to practitioners…to show that they USE whatever systems they have in ways to be prescribed by HHS.

    3) The shift of emphasis from “Certification” to “Meaningful Use”. It will not be enough to merely purchase an EMR (a significant cash outlay), but to PROVE “meaningful use”. HHS will soon make clear what the standards for “meaningful use” will be. Then, it will be up to individual practitioners to provide whatever data is required by the government to earn the incentives…over a five-year period. Providers bear the cost of that five-year float, as well.

    4) The fourth shift is the most sobering. This is the incipient shift in PERCEPTION that EMR is (or inevitably WILL BE) mandatory, not a matter of choice for practices and physicians. Sure, there is language in the HITECH Act that says EMR is not mandatory, but the incentives and eventual penalties will suggest to many that it is. Will this shift in perception, driven by the incentives and penalties in the ARRA, accelerate adoption of EMR…the same EMR’s that practices have been slow to adopt and have too-often failed up to this point? If it does, will the success rate improve at all?

    The impact of these four shifts is simply this. Much of the burden for this aspect of healthcare reform is going to fall on practitioners. For many high-performance practitioners and specialists, the traditional EMR products will not be the solution—incentives or not. Now that Open Source and modular products are being invited to the certification table, it’s time for Hybrid EMR to be acknowledged as well. Why is it called “hybrid”?…because there needs to be a proper balance between needed EMR functionality, and productivity issues for practitioners. Hybrid EMR has been what high-performance practitioners have been shifting to for several years…without the burden of blindly following the CCHIT path.

  14. Certifying an EMR for Meaningful Use? That doesn’t make sense. It’s not features or functions that lead to Meaningful Use, it’s ADOPTION that makes the difference. A certified EMR may be adopted – or it may not be. A non-certified EMR can be adopted, used 100%, enable a paperless worklfow, and maybe even allow for data exchange. If an EMR isn’t fully adopted, supported, and sustained, none of those achievements is possible. It makes little difference what the certification status is. What would be interesting would be to find an EMR that is actually so useable that adoption would be easy.

  15. Re: CCHIT, HIMSS and hegemony over the ‘certification’ process:

    It’s clear the American psyche does not like a bully.

  16. Re: “Ross Koppel pointed out that hospitals probably can’t sign software vendor contracts containing non-disclosure language without running afoul of the Joint Commission’s accreditation requirements, which require hospitals and providers to share information about known patient safety risks.”

    Ross was in fact citing my JAMA letter to the editor, published Julhy 21, 2009 ( http://jama.ama-assn.org/cgi/content/extract/302/4/382 ). If you are a JAMA subscriber, also read his and David Kreda’s reply to my observation.

  17. Mr HISTalk – disclosing vendor customer confidential stuff or encouraging those with access to it to disclose it anonymously just isn’t right.

    It’s no better than asking vendors who have access to customer data to inappropriately disclose that. Their mistake rate, how many times their docs prescribe something that almost kills a patient. How many med doses are missed. Their negotiated fee schedules, their discount schedules, etc.

    I would hope, and so far I do think, that you are the kind of person who always does the right thing. This just isn’t the right thing to do.

  18. Re: “Keep it Honest”

    Honesty is best. If only vendors were honest…

    What about information that might save patient’s lives?

    Are contractual clauses that forbid hospitals to share EHR defects, some that may put patients at risk, ethical? Clinical IT is unlike other IT, in that there is a special class of stakeholders involved with special rights: patients.

    Those who detest whistleblowers usually have a good reason, regarding when they beat their wife … (i.e., yesterday, or today?)







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