Certifying EHRs for "Meaningful Use"

On November 2, 2009, the Texas-based Drummond Group Inc. announced in a Press Release that it will submit to become a certifying body upon the release of the Office of the National Coordinator for Health Information Technology (ONC) requirements for certifying bodies for Electronic Health Records (EHR).  ONC is currently working on the scope and definition of "meaningful use" for EHR, expected to be finalized in early 2010. Along with these new policies on meaningful use of EHRs, ONC announced plans to expand the number of EHR certification agencies to support the new initiative. 

Currently, the only approved EHR certification agency, since 2004, is the Certification Commission for Health Information Technology (CCHIT).

Governance Considerations from HIT for the Board and Other Hospital Stakeholders - The Need for an IT Champion to Serve as a Link between IT Personnel and Other Stakeholders - Installment 7

This is the seventh installment in a series of blog posts that relate to the governance concerns surrounding developments in HIPAA, HITECH and HIT.

For a number of months this series has been emphasizing the importance of establishing a credible and knowledgeable liaison at the governing body and/or senior administrative level to articulate and educate the diverse stakeholders about the new challenges and initiatives in HIPAA and HIT. The liaison should be a champion and advocate for a rational and comprehensive approach for HIT.

The increasing complexities and costs of new IT systems and the need to demonstrate their “meaningful use” has greatly raised the stakes in this area for hospitals. Errors or false starts in HIT and the financial consequences of HIPAA violations under HITECH can be materially injurious to the organization’s finances, public image, internal stability and quality of patient care. It can also cause the loss of potential subsidies from HITECH.

Often the IT leader at a hospital does not have sufficient standing or skills set to serve as the champion. It was not the principal reason that he or she was hired. In such a case the governing boards should recruit either a knowledgeable board member or a senior staff person to serve this function.

The article on October 20, 2009 by Molly Merrill, Associate Editor of Healthcare IT News, adds further confirmation of the need for a qualified IT champion.

Ms. Merrill wrote that a new survey, conducted by Ponemon Institute and sponsored by San Jose, California-based LogLogic, shows that IT practitioners believe their organizations are lacking when it comes to protecting patient information. Moreover, Ms. Merrill continues, “[a]ccording to the study, 61 percent of [IT] practitioners believe their organizations don't have enough resources to meet privacy and data security requirements – and 70 percent think senior management doesn't consider it a priority.”

Ms. Merrill quotes the survey as concluding the following:

Without resources and support from senior management, preventing the loss of data may be very difficult. We recommend that organizations pursue a strategy of assigning accountability for the protection of electronic health information, appropriate technology to prevent the insider threat (such as DLP [data loss protection] solutions) and senior management buy-in for the necessary resources to get the job done right. [Emphasis supplied]

This survey underscores the frustrations and challenges that are present for the majority of IT leaders at hospitals. They may lack the standing within the organization to make a meaningful impact on senior management and the governing boards. Even if they hold a high level position within the organizations and are highly proficient in their jobs, they may lack be sufficient champions to interpret their complex world to their senior management and governing boards. It is incumbent on these organizations to identify a champion who possesses the skills to absorb and interpret the complex IT world for stakeholders who have limited knowledge of the subject.

[To be continued in Installment 8]

Distressed Hospital Survival Through HIT?

[Installment 6 - Governance Considerations from HIT for the Board and Other Hospital Stakeholders]

On August 4, 2009 the Associated Press reported at http://www.usatoday.com/news/health/2009-08-04-electronic-medical-records_N.htm that Sac-Osage Hospital, a 47-bed hospital in rural western Missouri, “is borrowing nearly $1 million to pitch its paper medical charts and purchase a state-of-the-art electronic health records  [EHR] system. The hospital is hinging its survival on what it hopes will be a $3 million windfall of federal incentives for hospitals that go digital.”

This survival strategy for Sac-Osage Hospital is hazardous because there is an inherent risk in the hoped-for windfall in 2011 under the economic stimulus law. As the AP report goes on to states: “The risk lies in the federal government's ultimate definition of what constitutes a ‘meaningful use’ of electronic records.”

As I reported in my fifth blog post on July 28, 2009, health providers will have to meet minimum prescribed standards (the meaningful use) for their EHRs if they are to benefit in the future from the federal economic stimulus package under the HITECH Act to recoup a portion of the heavy costs that they will incur to implement their EHRs programs. 

The bet that Sac-Osage Hospital says it is making by borrowing to invest in EHRs is the highest - the very survival of the hospital. Its Board and Administration have clearly made the determination that other possible alternatives for capital financing and investment by the hospital will not have the monetary potential return of the HITECH windfall. It is somewhat sobering that Sac-Osage Hospital bases its financial survival plan not on more effective delivery of healthcare or new treatment modalities but on digitalization of its health records. However, a positive by-product of EHRs and the demonstration of “meaningful use” that will be needed to realize the fruits from HITECH of an investment in EHRs presumably will be fewer medical errors, a more efficient healthcare delivery system and a higher quality of care.

Unfortunately for Sac-Osage Hospital and other health providers seeking to benefit from the HITECH windfall, the landscape for qualification could change markedly over the next two years. As technology evolves, the expectations as to what constitutes meaningfully use may rise. Sac-Osage Hospital and other small rural hospitals will also be competing for a share of HITECH money with larger and more well-financed institutions that are much further advanced with EHRs. 

Other challenges can come not just from the crystallization of “meaningful use” but also the enactment of the health reform package that is looming ahead. The package itself may directly or indirectly affect how EHRs are to be generated and used, thereby impacting programs for implementing HIT. 

Hopefully, the substantial majority of hospitals are not in a mode that their survival depends on the stimulus money from implementing EHRs. However, the Boards of health care providers cannot afford false starts and mistakes if they are to meet the meaningful use standards of the HITECH Act on a timely basis. These matters must be appropriately analyzed and monitored continuously at a high level in the hospital, with committed Board oversight. 

 [To be continued in Installment 7]

Twitter and Patient Privacy Rights

[Installment 2 - Governance Considerations from HIT for the Board and Other Hospital Stakeholders]

This is the second in a series of blog posts that relate to the governance concerns surrounding HIPAA, HITECH and HIT.  It is, however, not the second posting that I had originally planned. A front-page article on May 25, 2009 in the New York Times by Pam Belluck, entitled “Hospitals Using Internet to Interact with Public,” prompted me to write on this topic as part of the series

In her article Ms. Belluck stated, “Faced with economic pressures and patients with abundant choices, hospitals are using unconventional, even audacious, ways of connecting directly with the public.” She then reports that hospitals are using Twitter and transmissions from the operating room to communicate with the public on surgical results and YouTube to actually show surgery.  

This is seen by Ms. Belluck as a controversial approach to publicizing new procedures, to compete and attract patients and to stimulate contributions. In this day and age of increasing regulatory activity and heavy penalties for violations of HIPAA and state healthcare privacy and security rules, the Twitter practices should be subjected to careful scrutiny at the highest level by the governing bodies of hospitals.   The image of the hospital and its own sense of what are proper and acceptable marketing practices, the risks of legal or ethical violations from unwarranted communications, and the impact on publicity policies can be undermined by the uncontrolled actions of individuals.  The concept that the results of a complex surgical procedure can be meaningfully compressed into a rapid-fire, 140-character disclosure to the world can be somewhat perplexing.

The practice of using Twitter from the operating room to report on results is very risky and has serious implications for patient privacy. It may be a violation of existing laws or the general right of an individual to privacy.  It is always possible or even likely that the identity of a patient may become public, directly or indirectly, especially if the Twitter communication relates to a novel procedure. It is one thing to have a patient knowingly participate in publicity on YouTube and quite another to have someone send a Twitter message from the operating room while the patient is still recovering from anesthesia.

It is of equal concern that there is no control over the Twitter communications from the operating room. Anyone could make the transmission, which can be premature, totally erroneous and/or misleading.  It is a circumstance in some ways similar to the situation that judges are confronting from jurors who are sending Twitter or e-mail messages on the proceedings from the courtrooms of widely-publicized cases while the trial or jury deliberations are going on. Some judges are even prohibiting all electronic devices from being brought into the courtroom or jury deliberation room. In the case of the operating room there is the additional factor of the possibility that electronic transmissions from Twitter or e-mails may adversely affect or interfere with the normal operation of surrounding medical equipment.

The matter goes further. Will there be additional communications from the Tweeter or the hospital if the patient later develops complications or even dies? If the next patient who undergoes the same procedure does not fare well, will that be communicated through Twitter or other means to avoid misleading the public? How will the hospital control Twitter activity if it chooses to endeavor to do so? 

These questions and others should be properly considered at a high level in the hospital, with board oversight, in order to avoid or mitigate liability, maintain the hospital’s reputation for candor and transparency and avoid the adverse publicity of regulatory violations and penalties.  It is likely that the board should require that the hospital’s code of ethics address in greater detail how and when, if at all, electronic communications relating to patient procedures are communicated to the public and the nature of the patient consent that will be required.

A Little Intellectual Property 101 for HIT

Introduction to Intellectual Property

As my initial entry to this blog, I would like to provide a high-level overview of U.S. Intellectual Property ("IP”) law. This overview will provide background information on the various areas of IP. Future entries will consider how the various aspects of IP effect and are affected by HIPAA/HITECH and the electronic patient record initiatives. The basic components of IP include: patents, copyrights, trademarks and trade secrets.

Patents

A patent is essentially a grant from the federal government conveying to the owner the exclusive right to prevent others from making, using, offering for sale, selling or importing the patented invention. It grants these monopolistic powers for a limited period in exchange for full and complete disclosure of invention to the public.

Note that a patent does not convey an absolute right to practice the invention. For example, a patent on an improvement to a product does not invalidate any existing patent on the underlying product, which may be owned by a different inventor. Thus, hypothetically, an inventor holding a patent on a five-legged chair could still infringe a patent to a four-legged chair held by another inventor.

In order to be patentable, the subject matter must be new, useful and non-obvious. U.S. patent law provides certain “statutory classes” of patentable subject matter. These include: processes/methods, machines, articles of manufacture, compositions, and certain business models (a.k.a., “business methods”).

Examples of patentable subject matter in the healthcare, pharmaceutical and biotechnology arenas include: compounds, intermediates, compositions and methods of making these, diagnostic kits, methods for isolation/purification of compounds, methods for analysis, methods for treatment/use, screening methods, improvements to known compositions, improvements to known methods, combinations of active ingredients, microorganisms. cell lines, cellular compositions, viral isolates, vectors or cloning/expression vectors and DNA/RNA promoters, synthetic oligonucleotides, signal sequences, expressed sequence tags (ESTs), proteins, monoclonal antibodies/hybridomas, isolated antigens/vaccine compositions, methods for isolation/purification of biological materials, methods for cloning/protein production, methods for diagnosis, methods for treatment/use, screening methods, and transgenic animals/plants.

Patentability of “business methods” may also be of significant issue in this blog as the era of HIPAA/HITECH and electronic patient records unfolds, and as computer user interfaces, processing software, database structures and other aspects of electronic patient record generation, processing, storage and retrieval are developed.

Trademarks

A trademark is any word, symbol or device used to identify one’s product and distinguish it from the products of others. Trademark rights are available “appurtenant to use” – that is - to be valid, a Federally-registered trademark must be in use in interstate commerce. Also, an active trademark should be policed by its owner, as allowing a trademark to be infringed or diluted by another’s unauthorized use may lead to effective loss of the trademark. 

In the U.S., a person may apply for a Federal trademark registration by filing either an intent-to-use or an actual use trademark application. If an intent-to-use application is filed, a Statement of Use identifying actual use in interstate commerce will need to be filed before the trademark will be registered as active.

U.S. trademark law, particularly with respect to the court cases (i.e., “case law”), is particularly voluminous (i.e., “lots of it”). It would be easy to devote entire blogs to discussions of trademark case law. We’ll defer further discussion here for a future entry.

Copyrights

A copyright is the right that the government gives an author of any original work of expression to  exclude others from copying or commercially using the work of expression without proper authorization. Examples include books, poetry, plays, songs, catalogs, photographs, computer programs, advertisements, labels, movies, maps, drawings, sculpture, prints and art reproductions, game boards and rules, recordings. 

Copyright protection is easy to obtain by filing a form with a sample of the work and a small fee. Authors of copyrighted works should include an appropriate copyright notice on the work. 

Applying for Federal registration of a copyright is required prior to filing a lawsuit for copyright infringement in a U.S. Federal District court.

U.S. copyright may very well operate as a speed bump on the road to HITECH, electronic patient records, and government-run universal healthcare. We will particularly address copyright issues in one or more future blog entries.

Trade Secrets

A trade secret is any information, design, device, process, composition, technique or formula that is not known generally and that affords its owner a competitive business advantage. Reasonable measures to maintain the secret must be made so as to obtain relief against those who wrongfully obtain the information.

These are traditionally the basic components of IP law. Additionally, Internet-related issues are increasingly tied to other IP – such as domain name dispute resolution where the complainant owns a trademark to the domain name. 

My next entry will discuss potential patent issues with respect to HIPAA/HITECH and electronic patient records.

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Joint Commission Throws "HIT's" Weight In the Ring

The Joint Commission released a Report today titled "Health Care at the Crossroads: Guiding Principles for the Development of the Hospital of the Future" that, among other things, emphasizes that health information technology ("HIT") will be key to hospitals' viability in the future.  According to the Report, HIT will play a significant role in enhancing health care quality and safety.  More specifically, the Report recommends that hospitals adopt integrative technologies across their facilities and systems, and find competent consultants to provide technology and investment guidance.  Ultimately, the Report concludes that HIT is the inevitable way of the future for health care. 

In light of the release of the Report, I will be monitoring whether the Report will ultimately impact the Joint Commission's Hospital Accreditation Standards in the future.  Interestingly, the introductory page of the Report specifically states that the Report does not intend to describe new Joint Commission requirements for health care organizations, nor does it intend to suggest that new requirements will be forthcoming in the future.  However, it is certainly possible and imaginable that the adoption and use of HIT may be woven into any number of Elements of Performance in future versions of the Joint Commission's Accreditation Standards. 

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HIT Bills, Bills, and More Bills [*sic*]

Health information technology (HIT) bills continue to abound in Congress.   Recently, House bill (HR 6898) was introduced by House Ways and Means Health Subcommittee Chair Pete Stark, which includes proposed penalties for providers who do not adopt HIT by a certain date.  A similar House bill (HR 6357) was introduced by Energy and Commerce Committee Chair, John Dingell, but does not include penalties.  Now, House Speaker Nancy Pelosi is promising that there will be a “good” Democratic HIT bill ready early in the next Congressional session. The word is that congressional staffers are working on a draft even as I write this post, and that it will likely incorporate components of the Stark and Dingell bills. 

Yet, with the upcoming change in administration, and other pressing national issues taking priority, it is tough to predict which one (if any) of the several HIT bills that are currently pending, or any future bills that may be introduced in the next session, will actually become enacted law.  Nonetheless, providers should stay abreast of how proposed HIT legislation is progressing because funding opportunities that also are likely to become available for eligible applicants (i.e., providers) may need to be seized within a certain time frame.  If a deadline is missed, then the only "bills" that may be left are those for implementing HIT that has become standard, or mandated.

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Obama and McCain Support Health IT Adoption

As Election Day rapidly approaches, I thought that it would be interesting to note the presidential candidates' views on health information technology.  In short, both Barack Obama and John McCain appear to support and include health care IT adoption as a major part of their health care reform plans.

I have visited and reviewed each candidates' respective websites, and noted that McCain's plan includes general support for the rapid deployment of 21st century information systems and technology that would allow doctors to practice across state lines.  Obama's plan specifically includes allocating $10 billion annually for five years to help physicians and other health care providers adopt health IT.  The Obama-Biden plan also notes that a study by the Rand Corporation found that if most hospitals and doctors offices adopted electronic health records, up to $77 billion of savings would be realized each year through improvements such as reduced hospital stays, avoidance of duplicative and unnecessary testing, more appropriate drug utilization, and other efficiencies.

To read more about the McCain-Palin Health Care Plan, click here.

To read more about the Obama-Biden Health Care Plan, click here.

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CCHIT to Certify PHRs in 2009

The Certification Commission for Healthcare Information Technology (CCHIT) plans to certify personal health records (PHR) beginning in mid-2009.  Certification of PHR products would aim to ensure that records meet standards for patient privacy and security, as well as interoperability between providers.  CCHIT created a PHR Advisory Task Force to develop recommendations that the organization unanimously approved in mid-July. 

A list of other CCHIT certified HIT products are available for:

For the uninitiated, CCHIT is an independent, nonprofit organization that has been recognized by the federal government as an official certification body for electronic health record products.  Its certification requirements are based on widely-accepted industry standards and are said, on CCHIT's website, to involve the work of hundreds of expert volunteers and include input from a variety of stakeholders throughout the health care industry.  You can visit www.cchit.org for more information about CCHIT. 

 

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Think Tank Thinks ONC's Plan will Tank

Heartland Institute, a Chicago-based think tank published a "scathing critique of the government's efforts to promote healthcare information technology," reports Healthcare IT News.
In its August 2008 edition of Health Care News, Heartland's analysts call the ONC- Coordinated Federal Health Information Technology Strategic Plan 2008-2012 "poorly conceived" and argue that "any plan for changing the healthcare system is better coming from the private sector rather than government . . ."

Greg Scandlen, Director of Consumers for Health Care Choices at the Heartland Institute, further claims that "[a]ny system that is imposed today will be obsolete in five years," and that "[t]he federal government is woefully incapable of changing or eliminating outdated rules and regulations. So we will be stuck for all time with whatever they come up with today."

However, I think that Heartland does not address the fact that the myriad of incompatible standards that have been developed for HIT, privacy, and agreements in connection with health information exchange has also slowed progress.  And, as hundreds and maybe thousands of entrepreneurs and innovators across America "roll out new approaches, try them out, refine them based on experience, and repeat the process," we continue to be left with disjointed systems and vacuums for emerging standards. 

In short, we might not have the time and luxury of allowing market forces to reach their final determinations when the economic and clinical benefits of implementing coordinated systems for health information exchange are needed now.   As such, a centralized coordinator and gatekeeper, such as ONC, may potentially optimize the process -- if done right -- and so, cooperation between the private and public sector could be key to quicker progress.

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Wikipedia for Health Care? It's Coming . . .

The Los Angeles Times reported today about MEDPEDIA.com,  the website currently being developed by Internet entrepreneurs, together with doctors, researchers, and other medical professionals in order to create what is hoped (by them) will be largest body of health information on the Internet.  The information being gathered for the website is of the nature typically confined to academic circles.  The team working on Medpedia hopes to make that information understandable and available to consumers.  The LA Times indicates that Medpedia is "[m]odeled on the on-line encyclopedia Wikipedia, but [will be] written and edited only by trained professionals." 

The website lists Harvard Medical School, Stanford School of Medicine, and the [University of California] Berkeley School of Public Health as some of the organizations that will be assisting in building Medpedia's comprehensive medical clearinghouse.  The official launch of www.medpedia.com is scheduled for the end of 2008, but the website currently contains additional information about what is to come.    

Medpedia is just another example of how health care providers and Internet companies are experimenting with unique and helpful on-line tools to respond to the health IT momentum and a push to use such technology to empower patients.

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Horizon BC/BS Grants a Limited EHR Subsidy to New Jersey Health Care Providers

Health Data Management reported yesterday that Horizon Blue Cross Blue Shield of New Jersey will commit up to $500,000 to help select hospitals in its New Jersey network adopt electronic medication history technology.  This would give physicians real-time medication histories when patients check into a hospital or emergency department.  Under the program, Horizon will pay for 85% of the costs of the technology up to $40,000 for each hospital.  Horizon expects up to eight hospitals to join its subsidy program by the end of the year.

I would assume that the Horizon's subsidy program for hospitals would need to comply with the requirements under the EHR safeharbor to assure that the arrangement is not found as potentially violating the federal Anti-kickback Statute.  Under the safeharbor, a health plan is a protected donor, and a hospital a protected recipient, but several additional requirements must be met in addition to the hospital paying for 15% of the cost of the technology.  It does not appear that the subsidy program would need to meet the equivalent Stark Exception where the recipients of the technology will be limited to hospitals, and so the Stark prohibition on physicians' self-referrals should not be triggered. 

More information on Horizon's subsidy program, see drfirst.com and horizonblue.com.


ONC releases its Comprehensive HIT Plan

Today, the Office of the National Coordinator for Health Information Technology (ONC) released a comprehensive Strategic Plan for advancing health information technology (HIT). The Strategic Plan is intended to serve as a guide to coordinate the federal government’s health IT efforts to achieve nationwide implementation of an interoperable health IT infrastructure throughout both the public and private sector. 

Dr. Robert Kolodner, National Coordinator for HIT, stated that the Strategic Plan "[e]stablishes the next generation of HIT milestones to harness the power of information technology to help transform health care in this country.’’ ONC also notes that objectives, strategies, and milestones have been established for each goal and portray the totality of what must be done across the federal government to:

  • address privacy and security concerns;
  • achieve an interoperable health IT architecture to ensure reliable data exchange;
  • accelerate IT adoption; and
  • foster collaborative governance. 
ONC has posted a Full Report of the 115-page Strategic Plan as well as a shorter Synopsis on its website.
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