EHR and PHR

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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).

Google Health and National Hospice and Palliative Care Organization’s Caring Connections have partnered to allow patients to store and access their advance directives on line.  Advance directives are essentially "directions" that a person gives to their medical professionals about what interventions they wish to have provided or withheld under specific circumstances — especially in emergencies and at "end-of-life" moments — when such person can not express those wishes himself or herself.  Advance directives laws vary from state-to-state, but typically require such directives to be in writing, signed and to have a personal representative listed.

GoogleHealth and Caring Connections will offer a "living will" feature that allows users to download a free state-specific advance directive and store completed and signed scanned documents securely on line in their GoogleHealth account.  By "storing" such advanced directives in GoogleHealth’s centralized repository, the hope is to offer providers with a better method to insure that a patient’s true wishes with regard to health care interventions are honored.  But, will it?

What had me wondering is how exactly will the provider access the advanced directive on Google Health without the individual (who presumably has lost his or her ability to communicate) providing his or her password?   I suppose that in instances where a personal representative has been appointed, the individual could make sure to provide such password to his/her personal representative — but watch out, because if the personal representative changes, then the password may need to change too.  Another option may be for individuals to pre-authorize their entrusted health care provider with access to their personal Google Health account.  Yet, this also has problems where one does not necessarily know which emergency room provider might end up providing them with care. 

Nevertheless, even with its limitations, Google Health’s new advanced directive feature will likely be beneficial in many circumstances.  To learn more about GoogleHealth and Caring Connection’s new advance directive feature, click here.

[Installment 5 – Governance Considerations from HIT for the Board and Other Hospital Stakeholders] 

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

The other week, two separate and apparently unrelated events occurred on consecutive days with respect to electronic health records (“EHRs”) that dramatically underscore the focus of this series. Governing Boards of hospitals and other stakeholders must place a very high priority in their struggle to cope with the new and somewhat uneven landscape of health information technology (“HIT”).

On July 16, 2009, Health Data Management reported that “[t]he federal HIT Policy Committee has approved revised recommendations of a workgroup for an initial definition of ‘meaningful use’ of electronic health records systems. The report goes on to emphasize that “[t]he definition is important because providers must demonstrate meaningful use of EHRs to qualify for Medicare and Medicaid incentive payments starting in 2011 under the economic stimulus law.”

Therefore, health providers will have to meet minimum prescribed standards 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. 

On the following day, July 17, 2009, the federal Department of Veterans Affairs (“VA”) published a press release on its Web site that it will temporarily halt 45 information technology projects which are either behind schedule or over budget. These projects will be reviewed by the VA, and it will be determined whether these projects should be continued. The release goes on to say that each of the 45 affected projects will be temporarily halted with no further development until a new project plan that meets the requirements of Program Management Accountability System is created.

Some of the titles of the VA projects that will be halted include significant EHRs-related projects such as “Health Data Repository II,” “Clinical Data Service,” “Home Telehealth Development,” “Occupational Health Record Keeping System,” “Lab Data Sharing & Interoperability – Anatomic Pathology/Microbiology” and many others.

By simply securing additional funding from Congress, the VA, as an agency of the federal government that is generally a favorite of the legislators, can retool and retrench its EHRs initiatives after making a relatively embarrassing press release and perhaps enduring some criticism and lost time. 

The Boards of health care providers do not have the luxuries of the VA. They simply cannot afford false starts and mistakes if they are to meet the meaningful use standards of the HITECH Act on a timely basis. As this blog has stated in earlier installments, the survival of many hospitals is threatened by the uncertainties of possible health care reform, declining patient population, reduced reimbursement, heavy regulation, intense competition, dwindling donor contributions and heavy endowment losses for non-profit hospitals, a history of unclear returns from past substantial investments in HIT and many other factors. The costs of mistakes for the private sector hospitals are not simply the embarrassment or lost time of the VA. They are the huge outlays for conversion to EHRs and the potential for losing access to the federal stimulus funds.

These questions and others must be properly considered at a high level in the hospital, with committed Board oversight, in order to avoid or mitigate liability and loss that will result from expensive choices made with inadequate or incomplete information. 

 [To be continued in Installment 6] 

[Installment 3 – Governance Considerations from HIT for the Board and Other Hospital Stakeholders]

This is the third in a series of blog posts that relate to the governance concerns surrounding developments in HIPAA, HITECH and HIT. Jim Landers of the Washington Bureau of the Dallas News  wrote an article that was published on June 24, 2009, entitled "Administration: Hospitals unwilling to share electronic records will miss out on billions in stimulus funds." His article prompted me to write on the topic as part of this series. 

 

In his article Mr. Landers stated:

 

The Obama administration’s point man on electronic medical records [David Blumenthal, national coordinator for Health Information Technology] warned Tuesday that hospitals unwilling to share such files [electronic health records or EHR] with their competitors would not be eligible for billions of dollars in economic stimulus funds.

 

Mr. Blumenthal was further quoted by Mr. Landers as follows: “There’s a fair amount of money in the law for hospitals that adopt interoperability [the means to share EHRs]. If they don’t, they’re not likely to be eligible for payment."

 

Mr. Landers correctly points out that many hospitals would be concerned that such free sharing of EHR among hospitals could give rise to the potential for losing patients to competitive institutions. I believe that, faced with deepening economic pressures and more highly educated patients with abundant choices, hospitals and their governing bodies must be increasingly concerned about material collateral issues that arise from sharing EHR with their competitors. 

 

I would add to the observations of Mr. Landers that embedded in EHR in one form or another could be relatively proprietary financial and business information regarding costs, charges or reimbursement of the hospital and/or treating physicians. In the exchange of EHR among hospitals, such proprietary information could be included. There exists a potential for the violation of antitrust laws for sharing of sensitive pricing and business information among competitors. The effect of such a violation could be a major financial and public relations fiasco for the hospitals. Removal or de-identification of such proprietary information could be costly or relatively impractical. This aspect warrants review by competent legal counsel and information technology and financial experts for the hospital. 

 

The ever-increasing momentum for acceleration of hospital conversion to EHR creates challenges and opportunities for a hospital and its governing board. On the one hand a hospital’s initiatives in this area can possibly make the hospital eligible for stimulus money to assist in the expensive cost of conversion to EHR. On the other hand there must be careful analysis at the governing board level of such an initiative in light of the risks involved.

 

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 and litigation, maintain the hospital’s reputation for candor and transparency and avoid the adverse publicity of regulatory violations and penalties.  

When I first reviewed the Matrix and other documents released by the HIT Policy Committee’s “Meaningful Use” Workgroup, my initial reaction was “When did defining ‘Meaningful Use’ of EHR morph into attempting to use EHRs to ‘meaningfully’ reform the entire healthcare delivery system.”?  More simply put, the Workgroup’s initial recommendations seemed to me to be over-ambitious.

The term "Meaningful EHR User" in ARRA (at Title IV, subtitle A, section 4104) is described as "an eligible professional" who meets the following criteria: 

  1. demonstrates that he/she is using certified EHR technology in a "meaningful manner, which shall include the use of electronic prescribing";
  2. demonstrates that he/she uses the certified EHR technology to be "connected, in a manner that provides… for the electronic exchange of health information to improve the quality of health care, such as promoting care coordination"; and
  3. submits information on selected "clinical quality measures".   

In my view, the first round of "Meaningful Use" requirements should be specific and reasonably achievable by healthcare providers. For example, perhaps the terms could require that the healthcare provider demonstrate how he/she uses electronic prescribing at least 75% of the time; or, how a provider records patient notes and medical encounter information in a certified EHR for no less than 75% of his/her new patient encounters.   

 

Interestingly, the National Coordinator for HIT decided to “send the workgroup back to work on another set [of recommendations]" for defining Meaningful Use soon after the Workgroup released its first set of recommendations. In the second go around, I think that many in the healthcare industry hope to see Meaningful Use criteria that are attainable by healthcare providers on a practical level. Otherwise, the entire premise of the HITECH Act providing incentives to increase EHR adoption could be thwarted. 

 

The HIT Policy Committee is suppose to unveil its recommendations on the definition of "Meaningful Use" of electronic health records (EHRs) on June 16th, reports Health Data Management.  Any approved definition of "Meaningful Use" would then be forwarded to the Office of National Coordinator for further consideration.  

What will constitute "Meaningful Use" of an EHR has been the subject of much debate and speculation lately because it is a necessary condition that hospitals and physicians must meet in order to qualify for Medicare and Medicaid incentive payments under the American Recovery and Reinvestment Act (ARRA).  ARRA initially describes “Meaningful Use” to include:

  • The use of a certified EHR with ePrescribing capability;
  • The ability to report on clinical quality measures; and  
  • The use of EHR technology that allows electronic exchange of patient health information.

Further information with regard to required standards, reporting and connectivity levels are to be determined by the Secretary of Health and Human Services, and the Final Rule on the initial definition of "Meaningful Use" is due out by the end of 2009, so stay tuned….

 

Using Google Health, a free personal health record tool, requires patients to be proactive both in terms of creating their electronic health record (EHR) and in checking the accuracy of the information loaded into the EHR, particularly when it comes from insurance claims data.  An article published in the April 13, 2009 issue of "The Boston Globe" illustrates how inclusion of raw insurance claims data in an EHR can be misleading and result in inaccurate diagnoses and even life-threatening situations.

Google Health and other EHR tools can greatly improve communication among health care providers, and offer patients a way of taking charge of their health records.  However, while insurance claims data can help to quickly and efficiently populate the patient’s EHR, it can also create a misleading picture of a patient’s past medical history and current health status.  If, for example, a patient’s insurance paid for a colonoscopy or other diagnostic procedure to rule out cancer, the billing code information may make it appear that the patient was, in fact, diagnosed with the condition the procedure actually ruled out. 
 
The lesson?  Users of Google Health and other EHR tools should review their information for accuracy, and involve their physicians in the review and update of their personal health information.

The Health Information Technology for Economic and Clinical Health (HITECH) Act has been called the most significant legislation to ever address health information technology, but it is no cure-all, say many physicians.  The legislation, which was signed into law as part of the American Recovery and Reinvestment Act on February 17, 2009, provides $19 Billion toward acceleration of the adoption and use of electronic health records and information technology. Nevertheless, there are some doubts that this influx of federal funds will result in the effective use of HIT to track quality and outcomes, and to communicate effectively among hospitals, physicians and other providers to coordinate a patient’s care.

On March 25, 2007, the New York Times reported on two forthcoming articles which will appear in the New England Journal of Medicine that cast doubt on the current level of HIT utilization, and caution that uniform standards and open software platforms may be required to facilitate the interconnectivity and innovation needed to make HIT effective. See Doctors Raise Doubts on Digital Health Data. Pouring money into existing, proprietary software with fixed capabilities, portability barriers and upgrade/expansion limitations would be a costly policy mistake, according to the NEJM article by Boston HIT experts Dr. Kenneth D. Mandl and Dr. Isaac S. Kohane.

These concerns were echoed at a recent IT forum in Washington, D.C., hosted by IBM and the eHealth Initiative. Dr. Doug Henley, executive vice president with the American Academy of Family Physicians, was reported in InfoWorld as emphasizing the need for “data liquidity,” and ensuring the easy transfer of health care data among health care providers and between providers and patients. Kevin Hughes MD, of Massachusetts General Hospital in Boston, cited the need to improve software interfaces to remove redundant data entry as a way to induce physicians to want to use HIT systems.

 

Phase I of CMS’s EHR Demonstration project began September 1, 2008.  Physicians selected by CMS to participate in this EHR demo project will be eligible to receive incentives totaling up to $58,000 per physician over five years or $290,000 per practice over five years.

CMS’s selected Community Partners are now accepting applications from eligible physicians located in the following regions: 

I have provided links to a CMS-selected Community Partner for each region above.   For additional general information about the EHR demonstration project, visit CMS’s Frequently Asked Questions webpage.   

Interested physicians must complete and submit an application to a Community Partner for the applicable region no later than November 26, 2008.

At the end of June, Investor’s Business Daily reported that Google, Microsoft, Aetna, Blue Cross/ and 27 other private organizations "agreed on" ground rules for protecting the privacy of the sensitive information" c

ontained in personal health records (PHRs). Their Report indicated that the group has been working together for the past 18 months, and on Wednesday, June 26th, released the "hundreds of pages long" framework, which "starts with the idea that the information in a PHR is the user’s to control — and spells out how to guard it." 

The "best practices" agreed upon by this private workgroup are posted online. Among them is a policy that audit trails should be conducted so that consumers can see who is looking at their records.  In addition, the workgroup recommended that insurers, employers, and others be prohibited from seeing the information without the individual’s prior authorization.  

The point that PHR repositories, like the ones being offered by Google and Microsoft, are not subject to HIPAA has been focused on by opponents of these models.  However, in developing and releasing the Report containing privacy and security "best practices," I think that this is a step in the right direction and may reassure healthcare consumers that information maintained in such online filing cabinets will be kept as confidential and secure as when maintained by entities subject to federal privacy laws, like HIPAA.