Consortium News

  • 29 May 2015 1:57 PM | Deleted user

    from Dr. Halamka's Life as a Healthcare CIO blog, May 27, 2015

    Every technology has an adoption journey.     The classic Gartner hype curve travels from a Technology Trigger  to the Peak of Inflated Expectations followed by the Trough of Disillusionment. It often takes years before organizations reach the Slope of Enlightenment and finally achieve a Plateau of Productivity.

    Have you noticed that Congress and the popular press have entered the Trough of Disillusionment for EHRs and interoperability over the past month?

    Congressional staffers writing the 21st Century Cures bill (which is not yet law) seem to have concluded

    1) we don¹t have interoperability (although no one is sure what exactly we have and do not have)

    2) therefore we need more standards and that will solve all the business, political, and policy barriers to health information exchange

    3) The Health IT Standards Committee must not be doing a good job because there are not enough standards

    4) Therefore we should disband it and create a new politically appointed body

    5) That new body will invent all the standards we need and then force vendors to stop their information blocking behavior (whatever that is), enabling precision medicine

    USA Today, in one of the most one sided articles I’ve read, confuses ACA and HITECH, ignores the data about EHR adoption/health information exchange and concludes that EHRs “don’t talk to each other”, whatever that means.

    It’s time to take a step back, define our requirements, examine our current state, and then focus on closing any gaps we find.

    I oversee 5,000 patient data exchanges at BIDMC every day.   50,000 patients view/download/transmit their data every month.   We’re in beta testing with apps using Apple HealthKit, connecting home devices, iPhones and our EHR.     We have numerous affiliates with bidirectional data exchange.    There are few technology limitations.  The real challenges are political and policy barriers.

    The Direct protocol, although more complex than the RESTful methods used by Facebook, Amazon and Google that we should embrace, has provided a foundation for health information exchange across the country.    Below is a snapshot of the current Massachusetts State HIE (the Mass HiWay) connections to Health Information Services Providers (HISPs), creating thousands of connections among hospitals and eligible professionals nationwide.   Every week, some new practice or hospital comes knocking at the BIDMC door and within hours we can create a connection.

    Interoperability is real.  Interoperability has a very positive trajectory.   Saying otherwise is oversimplifying the reality of ongoing good work in progress.

    When confronted by naysayers, we have only three choices

    1.  Give up and declare defeat

    2.  Get angry, frustrated, and flustered by the negativity

    3.  Move forward with gusto, identifying gap after gap, then solving them.   We eat the elephant of interoperability one bite at a time.

    Over the past week, I’ve found myself setting aside my emotions.   I’ve redoubled my commitment to doing the right thing, hiring great people and broadly communicating the change processes needed to ensure more data is exchanged with more people for more reasons, while still respecting patient privacy preferences.

    I’ve thought long and hard about the day to day criticism we hear from government, special interests, and various press resources.  We have to avoid being distracted by the politics of any given moment.  In  a year and half the federal government will change completely .  Every major political leader in healthcare IT has changed since 2013.

    If we stay above the fray, work on interoperability one practice and one institution at a time, and toil diligently to enable new infrastructure such as record locator services/provider directories/quality registries, we will create a learning healthcare system that is better with each passing year.

    So next time you encounter the Trough of Disillusionment about interoperability, do your best to educate stakeholders about the trajectory we’re on and the challenges we can overcome by focusing and working together.

    Maybe we can all stand on a hilltop and sing "I'd Like to Teach the World to Interoperate (In Perfect Harmony)" celebrating our progress to date and highlighting the work yet to be done?

    POSTED BY JOHN HALAMKA AT 3:00 AM


  • 29 May 2015 10:15 AM | Deleted user

    May 28, 2015  |  Joan Stephenson PhD  |  MedPage Today 

    Proponents of less-is-more medicine stress that its focus is avoiding harm rather than mere cost-cutting, which consumers fear might reduce access to necessary care. But it's also clear that targeting tests and procedures that offer little or no value will reduce wasteful spending. From MedPage Today.

    When billionaire-entrepreneur-Dallas Mavericks owner Mark Cuban lobbed a Tweet in early April advising his followers to have their blood tested "for everything available" every 3 months, he probably didn't expect to unleash a Twitterspheric debate on medical overuse.

    Scores of health journalists and clinicians jumped on this ill-advised tweet, explaining that such overtesting can result in false positives, further testing, unneeded treatment, patient stress, and considerable costs.

    Although it's unlikely that the furor swayed opinions on either side, it reflects a larger, thoughtful conversation within the healthcare community. That discussion is the "less is more" movement to reduce overuse of "low-value" services such as screening, diagnostic tests, or treatments that are unlikely to help patients and pose risk of harm.

    Proponents of less-is-more medicine stress that its focus is avoiding harm rather than mere cost-cutting, which consumers fear might reduce access to necessary care. But it's also clear that targeting tests and procedures that offer little or no value, involve unnecessary risks to patients, and result in avoidable downstream care will indeed reduce wasteful healthcare spending.

    Researchers have suggested the cost of wasted healthcare dollars, including from overuse of low-value services, makes up a third of the nation's $2.8 trillion healthcare bill. Despite this hefty price tag, U.S. healthcare ranks last overall compared with 10 high-income countries, as well for three other health indicators: infant mortality, mortality from conditions amenable to treatment, and healthy life expectancy at age 60.

    Choosing Wisely

    The less-is-more movement has percolated against this backdrop over the past decade, gaining traction with the 2012 launch of the Choosing Wisely campaign by the American Board of Internal Medicine (ABIM) Foundation. The campaign enlisted clinician groups to help galvanize change by naming an evidence-based top 5 list of tests and procedures that physicians and patients should question because they offer little or no benefit and may cause harm.

    To date, more than 70 specialty societies have joined the campaign, each offering a top 5 list (some later updated to a top 10 or 15 list). Consumer Reports and other consumer groups have also signed on to help educate patients about how more medicine can be harmful.

    In addition, major medical journals are highlighting research findings that provide data illuminating low-value care, including the JAMA Internal Medicine Less is More series and the BMJ's Too Much Medicine campaign. Annual conferences, such as Preventing Overdiagnosis and the Lown Institute-sponsored RightCare Conference, are raising the medical community's consciousness about medical overuse.

    Bold vs. Timid Choices

    Some specialty groups embraced the challenge, and despite potential effects on their members' financial bottom lines, presented top 5 lists that included services often performed within their own specialty that could be considered low value.

    For example, the Society of General Internal Medicine advised against the routine annual physical, and the American College of Radiology listed five imaging tests to avoid under certain circumstances, such as admission or preoperative chest x-rays for ambulatory patients without specific findings from the physical exam and history.

    But in an analysis reported last year, researchers at Dartmouth and Harvard pointed out that 83% of the tests and procedures selected by medical groups, especially "proceduralist societies," for their top 5 lists are either rarely done or are typically performed by clinicians in other fields.

    "One of the interpretations of this was that specialty societies weren't choosing things that affected their own revenue streams, they were choosing things that affected others' revenue streams," said Carrie H. Colla, PhD, one of the Dartmouth researchers who co-authored the analysis.

    For example, the American Academy of Orthopedic Surgeons' top 5 list included three items related to patients with knee osteoarthritis: use of chondroitin and glucosamine supplements, a rarely performed procedure called needle lavage, and use of lateral wedge insoles.

    Noticeably absent from the list were some commonly performed orthopedic procedures that evidence shows are unlikely to help many of the patients who undergo them, explained orthopedic surgeon James Rickert, MD, president of the Society for Patient Centered Orthopedics.

    To take one example, each year 700,000 U.S. patients with knee osteoarthritis and degenerative meniscal tears undergo arthroscopic surgery, despite evidence from a 2002 randomized, controlled trial that found the procedure was no better than sham surgery in relieving pain or improving function in such patients.

    The orthopedic surgeons also didn't discuss spinal fusion, which has increased six-fold in the U.S. over the last 2 decades and is done much more frequently than in Canada, Europe, Australia, and New Zealand. Spinal fusion was also absent from the North American Spine Society's top 5 list. The spine surgeons did advise against performing elective spinal injections, such as steroid injections, without imaging guidance.

    What's problematic about the latter recommendation is that it doesn't specify that studies have found epidural steroid injections offer little benefit for the many patients who have back pain without sciatica who undergo this procedure, said Richard Deyo, MD, MPH, an expert in low back pain management at Oregon Health and Science University.

    "These injections have increased several hundred percent over the last 15 to 20 years, and it's hard to justify," said Deyo. Although epidural steroid injections are considered relatively safe, a 2012 outbreak of spinal meningitis caused by contaminated steroid injections underscored that rare, potentially serious complications do occur.

    Similarly, the American College of Cardiology, passed over a major -- and profitable -- overused intervention: stents in patients who have stable angina.

    "It's estimated from the cardiovascular data registry that 30% or possibly more of people who are getting stents are asymptomatic, and there has not been any benefit shown for cardiac stents over medical therapies in people who don't have symptoms and questionable benefit in people who do," said Rita Redberg, MD, MSc, of the University of California San Francisco (UCSF), and editor of JAMA Internal Medicine.

    A Bird in the Hand ...

    Even though critics have appropriately pointed out that some of the societies "went easy on themselves," it's more important at this point that the profession has started to engage with the issue, said John Santa, MD, medical director, Consumer Reports Health.

    Santa makes the case that small steps could lead to more significant changes down the line. "It was quite the accomplishment that [the ABIM Foundation] got all those doctor associations to admit they're overusing products and services," he said.

    "This is a new kind of activity for us all, and I think we're going to get better," said Daniel Wolfson, MHSA, executive vice president and chief operating officer at the ABIM Foundation. "People will be developing new lists, with better evidence, and I think there will be bolder recommendations coming down the pike."

    With the campaign's clout growing, "now is the time for professional societies to be bolder in identifying common interventions that add little value to our medical care," Redberg wrote in an April editorial in JAMA Internal Medicine.

    Impact of Efforts

    Even with a lack of boldness in some of the specialty societies' Choosing Wisely top 5 choices, emerging evidence suggests that the less-is-more movement is indeed gaining traction.

    As a sign the overtreatment tide is turning, H. Gilbert Welch, MD, of Dartmouth Medical School and a long-time critic of medical overuse, points to the 2014 recommendation by health experts to raise the threshold for beginning drug treatment for hypertension from 140/90 to 150/90 for people 60 or older. "It was the first time in my career that the guideline has called for a higher threshold, so I think we are seeing the beginning of a rebalancing," Welch said.

    "It's become legitimate to talk about overuse and not get accused of being a lackey for the insurance industry, an out-of-touch doctor, or -- dare I say it? -- a member of a 'death panel,'" said Santa.

    A national survey of primary-care and specialist physicians commissioned for the ABIM Foundation found that nearly three in four physicians said that unnecessary tests and procedures are a serious problem and 72% said the average physician prescribes an unnecessary test or procedure at least once a week. When asked about their own practice, nearly half said patients ask for an unnecessary test or procedure at least once weekly, and 30% said they get such requests at least several times a week.

    The surveyed physicians conceded that they sometimes order an unnecessary test or procedure for a host of reasons, including malpractice concerns, a desire "just to be safe" and obtain information to reassure themselves, patient insistence on a test, and not having enough time to spend with patients. Compared with physicians who didn't recall exposure to the Choosing Wisely campaign, those who did said they were less likely to suggest a "low-value" test or procedure (62% versus 45%).

    Institutional Buy-In

    Some academic medical centers have spearheaded initiatives that tackle specific examples of medical overuse and are seeing positive results. For example, after a team of physicians at Mount Sinai Hospital in New York launched a "Lose the Tube" campaign to address the inappropriate use of urinary catheters in five hospitalist medicine units, catheter use and associated urinary tract infection rates dropped sharply.

    Although professional societies can provide leadership, as U.S. medicine moves toward paying for the quality and effectiveness of care rather than the sheer volume of services, some interventions to reduce low-value care need to be taken on at the physician group level, said Colla. "Risk-sharing and moving away from fee-for-service allow physician groups to make decisions that would work best for their group to control utilization of low-value services, through things such as clinical decision support [such as reminders embedded in an electronic health records (EHR) system], physician education, and feedback."

    Some institutions are also embracing the effort and embedding the campaign's lists into clinical settings. When Christiana Care Health System in Delaware focused on reducing inappropriate use of continuous telemetry monitoring outside of intensive care units, an item on the Society of Hospital Medicine's Choosing Wisely campaign, it resulted in a 70% reduction in telemetry use overall without any negative effects on patient safety.

    In a more comprehensive effort, Cedars-Sinai Health System in Los Angeles has incorporated Choosing Wisely recommendations into its electronic health records system to provide alerts to help physicians avoid ordering potentially problematic tests or treatments.

    After an alert was set up to warn against use of benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation, or delirium, such use decreased 30%, said Scott Weingarten, MD, MPH, senior vice president and chief clinical transformation officer at Cedars-Sinai. (Weingarten is chairman of the board of Stanson Health, which markets the clinical decision support software being used at Cedars-Sinai.)

    "Long-acting benzodiazepines can cause patients to fall, develop hip fracture, and get into motor vehicle accidents. They're actually associated with increased death," said Weingarten.

    When an alert is triggered, the system displays links to citations provided by the specialty society that made the recommendation. Physicians can still override alerts if they wish, but the process makes it more likely they will consider the information provided before reflexively issuing an order.

    Reviews of medical records indicate that orders have dropped about 20% on average for items linked to soft stops (which don't require an explanation to place an order) and by about 40% for medium stops (which do require physicians to say why they are making the order), said Weingarten. So far, this reduction translates into an annualized savings of about $4 million, he said.

    Each alert also links to the Consumer Reports patient information that explains why the test or procedure may not be appropriate, which the physician can share with a patient who is pressing for it. "Our hope is that physicians use this opportunity as an opportunity to talk to patients," Weingarten said.

    Educating Patients

    But physicians have limited time to talk with patients to help them understand that more medicine isn't necessarily better medicine, an important message in light of direct-to-consumer advertising of medical products and services that stokes consumer demand. Santa points to the hundreds of millions of advertising dollars fueling an increase in prescriptions of testosterone replacement therapy, from 1.3 million patients in 2009 to 2.3 million patients in 2013, despite warnings about the possible risk of heart attack and stroke.

    Even when advertising isn't an issue, it's important to educate patients about practices that should be avoided altogether, said Harlan Krumholz, MD, SM, director of the Center for Outcome Research at Yale University School of Medicine. But, if possible, patients also need to be engaged in shared decision-making with physicians, to ensure that risks, benefits, and the patient's preference are weighed.

    "For the vast majority of tests and procedures, there's a fair amount of uncertainty, and physicians often don't disclose these uncertainties," said Krumholz.

    There is evidence, however, that decision aids can clarify for patients the benefits, limitations, and potential harms of tests and procedures, so they can have better-informed discussions with their physicians.

    "Decision aids are a practical solution to the problem that doctors don't have enough time to get into nuances," Deyo said. "They also have an important role in the gray areas of medicine, where reasonable people might make different choices." A 2014 review of studies of decision aids found that many patients who use them are more likely to choose less-aggressive or no treatment after learning about potential benefits and risks.

    Doctor in the trenches have their own ideas about what will help foster a less-is-more culture. In the ABIM Foundation's survey, 91% said malpractice reform; 85% said specific, evidence-based recommendations that a physician can use with patients; 78% said having more time with patients to discuss alternatives; and 61% said changing the system of financial rewards some physicians receive for ordering tests or procedures.

    What's needed, given these various pressures, is likely to be "a multifactorial approach" to reducing low-value care, said Colla, who described a range of "supply-side" interventions (targeting healthcare providers) and "demand-side" interventions (aimed at patients) in a recent article.

    Payment reform can play a substantial role in reducing low-value care, Colla added.

    "Through accountable care organizations, for example, the physician group would be responsible for the total cost of care," she said. That responsibility provides an incentive to doctors to think through with patients the value of services they are providing.

    Moving away from payment systems that reward volume to those that reward value -- which is what Medicare is rolling out in the post-SGR era -- may also help accelerate investment in clinical decision support linked to EHRs to reduce low-value care.

    "Right now, there is no financial reason for a physician group to invest in that kind of technology," said Colla. "Risk-sharing arrangements such as accountable care organizations may create an impetus for physician organizations to put things in place like what Cedars-Sinai is doing, providing financial reasons to invest, on top of the motivation to improve quality of care."

    Whatever changes are needed to move the less-is-more movement forward, the idea has staked its claim in the culture of medicine. "What's been accomplished," said Santa, "is a cultural sea change, a cultural wave around safety issues and a cultural wave about overuse."


  • 28 May 2015 3:17 PM | Deleted user

    May 28, 2015   |   Jessica Bartlett   |   Boston Business Journal

    The state’s largest independent physicians’ group has a new CEO, the company announced Thursday.

    Dr. Steven Strongwater, the chief transformation officer and chief medical executive for Acquisition Integration at Pennsylvania-based Geisinger Health, will become Atrius Health’s new president and CEO, leading the 42-practice, 750-physician organization into its next chapter.

    He will start in the position in late July or early August.

    “We are truly fortunate to have found a leader with such a solid record of driving positive change,“ said Dr. Guy Spinelli, chair of the Atrius Health Board, in a release. “We welcome Dr. Strongwater and look forward to working together to continue on the path to achieving our goals of outstanding quality, exceptional patient experience, lower cost of care, and market-leading physician and staff experience.”

    Atrius Health - which is comprised of Dedham Medical Associates, Granite Medical Group, Harvard Vanguard Medical Associates, and VNA Care Network & Hospice – serves 675,000 patients across the state.

    Though the position is new role for Strongwater, he is not unaccustomed to executive level positions. Prior to working at Geisinger Health, Strongwater served at the University of Massachusetts Medical Center as its medical director and assistant chancellor. He has also worked as CEO of Stony Brook University Hospital.

    He has also served as the advisor to the Association of American Medical Colleges, and held numerous positions at the University of Connecticut Health Center.

    Strongwater was chosen for the Atrius Health role after a six-month nationwide search led by Russell Reynolds Associates.

    “I have tremendous admiration for what Atrius Health has accomplished and look forward to working with all the talented and dedicated healthcare professionals at Atrius Health to ensure we remain connected to our patients and the communities we serve, and at the cutting edge of healthcare,” Strongwater said in a release. “Atrius Health has demonstrated it is possible to provide the highest level of care and convenience at the lowest possible cost.”

    Strongwater will take over for Dr. Gene Lindsey, who stepped down from the health group in September 2013 but remained CEO emeritus until the end of the year. The Atrius website lists Dr. Daniel Burnes, who has worked with Harvard Vanguard's Board of Directors, as the transition CEO.


  • 26 May 2015 4:53 PM | Deleted user

    retrieved from govhealthit.com  |  May 26, 2015
    Read original article.

    With major data breaches making headline news on a near-weekly basis, the healthcare industry is increasingly focused on cybersecurity, as well it should be.

    In addition to working toward a culture of security wherein all employees are trained to spot and prevent attempted cyber-attacks, a strong program is an essential part of any long-term business strategy, and healthcare entities are not exempt. 

    But where to begin? And how best to move forward?

    These 10 tips can help healthcare organizations establish such a program:

    1. Create a strong, cross-sectional cybersecurity team that includes personnel from legal, information technology, human resources, and public relations departments. The team should also include at least one member of senior management.
    2. Conduct a “privacy survey,” which is the process of identifying the legal, regulatory, and contractual obligations to protect data. Healthcare companies and their business associates must be particularly aware of their obligations to safeguard protected health information under both HIPAA and HITECH. Companies should also consider state laws to protect “personally identifiable information” (“PII”), and should understand contractual obligations, which likely include obligations to protect payment card information (“PCI”) under the rules established by card brands like Visa and MasterCard.
    3. Perform risk analysis required under HIPAA’s Security Rule. As part of the risk analysis process, companies need to identify the PHI they maintain and develop a detailed understanding of their technical systems and the potential threats they may face.
    4. Segregate sensitive data from regular data and protect it with additional physical, technical, or procedural safeguards (including firewalls, password protection and encryption). 
    5. Implement “privacy by design” when developing cybersecurity solutions. The company should create policies and procedures that account for patient privacy, legal compliance, and data protection throughout the data lifecycle (i.e., collection, processing, storage, and destruction). As part of this effort, the company should develop comprehensive policies to address privacy and data security, including:

      a BYOD policy, a password policy requiring use of strong, complex, unique passwords; personnel policies (including onboarding and off-boarding policies) that enhance security; and a network tracking policy requiring regular monitoring of network traffic for evidence of suspicious access.
    6. Manage vendors and scrutinize the adequacy of their cybersecurity policies and procedures before entering into relationships with them. Enact contractual safeguards to minimize risk, including by requiring protection of sensitive data, providing rights to audit vendors’ security practices, and requiring vendors to notify the company if a breach occurs. The contract should allocate risk in the event that a breach at the vendor harms the company, and companies should consider requiring vendors to carry cyber insurance. Companies must enter business associate agreements with vendors that will have access to PHI.  But before entering a business associate agreement, healthcare organizations should assess whether a vendor’s access to PHI is necessary. If not, the vendor should not have access to the PHI, and the company may avoid the compliance costs associated with business associates.
    7. Engage in cybersecurity information sharing through, for example, the National Health ISAC. The NH-ISAC allows industry players to keep abreast of evolving cyber-attack tactics and industry security standards.
    8. Consider cybersecurity insurance, which, depending on the policy, may cover forensic investigation and system restoration costs; defense and indemnity costs associated with litigation resulting from the loss of personal information or other sensitive data; regulatory investigation defense costs and penalties; notification costs and credit monitoring for affected customers and employees; losses attributable to the theft of the policyholder-company’s own data (including transfer of funds);  business interruption costs; costs required to investigate threats of cyber-extortion and payments to extortionists; and (viii) crisis management costs, such as the hiring of public relations firms. Unlike many traditional policies, cyber liability policies differ significantly because they are not (yet) based on a standard form. It is therefore critical to carefully review the exclusions of cyber policies with a broker and coverage counsel. 
    9. Develop an incident response plan, which is a detailed plan that outlines how a company will respond to suspected cyber-events. These plans help companies quickly and effectively investigate and remediate attacks. An incident response plan should identify the leaders of the response team and present easy-to-follow, scenario-based responses to different types of cyber incidents. The plan should clearly delineate first steps and include a timeline of major investigative events. The plan should also provide for involvement of experienced legal counsel in all aspects of the investigation of a suspected cyber-event (including communications about the potential event, remediation efforts, and disclosure and reporting) to ensure that the investigation is protected under the attorney-client and work product privileges. Privilege is critical because the company may soon find itself the defendant in a variety of lawsuits, including lawsuits by regulators, customers, issuing banks, or investors.  
    10. Develop a business continuity plan to facilitate efficient data recovery and resumption of operations in compliance with HIPAA requirements. Cyber-attacks may result in victim-companies losing access to their data and systems. For example, many companies have been affected by the Cryptolocker malware, which encrypts (and renders useless) the company’s data until a ransom is paid.  If companies are not prepared for these types of attacks, they may face enforcement actions, private litigation, and a substantial interruption of services, which can each be extremely costly. The first step in creating an effective business continuity plan is identifying critical systems. Systems should be prioritized based on the maximum time that each can be down without causing substantial harm to the business. The company must then select a back-up system, and should consider the following factors in choosing a back-up system: how quickly the data needs to be restored, how much data must be stored, and how long data must be maintained. It is critical that the company’s back-up system be sufficiently segregated from the company’s day-to-day systems so that a cyber-attacker cannot access the back-up system during an attack.

    Emily Westridge Black is an attorney in the Austin office of Haynes and Boone, LLP, and Chris Quinlan is an attorney in the Dallas office. Both specialize in data security, white-collar criminal defense, and the prosecution and defense of complex commercial litigation matters.


  • 26 May 2015 4:44 PM | Deleted user

    retrieved from nytimes.com  |  By ROBERT PEAR  |  MAY 26, 2015

    WASHINGTON — Since President Obama took office, the federal government has poured more than $29 billion into health information technology and told doctors and hospitals to use electronic medical records or face financial penalties.

    But some tech companies, hospitals and laboratories are intentionally blocking the electronic exchange of health information because they fear that they will lose business if they share information on patients with competing providers, administration officials said. In addition, officials said, some sellers of health information technology try to “lock in” customers by making it difficult for them to switch to competing vendors.

    “We have received many complaints of information blocking,” said Dr. Karen B. DeSalvo, the national coordinator for health information technology. “We are becoming increasingly concerned about these practices.”

    The White House and Congress are looking for ways to ensure a freer flow of information.

    Mr. Obama has made computerizing patients’ medical records a priority of his administration. Four weeks after taking office, he signed an economic stimulus bill that offered bonus payments to doctors and hospitals adopting the new technology. He said that it would save money by reducing waste and duplication, and that it could save lives by improving care.

    Many doctors and hospitals have begun using electronic medical records, but providers with different systems are often unable to share data in electronic form.

    “We have electronic records at our clinic, but the hospital, which I can see from my window, has a separate system from a different vendor,” said Dr. Reid B. Blackwelder of Kingsport, Tenn., chairman of the American Academy of Family Physicians. “The two don’t communicate. When I admit patients to the hospital, I have to print out my notes and send a copy to the hospital so they can be incorporated into the hospital’s electronic records.”

    Dr. Peter E. Masucci, a pediatrician in Everett, Mass., said he had been trying for more than five years to connect his electronic medical records with those of a hospital where he often sends patients. “It’s never happened,” he said.

    In a report to Congress, Dr. DeSalvo gave several other examples:

    • A doctor may have to pay exorbitant fees to transfer information on patients from the medical record system of one vendor to that of another.
    • A network of doctors and hospitals refuses to share electronic information on patients with providers outside the network, even when the information is needed to treat patients and sharing the data is allowed by federal rules.
    • Doctors obtain laboratory services and health records technology from one company, which will not let them connect to a competing laboratory, even though the connection is technically feasible and the doctors are willing to pay for it.

    The Obama administration said that some hospitals and technology companies appeared to be using electronic health records as part of a business strategy to “enhance their market dominance.” But Dr. DeSalvo said it was difficult to discover the details of such arrangements because some information technology companies “prohibit customers from reporting or even discussing” terms of their contracts.

    Dr. DeSalvo’s office is working with the Federal Trade Commission, which enforces antitrust and consumer protection laws. Tara Isa Koslov, a lawyer at the commission, said her agency was “paying close attention to developments in health I.T. markets and the reports of information blocking.”

    Peter J. DeVault, a vice president of the Epic Systems Corporation in Verona, Wis., one of the largest suppliers of software for electronic health records, said: “We do not participate in any activities that could be described as information blocking. To our knowledge, these activities are very rare, if they exist at all.”

    But Dan Haley, vice president of a competing company, Athenahealth, based in Watertown, Mass., said: “This is a serious problem. Some health I.T. vendors have business models that create real impediments to the sharing of medical information.”

    Under a typical arrangement, Mr. Haley said, a vendor tells hospitals, “It will cost you $1 million to build a connection to another system, we will charge $500,000 a year to maintain that connection, and on top of that we’ll charge $2 each time we send a patient’s records to hospitals that use a different system.”

    Congress took a first step to address the problem in a bill signed into law last month. It said that doctors and hospitals must not deliberately block the sharing of information if they receive federal bonus payments for using electronic health records.

    A separate bill approved last week by a House committee defines “information blocking” as a federal offense. Doctors, hospitals and technology vendors could be punished with civil fines of up to $10,000 for each violation.

    “Since 2009, we have spent $29 billion to encourage the adoption of electronic health records, but the data is still fragmented,” said Representative Michael C. Burgess, Republican of Texas. “Vendors continue to impede the exchange of information.”

    Even within a hospital, communications can be a challenge.

    William F. Barrow II, president of Our Lady of Lourdes Regional Medical Center in Lafayette, La., said his 186-bed hospital had two systems of electronic health records — one from the Cerner Corporation for inpatients, another from Epic for outpatients.

    “It’s hard to get the two to work optimally together,” Mr. Barrow said.

    Amalia R. Miller, an economist at the University of Virginia who has studied the industry, said: “Even when hospitals have the technological capability, they do not always share information with hospitals outside their system. If information is portable, patients can switch providers more easily, and that could hurt the business of some hospitals.”

    Thus, Ms. Miller said, federal money meant to foster an interconnected web of health care providers may inadvertently have subsidized the creation of “information silos,” making it more difficult to share data and coordinate care for consumers.


  • 26 May 2015 2:23 PM | Deleted user

    retrieved from businesswire.com   |   May 26, 2015

    CAMBRIDGE, Mass.--(BUSINESS WIRE)--PatientsLikeMe and Partners HealthCare announced today that they are working together to give Partners HealthCare patients access to tools and information that can help improve decision making with their clinical teams and enhance health outcomes.

    PatientsLikeMe Executive Vice President of Marketing and Patient Advocacy Michael Evers said the agreement is the first to provide access to the website from within a provider’s patient portal. 

    “We’re excited to work with such an esteemed health system to help patients and their care teams have a more complete understanding of patients’ whole health experience, and to support shared decision making about next steps.”

    Partners Population Health Management Associate Medical Director Adam Licurse, MD, MHS, who is a leader in population health patient engagement efforts at Partners, added the agreement is a key building block towards the healthcare system’s vision for better involving patients in their care. 

    “We know that as patients become more engaged in their care, they have better care experiences, make more informed decisions based on their goals, and in some cases can actually receive higher value care at the end of the day. Peer mentorship, patient self-management, and patient education are all critical pieces to that puzzle. We believe PatientsLikeMe’s online patient community provides a meaningful solution to help meet these needs.”

    As part of the agreement, the organizations:

    Have provided access to PatientsLikeMe from Partners Patient Gateway, an online tool for patients to learn more about their condition and communicate with their doctors’ offices.

    Will introduce a new “PatientsLikeMe 101” training series to guide Partners HealthCare clinical teams in helping patients and caregivers get the most out of PatientsLikeMe’s tools and support network.

    Plan to include patients’ use of the website and its tools at the point of care in select Partners HealthCare clinical care sites and practices. Partners HealthCare clinicians are currently outlining several projects designed to understand how the use of patient-generated health data at the point of care can impact health outcomes, patient engagement, patient empowerment, care coordination and patient satisfaction. The projects are expected to kick off this year.


  • 26 May 2015 11:58 AM | Deleted user

    retrieved from Life as a Healthcare CIO - Dr. John Halamka
    WEDNESDAY, MAY 20, 2015  |  

    21st Century Cures Act

    I’m in Washington today for the HIT Standards Committee and I will post the usual summary of the meeting this evening.  However, I wanted to post a morning preview of the opening comments I’ll make a the meeting.

    We are in a time of great turmoil in healthcare IT policy making.   We have the CMS and ONC Notices of Proposed Rulemaking for Meaningful Use Stage 3, both of which need to be radically pared down.   We have the Burgess Bill which attempts to fix interoperability with the blunt instrument of legislation.  Most importantly we have the 21st Century Cures Act, which few want to publicly criticize.   I’m happy to serve as the lightening rod for this discussion, pointing out the assumptions that are unlikely to be helpful and most likely to be hurtful.

    The interoperability language to be included in the 21st Century Cures Act would sunset the Health IT Standards Committee while a new “charter organization” would help define the standards of interoperability.

    Under the latest language, which was revised over the weekend and yesterday, electronic records must meet those interoperability standards by Jan. 1, 2018 and face being decertified by Jan. 1, 2019 if they don’t. 

    The bill would also require EHR vendors to publish their application program interfaces. Vendors must also publish fees to “purchase, license, implement, maintain, upgrade, use or otherwise enable and support” their products.

    There is no provision mentioning the sharing of substance abuse treatment records, which Rep. Tim Murphy said last week he was working to include. Congressional staffers said the version the House Energy and Commerce Committee marks up Wednesday may still be changed before a floor vote, which is expected sometime next month.

    It does not make sense to officially sanction a “charter organization” and seed it with $10 million, creating yet another player in an already crowded field of groups working on interoperability.  I agree that coordinating the standards development organizations makes a lot of sense -- why not just direct ONC to create a permanent Task Force that reports to the HIT Standards Committee, and let ONC support it out of existing resources?

    The drafts have other significant issues

    “standards to measure interoperability” –  I have no idea what that means.  I suggest that ONC create and report outcome measures that require interoperability rather than trying to measure the process of interoperability.  With Meaningful Use Stage 2 we experienced the failure of process measures to truly measure interoperability - transitions of care sent from and to the same organizations, transitions of care sent to an outside organization then thrown away.

    “information blocking” - I believe this concept is like the Loch Ness Monster, often described but rarely seen.   As written, the information blocking language will result in some vendors lobbying in new political forums (Federal Trade Commission and Inspector General) to investigate every instance where they are getting beaten in the market by other vendors.  The criteria are not objective and will be unenforceable except in the most egregious cases, which none of us have ever experienced.

    “De-certification” makes no sense.  Every provider would have to be granted a hardship exemption, so what is the point of the decertification?

    So, how do we accelerate interoperability?

    1. Make Meaningful Use and certification more manageable by narrowing its scope but tightening its enforcement.  Encourage and expand value-based purchasing initiatives and sunset Meaningful Use as quickly as possible. Meaningful Use/certification should be used to lay the foundation ecosystem, but value-based purchasing is what will transform health care.

    2. ONC should  focus/narrow the number of projects it is executing simultaneously

    3. The Role of ONC should be  certification, safety, alignment of Federal agencies, making available data to support nationwide interoperability (such as NPPES/PECOS data for provider directories), and creating transparency by disseminating market information. 

    4. Aggressively clean up privacy/security heterogeneity.   We need to get alignment of state laws.  We need to remove barriers to patient identity management.  We need to get rid of arcane Federal laws such as CFR 42 Part 2.  This will require bold leadership and a significant effort.  It won’t lead to political career advancement, but interoperability will be enabled and it will improve outcomes for patients over the medium- to long-term.

    5. We need a full time leader at ONC once Karen DeSalvo is confirmed as Assistant Secretary of Health

    Throughout my life, I have tried to be a neutral convener without an agenda.   I hope the industry realizes that my observations above are not meant to be emotional or dogmatic.   My only self-interest is to make a difference and prevent poor legislation and regulation from doing harm.

    Visit Dr. Halmka's Blog


  • 21 May 2015 4:25 PM | Deleted user

    retrieved from Boston Business Journal  
    May 21, 2015  |  Jessica Bartlett

    Children’s has acquired its first ever primary care physician group – and it’s not in Massachusetts.

    The pediatric institution is finalizing a deal to acquire Children’s & Women’s Physicians of Westchester (CWPW), a group of more than 276 physicians across 57 locations in New York, Connecticut and New Jersey.

    Executives wouldn’t disclose the terms of the deal, but said they expect it to be finalized by July.

    Dr. Kevin Churchwell, executive vice president of health affairs and chief operating officer at Children’s, details why Children’s sought out connections out of state, and what the changes could be long-term.

    How did this relationship come about?

    This has been over a year of discussion, to be honest with you. It started as a mutual (conversation as) to what the possibilities were or could be between the two groups, knowing we had a history of referrals from the New York area and had relationships with CWPW in Westchester hospital system. The more we talked the more we realized there was a significant amount of synergies of our belief, values, commitment to patients and recognizing how the landscape of healthcare would change. There would be a great relationship of us working together.

    How will this affiliation work?

    They will be part of our community of care as we continue to develop our northeastern pediatric network. They will have their appointments with the New York medical college and their medical staff for Maria Fareri Children’s Hospital at Westchester Medical Center - and that won’t change. They will also be part of our continuum. We will have the intricacies of their board and decision-making we’re working through, but they will be part of Children’s from that standpoint. They will have local administrative oversight there, with Children’s being the parent and helping support that. It’s new for us so we will continue to work through these intricacies as we develop it over the next year or two years.

    You mentioned you’ve already had referrals from New York, so why is this advantageous to Children’s?

    It’s more about patients and the family. We recognize that Children’s is a local, regional, national, international destination for patients with special problems. …they also recognize that there is gap in the continuum of care in patients coming to us and being sent back and how the continuum is lacking and impacts the quality of care we need to provide…

    We’ll have constant communication, the ability to have an impact of care quality at the local level, from resources but also just the protocols that we have and that they have…especially with those children with tertiary (and higher) care needs. That’s important and the future of medicine…expecting that those children will be at Children’s and will have an easy referral to us and that we can refer back and make sure care remains local.

    Will this change CWPW physician rates?

    That’s a great question. Rates continue to change. We expect the rates won’t change overnight but they will be most likely some adaptation with our involvement that we will see, that will be impacted by the landscape but by different legislation and the needs of patients and payers. We will see how that’s going to evolve.

    How many affiliated physicians does Children’s currently have?

    Within children’s we have our departments that are part of the Boston children’s hospital enterprise. That’s a lot of physicians, over 1,000 (approximately 1,300) – specialists in our department and in our permanent care practice that is children’s based.

    We don’t own a primary care practice outside of Children’s. We have alliances within New England, and that is through the Pediatric Physicians' Organization at Children's Hospital Boston (a 300-physician group of doctors at more than 75 practices throughout Eastern Massachusetts) – but we don’t own those practices.

    We will purchase the CWPW practice.


  • 15 May 2015 4:21 PM | Deleted user

    Retrieved from Healthcare-informatics.com
    May 15, 2015 by Rajiv Leventhal

    Another bill regarding ICD-10 has been introduced into the U.S. House of Representatives. Rather than call for the new coding set to be prohibited like the most recent bill did, this one pushes for a required ICD-10 transition period following implementation on October 1.

    This bill, H.R. 2247, the Increasing Clarity for Doctors by Transitioning Effectively Now Act (ICD-TEN Act), would “require the Secretary of Health and Human Services (HHS) to provide for transparent testing to assess the transition under the Medicare fee-for-service claims processing system from the ICD-9 to the ICD-10 standard, and for other purposes,” according to a blog post by the Journal of AHIMA (the American Health Information Management Association).

    The bill, introduced on May 12 by Rep. Diane Black (R-TN), would not halt or delay the Oct.1, 2015 implementation deadline for using ICD-10-CM/PCS, nor would it require the Centers for Medicare and Medicaid Services (CMS) to accept dual coding—claims coded in either ICD-9 or ICD-10. However, the bill would require HHS to conduct “comprehensive, end-to-end testing” to assess whether the Medicare fee-for-service claims processing system based on the ICD-10 standard is fully functioning. HHS would be required to make the end-to-end testing process available to all providers of services and suppliers participating in the Medicare fee-for-service program, according to AHIMA.

    Not later than 30 days after the date of completion of the end-to-end testing process the HHS Secretary would be required to submit to Congress a certification on whether or not the Medicare fee-for-service claims processing system based on the ICD-10 standard is fully functioning.

    HHS would need to prove that it is processing and approving at least as many claims as it did in the previous year using ICD-9. If the transition is not deemed “functional” based on this benchmark, HHS would need to identify additional steps that it would take to ensure ICD-10 is fully operational in the near future, according to the bill.

    During an 18-month transition period and any ensuing extensions, no reimbursement claim submitted to Medicare could be denied due solely to the “use of an unspecified or inaccurate subcode,” according to the bill.

    “In the past, Congress has repeatedly delayed the switch from the ICD-9 coding system to the far more complex ICD-10 system out of concern about the effect on providers. Neither Congress nor the provider community support kicking the can down the road and supporting another delay, but we must ensure the transition does not unfairly cause burdens and risks to our providers, especially those serving Medicare patients,” Black wrote in a letter urging fellow legislators to cosponsor the ICD-TEN Act. “During the ICD-10 transitional period, it is essential for CMS to ensure a fully functioning payment system and institute safeguards that prevent physicians and hospitals from being unfairly penalized due to coding errors.”

    The most recent ICD-10 bill, H.R. 2126, introduced by Rep. Ted Poe (R-TX) on April 30, would “prohibit the Secretary of Health and Human Services from replacing ICD-9 with ICD-10 in implementing the HIPAA code set.” Soon after that bill was introduced, AHIMA predicted that it could face difficulty getting through the committee process and to the House floor for a vote.

    Similarly, AHIMA is against this bill as well, as it says ICD-10 contingency plans already supported by CMS have been put in place and are working well. H.R. 2247’s proposed 18-month grace period on coding, where nearly all claims would be accepted, would “create an environment that’s ripe for fraud and abuse,” said Margarita Valdez, senior director of congressional relations at AHIMA.


  • 14 May 2015 10:55 AM | Deleted user

    Retrieved from New England Journal of Medicine
    May 14, 2015  |  Austin B. Frakt, Ph.D., and Nicholas Bagley, J.D.

    What if it were impossible to closely study a disease affecting 1 in 11 Americans over 11 years of age — a disease that's associated with more than 60,000 deaths in the United States each year, that tears families apart, and that costs society hundreds of billions of dollars?1 What if the affected population included vulnerable and underserved patients and those more likely than most Americans to have costly and deadly communicable diseases, including HIV–AIDS? What if we could not thoroughly evaluate policies designed to reduce costs or improve care for such patients?

    These questions are not rhetorical. In an unannounced break with long-standing practice, the Centers for Medicare and Medicaid Services (CMS) began in late 2013 to withhold from research data sets any Medicare or Medicaid claim with a substance-use–disorder diagnosis or related procedure code. This move — the result of privacy-protection concerns — affects about 4.5% of inpatient Medicare claims and about 8% of inpatient Medicaid claims from key research files (see table),

     

    impeding a wide range of research evaluating policies and practices intended to improve care for patients with substance-use disorders.

    The timing could not be worse. Just as states and federal agencies are implementing policies to address epidemic opioid abuse and coincident with the arrival of new and costly drugs for hepatitis C — a disease that disproportionately affects drug users — we are flying blind.

    The affected data sources include Medicare and Medicaid Research Identifiable Files, which contain beneficiary ZIP Codes, dates of birth and death, and in some cases Social Security numbers. For tasks common to most health services research — such as combining patient-level data across systems (e.g., Medicare, Medicaid, and the Veterans Health Administration [VHA]), associating them with community or market factors (e.g., provider density or type of health insurance plans available), or studying mortality as an outcome — these are essential variables.

    For decades, CMS has released data on claims related to substance-use disorders to allow researchers to study health systems and medical practice. One early example of such work is a study based on 1991 Medicare claims data that showed that few elderly patients received follow-up outpatient mental health care after being discharged with a substance-use–disorder diagnosis. Patients who received prompt follow-up care were less likely to die, a finding that could not have been obtained without information on patients' precise date of death.2 More recently, a 2010 study used 2003–2004 Medicare claims data linked by Social Security number to records from the VHA to assess the extent to which patients with substance-use disorders relied on the VHA for care.3 Substance-use disorders are among the diagnoses that have been included in the Dartmouth Atlas analyses of geographic variation in Medicare spending — which rely on ZIP Code identifiers — going back to at least 1998. To our knowledge, no patients have been harmed because of data breaches associated with studies such as these.

    CMS has justified the data suppression by pointing to privacy regulations that prescribe the stringent conditions under which information related to the treatment of substance-use disorders may be shared.4 These regulations, which are overseen by the Substance Abuse and Mental Health Services Administration (SAMHSA), already frustrate accountable care organizations and health-information exchanges, since their elaborate consent requirements make it difficult or impossible to share patient data related to substance-use disorders. As a result, many organizations exclude such information from their systems, undercutting efforts to improve care and efficiency.

    For researchers, the problem is more acute. Although the privacy regulations authorize providers to disclose data on substance-use disorders for research purposes, they prohibit third-party payers — including CMS — from doing so. In 1976, when the regulations were first adopted, this prohibition was not a substantial impediment to research. Before computers came into widespread use, researchers could not look to insurers or CMS to provide large claims-based data sets. Even if they could, crunching those data would have been exceedingly difficult.

    But the world has changed. Access to reliable Medicare and Medicaid data has long offered researchers a window into U.S health care.2,3 Indeed, given the unwillingness of private insurers to share their data, Medicare and Medicaid data often provide our only way of gathering information about medical practice, patient outcomes, and costs. The very importance of the data may explain why CMS has long overlooked the prohibition on disclosure.

    In 2013, however, SAMHSA advised CMS that the privacy regulations require suppression of claims related to substance-use disorders. The agency's sudden insistence on this point is puzzling. The law that the privacy regulations are intended to implement states that identifiable data on substance-use disorders “may be disclosed,” even without patient consent, “to qualified personnel for the purpose of conducting scientific research.” Banning CMS from sharing such data with researchers is difficult to square with that statutory exemption.

    Nonetheless, in November 2013, CMS began scrubbing Medicare data of claims related to substance-use disorders. It did the same for Medicaid data in early 2014. No notice was given to the research community about the policy change. Most of our colleagues have been shocked to learn of it; many others probably remain unaware of the change.

    The suppression has skewed Medicaid data more than Medicare data, a disparity that reflects differences between the populations served by the two programs (see table, and the Supplementary Appendix, available with the full text of this article at NEJM.org). In both programs, inpatient claims are much more likely to be affected than outpatient claims.

    In the vast majority of cases, claims are suppressed because the patients have secondary diagnoses of substance-use disorders. That raises an additional concern: many of the withheld data pertain to admissions for services that address not substance-use disorders but rather conditions that may be exacerbated by substance abuse. In other words, the data suppression extends well beyond its intended domain.

    The effects of the CMS actions are thus much broader than they might initially seem. Clearly, it is now infeasible to conduct any study of patients with substance-use disorders based on Research Identifiable Files. But studies of conditions disproportionately affecting such patients — such as hepatitis C or HIV — will also be hampered. Moreover, any study relying on those files cannot make full diagnosis-based risk adjustments that include substance-use–disorder diagnoses. And because the data have been altered in a systematic, nonrandom manner — with suppression affecting different populations, age groups, regions, and providers to different degrees — the results of many studies that have no apparent connection to substance use will be biased.

    And to what end? Without question, protecting patient confidentiality is essential, especially when it comes to potentially stigmatizing diagnoses and treatments. But there is no evidence that researchers — who, under current rules, must adhere to strict data-protection protocols, backed by criminal penalties — cannot appropriately secure research data. And most Americans want their health data to be available for research.5 At the same time, data suppression and access limitations remove from scrutiny a great deal of taxpayer-financed care.

    We believe that the federal government's short-sighted policy will harm the very people it was meant to protect. We encourage SAMHSA and CMS, in dialogue with researchers and providers, to restore access to data that are necessary to improving care for patients with substance-use disorders.


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