Consortium News

  • 30 Jan 2015 10:22 AM | Anonymous

    The federal health information technology coordinator released a wide-ranging report Friday morning on how to improve interoperability in electronic health-record systems.

    The report, “Connecting Health and Care for the Nation, A Shared Nationwide Interoperability Roadmap,” (PDF) calls for most providers to be able to use their systems to send, receive and use “a common set of electronic clinical information ... at the nationwide level by the end of 2017.”

    The common data set consists of about 20 basic elements, such as patient demographics, lab test results and identifiers for a patient's care team members. The plan is open for public comment through April 3.

    Accompanying the 10-year interoperability plan is a 13-page “advisory” to the health IT community on what the feds see as the best available healthcare information exchange standards and implementation specifications to facilitate health data information exchange. The ONC intends to keep the list updated periodically.

    Some health information is being exchanged among these EHR users, in regions, and among customers of the same EHR vendors, and through statewide health information exchanges, according to the report. These success stories should provide “best practice models we can look to where data and information is flowing,” said Dr. Karen DeSalvo, coordinator of HHS' Office of the National Coordinator for Health IT.

    But the agency also has heard from both insurers and providers that the level of health information exchange is insufficient for their needs, she said. Healthcare organizations wanting to exchange information have been hampered by a lack of consensus on which information exchange standards to use, how to configure computer systems to use them, and which rules and business practices to follow. 

    “What we don't see yet is a complete coalescing around the rules of the road” for a nationwide exchange network, DeSalvo said.

    The ONC's interoperability roadmap calls for a public-private partnership to create a “governance framework” for health information exchange. It also calls for more work to be done developing and harmonizing interoperability standards “that will allow us to facilitate the sharing without a whole lot of extra effort,” she said.

    The plan also calls for both government and private sector players to provide additional incentives for interoperability – beyond those in the EHR incentive payment program. And it sees a need to better educate providers and their health information exchange partners on federal privacy and security rules, which the report says should enable data sharing, rather than inhibit it as is often the case now.

    The 2009 economic stimulus legislation that created the EHR incentive payment program, specifically ordered the ONC to “establish a governance mechanism for the nationwide health information network.” Since then, the agency has been under increasing criticism from members of Congress and professional groups about the lack of interoperability of EHRs despite the substantial public investment in them.

    Improving interoperability of health information is a critical prerequisite for providers seeking to create patient-centered medical homes, population-based care management systems and accountable care organizations as both government and private sector payment reforms shift from fee-for-service to performance-based payment models.

    On Monday, HHS Secretary Sylvia Mathews Burwell announced that by 2016 the CMS wants 30% of Medicare payments to be linked to these payment reform models, and 50% by 2018.

    Wednesday, a coalition of providers, insurers and employers pledged to have 75% of their members' business switched to performance-based contracts by 2020.

    In 2013, six Republican senators chastised the ONC for multiple health IT program failings, including a “lack of a clear path toward interoperability.” That month, the ONC issued a formal “request for information,” about possible governance models for health information exchange, a move that was viewed fearfully by some healthcare IT players as a possible first step toward federal regulation of health information exchange.

    The ONC backed off in September in the face of industry pleadings to allow interoperability to develop, unregulated, through market-based approaches.

    Earlier this month, in a letter to DeSalvo, the American Medical Association and nearly three dozen other medical societies and associations took the ONC to task on its health IT program problems, including a lack of interoperability

    “Ensuring electronic health information follows patients during transitions of care is one of the most sought after, yet the least successful exchange paradigms in health care today,” the AMA letter said.

    DeSalvo insists the ONC roadmap isn't an attempt by the agency to become a national network regulator. A heading on a section of the roadmap refers to “non-governmental governance.”

    “We are not specifically calling for a new entity for nationwide governance,” DeSalvo said, but, “We still want to give guidance and a timeline” for meeting plan objectives.

    Veteran physician informaticist Dr. William Bria applauded the inclusion of priority use cases targeting electronic sharing of patient data with public health authorities and enabling patients to access to their own healthcare information, particularly on mobile devices. 

    “It strikes me that it's way past time to give the American public access to their own information and in a way they can actually use (it),” said Bria, president of the Association of Medical Directors of Information Systems. “They are the key customer that's really been left. It's overdue.”

    View the first release of the Health IT Roadmap here.

  • 30 Jan 2015 9:42 AM | Anonymous

    The Massachusetts Medical Society is presenting a live Webinar on Clinical Documentation Requirements for ICD-10 on Wednesday March 18, 2015 at noon.  

    ICD-10 is one of the most significant changes in our industry’s history, and with less than a year until the October 1, 2015 go-live date, now is the time to focus on preparing your practice and staff for the changes ahead. Accurate documentation of the patient encounter is critical to outpatient billing. Without it, providers may risk loss of revenue. Be sure that your documentation practices are ready for ICD-10 by signing up for this webinar today!

    As a result of participating in this activity, you should be able to:

    • Identify why detailed clinical documentation is important for the ICD-10 transition, including high-impact differences between ICD-9 and ICD-10
    • Plan and optimize your clinical documentation strategies
    • Apply best practices for educating and training your staff

    AMA Credit Designation Statement:
    The Massachusetts Medical Society designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    This activity meets the criteria of the Massachusetts Board of Registration in Medicine for risk management study.

    Accreditation Statement:
    The Massachusetts Medical Society is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

    Click here for Registration, prices and more information.

  • 22 Jan 2015 4:53 PM | Anonymous
    retrieved Jan 22, 2015 |  Boston Business Journal  |  Jessica Bartlett 

    Gov. Charlie Baker has appointed two people to manage the Health Connector and MassHealth, and has elevated the MassHealth role to a higher level in the organization.

    The new executives will be charged with leading two organizations that Baker has criticized for contributing to a $765 million state budget deficit, and that have seen significant turmoil over the last year as the state grappled with instituting the Affordable Care Act and a revised online health care marketplace.

    In a press release sent on Thursday, Baker said Daniel Tsai would run MassHealth, the state's medicaid system to help low income residents. His title will be assistant secretary, an elevated role that will answer to Health and Human Services Secretary Marylou Sudders.

    The move coincides with a December recommendation from the Massachusetts Medicaid Policy Institute to elevate the Medicaid director role to a higher decision-making authority.

    "This change in designation will allow for enhanced coordination between MassHealth and other state agencies and empower policy, payment and service reforms needed to benefit members and the Commonwealth," the administration said in a release.

    Tsai currently works as a partner in McKinsey & Company's Healthcare Systems and Services practice, and has co-lead the firm's Medicaid service line. He will replace Kristen Thorn.

    Louis Gutierrez was also appointed to be the next executive director for the Massachusetts Health Connector, the organization that oversees the website to sign up for health insurance.

    Gutierrez, who has spent the last seven years as a principal in IT consulting firm Exeter Group and on the board of directors of Harvard Pilgrim Health Care and the New England Health Exchange Network, will replace Jean Yang.

    Yang departed the organization on Jan. 16 after two years into the role, saying she would transition to a different role within the health care market.

    Gutierrez will serve under Administration and Finance Secretary Kristen Lepore, who serves as the chair of the Health Connector Board of Directors.

    "I am confident in Daniel's ability to fill this new and expanded role as assistant secretary to facilitate further cooperation among agencies who assist and care for our Medicaid population, and Louis' talent will be a welcome voice and mind for those families and individuals searching for quality and affordable healthcare," Baker said in a statement.

  • 22 Jan 2015 2:56 PM | Anonymous

    retrieved from Life as a Healthcare CIO  |  January 21, 2015

    As I travel across the country and listen to CIOs struggling with mandates from Meaningful Use to ICD-10 to the HIPAA Omnibus rule to the Affordable Care Act, I'm always looking for ways to reduce the burden on IT leaders.

    All have expressed frustration with the health information exchange (HIE) policies and technologies for care coordination. quality measurement, and patient engagement.

    As a country, what can we do to reduce this anxiety?

    Meaningful Use Stage 1 brought some interoperability especially around public health reporting. Stage 2 brought additional interoperability, with well defined content, vocabulary, and transport standards for transitions of care.

    Most CIOs have implemented certified EHRs and the required standards. Here’s a capsule summary of what I’ve heard

    HL7 2.x

    HL7 messaging addresses lab result and public health use cases very well. Lab results interfaces are straight forward, however there is still some need to reduce optionality in implementation guides so that the average lab interface costs $500 and not $5000. Public health transactions for immunizations, reportable lab, and syndromic surveillance are standardized from a content perspective but there is still a need to specify a single transport mechanism for all public health agencies.


    CCDA documents address transitions of care use cases reasonably well. CCDA is easier to work and parse than CCD/C32 because it has additional constraints and specifications, but there is still enough optionality that merging CCDA data into an EHR can be challenging. In addition, most EHRs generate a CCDA automatically and include all data that may possibly be relevant. In some cases, this leads to C-CDAs that are rendered at 50+ pages. We need to reduce optionality so that CCDAs are easier to generate correctly and parse. EHR workflow needs to better support the creation of clinically relevant documents with narrative and data more specific to transitions.

    Direct was a good first step for transport - we needed to pick something. We could have required sFTP, REST, SOAP, SMTP/SMIME or even Morse Code as long as it was completely standardized. Unfortunately, we picked multiple options. Some EHRs use XDR (a SOAP transaction) and some use SMTP/SMIME. Whenever standards have an "OR", all vendors must implement an "AND". XDR must be translated into SMTP/SMIME and SMTP/SMIME must be translated into XDR. The reality of Direct implementation has show us that this optionality provides a lot of plumbing challenges. Certificate and trust issues are still an ongoing project. Getting data from medical devices via Direct is challenging since devices tend to use heterogeneous transmission protocols. Finally, SMTP/SMIME was never designed for large payloads of multiple files, so sending datasets greater than 10 megabytes can be a struggle. The use of XDM for zipping files before they are sent is overly complex to use as part of a transport protocol.

    Although Direct works, it is often not well integrated into the EHR workflow.

    FHIR, as discussed in multiple recent posts, can help address these challenges and leverage the lessons learned. The FHIR concept is that every EHR will provide a standardized interface for the query, retrieval, and submission of specific data elements and documents using a web-based RESTful transport mechanism and OAuth security. This use case can easily support unique modules or “bolt on” application functionality to EHRs. It significantly simplifies the interfacing challenge, works for large payloads, and minimizes optionality. There are no multiple transport options, no certificates to manage, and the query/retrieve processes can occur behind the scenes, enabling smoother workflow.

    FHIR can even be helpful as a transition strategy while Direct is still used for pushing payloads between EHR. If FHIR/REST/OAuth replaced the XDR/XDM options of Direct, that provides a glide path to the eventual end to end replacement of Direct with FHIR

    Once FHIR is available, EHR vendors should design a user experience that follows the IEEE definition of interoperability - “the ability of a system or a product to work with other systems or products without special effort on the part of the customer. "

    In summary, think of HL7 2.x as good enough for messages pushed between systems, Direct/CCDA as suitable but challenging for pushing XML documents between systems, and FHIR as a means to integrate multiple platforms via the use of application program interfaces that support the simple query/retreat/submission of data among applications.

    FHIR will solve many of our interoperability challenges with appropriate support from EHR developers for clinically relevant workflow. We have to be careful not to oversell it, but for many use cases, FHIR is our best hope for the future.

    posted by Dr. John Halamka, "Life as a Healthcare CIO", Jan 21, 2015

  • 14 Jan 2015 6:22 PM | Anonymous
    Mass Collaborative aims to cut costs, increase efficiency
    Posted to  |  January 14, 2015  |  By Ilene MacDonald

    The Mass Collaborative, an organization of more than 35 health plans, healthcare providers and trade associations, has developed a new website to standardize and simplify healthcare administration processes and costs.

    The group hopes the resources will help increase efficiency and promote industry standardization, according to an announcement about the website's launch.
    "Although just 10 percent of every healthcare premium dollar goes towards administrative spending, there is more progress to be made," said Deborah Devaux, senior vice president of Blue Cross Blue Shield of Massachusetts.
    Indeed, recent research indicates that hospital administration costs in the United States run about $667 per person each year, whether or not a patient is hospitalized--for about $215 billion in total. Researchers blame the high costs on the fact that hospitals have to negotiate multiple contracts with insurers and organizations also have several layers of management.
    "Simplifying healthcare administration reduces cost, improves the patient and provider experience and enables all healthcare stakeholders to focus more on quality and effectiveness," Denny Brennan, executive director of the Massachusetts Health Data Consortium, said in the statement.
    The website features standardized industry forms and strategies to address insurance eligibility verification and claim appeals. Its goal is to take the cost and complexity out of the system and improve the overall end-to-end experience for healthcare providers, payers and patients in the state, according to Lynn Nicholas, president and CEO of the Massachusetts Hospital Association.
    "As both state and federal reform move our healthcare system forward, this sort of administrative simplification is plain common sense," she said.
    The initiative also attempts to address concerns that impact the entire industry and not just a particular segment, said Lora Pellegrini, president and CEO of the Massachusetts Association of Health Plans. "Reducing unnecessary administrative costs is an important step toward improving the efficiency and quality of the healthcare system," she said.

    To learn more:

  • 14 Jan 2015 3:46 PM | Anonymous
    Retrieved from   |  Jan 14, 2015   |  CARL NATALE

    We need to stop calculating the odds of another ICD-10 delay and get to work. There is less than nine months to be ready for ICD-10 implementation.

    According to the Centers for Medicare and Medicaid Services (CMS) Road to 10 planning tools, medical practices should be this far in the ICD-10 transition:

    Planning (Should have been finished already so get on it now)
    • Create an ICD-10 team
    • Create an internal impact assessment
    • List work processes and current electronic systems that use ICD-9 codes. The AMA suggests looking at:
      • Claims submission
      • Billing system
      • Posting payments
      • Clinical documentation, e.g., patient reports, electronic medical record
      • Patient registration system
      • Checking patient’s eligibility
      • Verifying referral/prior authorization
      • Writing referrals
      • Writing orders
      • Encounter forms
      • Coding tools, e.g., “superbills”, programs, books, resource materials
      • Quality reporting
      • Public health reporting
      • Disease registry/disease management
      • Health insurance contracting
      • Laboratory systems
      • Where else?
    • Evaluate how ICD-10 will affect your practice
      • Identify the diagnoses most frequently used.
      • Look up these diagnoses and review the potential new codes for the best match.
    • Identify staff who work with ICD-9 codes and how their job relates to those codes.
      • Understand how your clinicians and coding/billing personnel communicate.
      • What words do they use to describe their routine protocols to medical coders/billers?
    • Identify possible work flow changes needed to implement ICD-10 codes (e.g., data collection forms, encounter forms, superbills)
      • Medical coding
      • Training for medical coders
      • Increased to time to process medical claims
      • Managing the increased queries for physicians and clinicians
      • Physicians and clinicians
      • Clinical documentation
      • Quality improvement
      • Case management
      • Information technology
      • Upgrades
      • Internally (home grown) developed applications
      • External applications (Review contracts for commercial information system applications)
      • Reporting
      • Generating reports
      • File exporting
      • Data entry
      • Inputing
      • File importing
      • Data warehousing
      • Decision support
      • Research
      • Financial management and revenue cycle
      • Productivity
      • Reimbursement Structures
      • Contract negotiations
      • New reimbursement policies
      • Pre-Authorization
      • Eligibility
      • Scheduling
      • Admitting/Registration
      • Charges, Coding
      • Claims/Billing
      • Collections/Follow-up
      • Payment Posting
      • Denials Management
      • Education/Training
      • Business practices
      • Referrals
      • Authorizations/pre-certifications
      • Patient intake
      • Physician orders
      • Patient encounters
      • Clinical documentation: The increased specificity will require that patient encounters are documented with with greater detail.
      • Impacts
      • Staff training
      • Physician workflow
      • Patient volume
      • Forms, documents, and encounter forms need to be revised to reflect ICD-10 codes
      • Processes for ordering and reporting lab/diagnostic services to health plans
      • Evaluate whether clinical documentation can support ICD-10 specificity
      • Prepare clinical documentation improvement (CDI) strategies
      • Identify how staff will enter key words, medical notes and content in medical records.
      • Determine if hiring a consultant is needed as a part of your implementation process
    • Figure out how much the ICD-10 transition will cost.
      • Focus on four areas:
      • Coding
      • Revenue cycle
      • Project management
      • IT
      • Each area requires resources - time and money - to accommodate:
      • Software and hardware
      • In house and vendor modifications
      • Upgrades
      • New software, systems and equipment
      • Education
      • Coder training
      • Clinician education
      • Awareness raising
      • Testing related costs
      • Staff time needed for:
      • Implementation planning
      • Training
      • Testing
      • Vendor management
      • Temp staffing to assist with extra work resulting from:
      • Decreased coding productivity
      • Billing backlogs
      • Claims denial and rejection management
      • IT work on upgrades and systems
      • Lost time during training
      • Consulting services
      • Forms and reports
      • Redesign
      • Printing costs
      • Data conversion
      • Dual coding
      • Added time
      • Maintaining data collection
      • Analyzing data
    • Plan training and education initiatives.
      • Assess needed training and education
      • Subjects
      • ICD-10 coding
      • Anatomy
      • Physiology
      • Pharmacology
      • Medical terminology
      • Procedures
      • Pick best training options
      • Formal classroom sessions
      • In-house sessions
      • Remote, online sessions
      • Identify which staff members will need what training
      • Three levels of training:
      • ICD-10 code training
      • Medical coders
      • ICD-10-CM/PCS code set
      • Anatomy and physiology refreshers
      • In-house trainers
      • Medical coder with ICD-10 training
      • Train co-workers
      • Dual coding
      • Assign ICD-9 codes and ICD-10 codes before Oct. 1, 2014
      • Advantages:
      • Medical coders can practice their ICD-10 knowledge
      • Clinical documentation deficiencies are exposed
      • Extensive internal and external testing can be done
      • Non-coding staff members
      • Educate IT staff about requirements and structure of ICD-10 code sets
      • Coding champion
      • Staff member with ICD-10 training
      • Educate and create awareness among the non-coding staff
      • Help understand what vendors are selling
      • Plan implementation and testing
      • Awareness
      • Start immediately
      • Create an education plan that fits their schedules and needs
      • Explain how their work with ICD-10 codes will affect reimbursement.
      • Assess what they need to know:
      • Major differences between ICD-9 codes and ICD-codes
      • ICD-10 cheat sheets
      • Regular communications with management, IT staff and medical staff about:
      • Differences between ICD-9 and ICD-10 code sets
      • Differences between ICD-10-CM and ICD-10-PCS code sets
      • Regulatory requirements
      • Value of ICD-10 code sets
      • How ICD-10 implementation works with other initiatives
      • Impact on coding productivity and accuracy
      • Budget impacts
      • How the transition will impact departments
      • Impact on physicians' time
      • How ICD-10 coding could affect patient encounters
      • Updates on progress of the ICD-10 transition
      • Recruit physicians and other clinicians to help champion your ICD-10 project. This has two key benefits:
      • Physicians and clinicians will be more influential in getting colleagues to cooperate. Which will come in handy when they learn they need to add more detail to documentation.
      • Physicians and clinicians can offer reality checks to how things really work in your practice. Something that the IT staff or consultants may not be aware of.
      • Consider expanding their coding skills and knowledge to make up for lost productivity.
      • Procedural training
      • New procedures and systems
      • How to use new software and tools
      • Electronic health records (EHRs)
      • Computer assisted coding (CAC) systems
      • Practice management systems
      • New forms such as superbills
      • New billing and claims procedures
      • New documentation procedures
      • Clinical documentation improvement (CDI) initiatives
      • Impact on documentation
      • CDI strategy
      • Schedule training
      • Arrange sessions for staff
      • Spread training so coding shifts covered
      • Plan training slots for yet-to-be hired personnel
      • Investigate training vendors
      • Budget resources
      • Cost of training sessions and materials
      • Time for staff members to learn.
      • Cost of staff or temp workers who cover while your people are in training sessions
      • Cost of outsourcing medical coding while staff coders are in training sessions
      • AHIMA training courses
      • Organization wide education (especially non-coding staff)
      • Awareness, preparation and awareness (up to three hours)
      • How ICD-10 implementation will affect the organization
      • Prepares everyone for ICD-10 implementation
      • Instructions for executives, clinicians and other staff
      • Practical training (four hours)
      • Introduction to ICD-10-CM/PCS code sets
      • How implementation tools work
      • HIM directors, IT staff and other staff
      • Coding training
      • Awareness (three to six hours)
      • ICD-10 overview
      • Assess readiness
      • Reinforce foundation training
      • Anatomy
      • Physiology
      • Pharmacology
      • Medical terminology
      • ICD-10-CM training (28 hours)
      • Introduction to coding system
      • Comprehensive diagnosis coding instructions
      • ICD-10-PCS training (23-28 hours)
      • Introduction to coding system
      • Comprehensive procedure coding instructions
      • Practice (AHIMA plans four hours per course)
      • Inpatient scenarios
      • Outpatient scenarios
      • Coding training for specialty settings
      • Awareness (three to six hours)
      • ICD-10 overview
      • Assess readiness
      • Reinforce foundation training
      • ICD-10-CM training (28 hours)
      • Introduction to coding system
      • Comprehensive coding instruction
      • Practice (AHIMA plans four hours per course)
      • Practice by specialty setting
    It looks like a lot but it's doable. The goal is to understand what medical practices will need to do to be ready Oct.1.

    In a nutshell, the rest of 2015 will be spent on:

    • Conduct training (Keep training until June 1 then practice)
      • Obtain Clinical Documentation Education Ongoing Practice and Validation
      • Obtain Coding Education
      • Obtain ICD-10 Overview Education
    • Update processes
      • Improve Clinical Documentation (through Oct. 1)
      • Revise Paper Forms and Templates (April 1 deadline)
      • Modify Policies and Procedure (April 1 deadline)
    • Engage vendors and payers (Aug. 1 deadline)
      • Engage Technology Vendors and Update Systems
      • Engage Staffing/Billing Vendors and Evaluate Readiness
      • Engage Clearinghouses and Evaulate Readiness
      • Engage Payers and Evaluate Readiness
    • Testing
      • Prepare Internal Testing of Systems and Processes (Should be done by now)
      • Perform Internal Testing of Systems and Processes (Should be done by now)
      • Conduct External Testing with Partners (Aug. 1 deadline)

    We will tackle training next time.

  • 09 Jan 2015 2:14 PM | Anonymous
    'A lot of doctors told us to go to hell'
    Retrieved from  |  Boston Jan 9, 2015

    Tom Delbanco, MD, professor of general medicine and primary care at Harvard Medical School and former chief of general medicine at Beth Israel Deaconess Medical Center, is also co-director of the OpenNotes project, which gives patients access to the clinical notes written by their doctors and nurses.

    OpenNotes initially launched in 2010 as a pilot program in three select locations: BIDMC, Geisinger Health System and Harborview Medical Center in Seattle. It soon became apparent that what may have seemed, at first, to be a revolutionary concept had struck a nerve.

    Over the past five years, the initiative -- which Delbanco first developed alongside BIDMC researcher Jan Walker, RN -- has grown almost exponentially, finding footholds at some of the largest and most prestigious providers in the country, including the VA, Kaiser Permanente Northwest, Oregon Health & Science University and University of Colorado Health.

    On Feb. 10, at the Healthcare IT News/HIMSS Media Patient Engagement Summit, at the Hyatt Regency in Orlando, Delbanco’s BIDMC colleague, National OpenNotes Program Director Melissa Anselmo, will talk about why OpenNotes is such a hit with patients – and, despite some initial resistance, most of the physicians who take part in it as well.

    In the meantime. Delbanco describes how the project has evolved thus far, and how it plans to expand to a truly nationwide movement.

    Q: OpenNotes has experienced some pretty impressive growth since that first pilot in 2010.

    A: We've gone from 20,000 people two years ago to, we think, between 4.5 million and 5 million now, who have access to their notes via secure electronic portals.

    Q: Clearly this is an idea that had legs. So how did it all get started?

    A: I've always thought the medical record is the hub of the wheel, the way to bring patients much closer to those who care for them. I did an experiment 30 years ago where I actually had patients walking around this hospital with records they kept – and writing their own records along with the doctors writing theirs – and saying, 'Let's compare notes.' We published a paper about that, the doctors thought the patients were crazy. It was a little early.

    Then we got a grant (in 2010) from the Robert Wood Johnson Foundation to try this out in a big way using electronic portals. We asked doctors to volunteer in three settings. One is Beth Israel Deaconess, one of the big Harvard teaching hospitals. Another is the Geisinger Health System, which is this enormous integrated health system, serving rural Pennsylvania. And the third is Harborview, a safety net hospital in Seattle. We wanted three very different sites.

    A lot of doctors told us to go to hell. But we got more than 100 to volunteer – primary care doctors – which meant that automatically their patients who were registered on portals would be part of the study. There were about 20,000 of them.

    Q: Did you notice any differences between those three very different locales?

    A: We found extraordinarily few differences, which was very interesting. Much fewer than we expected. Part of what helped our study was that we didn't just do it in one place, and that the findings, from both doctors and patients, were so similar. People felt it really had some generalizability to it.

    The intervention was very simple: After the doctor signed his or her note, the patient automatically got an email saying, "Tom just signed his note; Mike, you're welcome to read, it." And then, two weeks before your appointment with your primary care doctor, you got a reminder email saying, "You might want to review your notes."

    That's all there was to it. A very simple intervention. All the vendors have them. But what's been hidden, up to now, is what the doctor writes, and what he or she thinks about you. You can look up your lab work, you can look up your X-ray results, you can send secure emails, you can ask for appointments and refills. But you have not, in the past, been able to look up what the doctor wrote about you. That's what the disruptive innovation is.

    Q: You can understand why many doctors would be resistant to this.

    A: Oh yeah. They had many fears that they said out loud. The biggest was that it would disrupt their workflow – and primary care doctors feel overwhelmed already. The second was that it would scare the hell out of their patients. Those were the two biggest fears.

    And I think there were other fears … I guess we can get into it, because we've been writing about it. (Pauses.) I think that notes are not always truthful. I asked an internist recently at a New England Journal of Medicine meeting, "How many 40-minute visits can you do in an hour?"

    Because of reimbursement in a fee-for-service world, doctors are really paid for their time and what they do. We've had quite a few anecdotes now of a note that says, "I spent 40 minutes with a patient and examined him from stem to stern. And the patient reads it and says, "Wait a minute, you never touched me." And I think although the doctors won't say it out loud, that's one of the reasons they're hesitant to do it.

    Now, when you go to population-based care, when you go to ACOs, when you go to systems that reward quality rather than quantity, that doesn't become an issue anymore. You don't have to write that kind of note.

    Q: The doctors who did sign on – did they do so grudgingly, or enthusiastically?

    A: There was a broad range. Some were enthusiastic. Some kind of said, "Well, it's going to come anyway, I might as well try it." And some were, frankly, almost conscripted. So there was a range of expectations. About 80 percent of the doctors who told us to go to hell felt it would mean more work for them. About 50 percent of the doctors who volunteered also felt it would mean more work.

    We did a study before we started – we studied the expectations of doctors and patients – and then the study that got us all the attention was, after we had done it for a year – what happened.

    We asked three basic questions: First, will patients read their notes, and will they report benefits from them? Number two, will it (overburden) the doctor? And number three, after a year, will the patient and doctor want to continue? They were very simple research questions.

    The results were that the patients were extraordinarily enthusiastic: 80 percent of them read their notes. That said, one out of five chose not to read their notes. I always make that point: Freedom of choice. We had a wonderful quote from a woman in Maine who said, "I want to have it, it's all mine, it's my business. But I may not read it.”

    So, 80 percent read them, but 99 percent said the practice should continue. The patients loved it. And more importantly they reported really important clinical benefits: 70 percent felt more in control of their care, and better educated. They felt better prepared for visits. They remembered their visits better, which is a big issue – you go to your doctor and you remember about 40 percent of what happened, and what you remember may be wrong. It's a high-stress situation, even if you're well.

    It's a big deal. And the biggest deal of all is that about 70 percent of patients said they were taking medicines better. Which, even if it's a five-fold exaggeration would be mind-blowing.

    They also shared them with other people: 35 to 40 percent of patients shared their notes with other people. That's important. You share them with your aunt the doctor, or your cousin the lawyer. You can put them on Facebook if you want. The doctor-patient relationship is confidential. But whether it's private now is up to you. You can download now and share with whomever you want and say, "What do you think?" You're in control. It's much more your record than it ever was.

    Q: And the doctors? What were their early thoughts?

    A: Not one doctor quit. They didn't all love it. They wrote their notes somewhat differently – about a quarter of them did – but not one quit after a year. And we now have thousands and thousands of doctors doing it and we've not heard yet about one who's started, then stopped.

    Partly, because I think patients just expect and want it. Eighty-five percent of patients said it would help determine their future choice of provider – whether or not OpenNotes was present. Once they tasted it, they really wanted it.

    Two years after we published these results, we had this amazing spread – and to flagship places. It's kind of a who's-who of American medicine: Mayo and Cleveland Clinic and Kaiser Northwest and Dartmouth-Hitchcock and University of Colorado. etc. It's a lot of very fancy places.

    The next trick is to spread it to what's called the early majority. The people in the real world who serve real America. Mayo Clinic is not the real world. So that's our next goal, to go from 5 million to 50 million. And our real goal is to have it become the standard of care in this country.

    Q: In the meantime, what else is next?

    A: (OpenNotes) has implications for patient safety. We're doing a big study to see what errors are picked up by patients, what mistakes are averted. And we have lots of anecdotes along those lines already.

    It has big implications for cost and quality and value: The patient who says, 'I did what you said, Tom. I'm doing fine, I feel better, I'll cancel the next visit.' Cancel a few visits, keep people out of the doctor's office, and that becomes a serious money saver if you multiply it by a few million people. So it has big implications for value.

    It has implication for medical education. Why shouldn't a young doctor have his notes critiqued by a patient?

    But it's not black and white. For example, we're about to send off a paper that shows that if you remind patients to read the notes, they're much more apt to do it than if you don't. Doctors want to be able to hide some notes. Should they be able to hid part of their notes? Patients may want to have part of their notes hidden from their caregivers

    Q: Have you found that any physicians are less than forthcoming?

    A: That's a good question: Is the note dumbed down? We have no evidence of that. People were afraid it would happen but we have not evidence that it's happened.

    There are fewer abbreviations. (Doctors) are quietly, I think, aiming the note more toward the patient. The example we always give is SOB: SOB to me means shortness of breath. To you it may mean something else. There are abbreviations we use that you don't know. There are words we use that you don't know.

    We use the word "dyspnea." It also means shortness of breath. Pretty soon, with new technologies, you'll be able to put a cursor on that word and it will say "shortness of breath."

    Q: Talk about the technology angle of all this.

    A: The big players are Epic, Cerner, Meditech, athenahealth and folks like that. We've been working with Epic. Epic next year plans to have OpenNotes as the default foundation. If a hospital buys Epic, it will be delivered with OpenNotes in it. That's a big deal for us. And the upgrades, too: every upgrade they have will make it very easy to go to OpenNotes if you don't have it already.

    Epic is going to instruct their customers how to work with OpenNotes. We're working with Cerner, we're working with other people too. Epic says it serves 170 million people. Cerner says it serves 60 million people. That's a lot of people.

    The other targets for us are the CMIOs. They become the transformational officers for their institutions. We're working very closely with them because they're the ones who can flip the switch and make it work.

    Our hospital has a homegrown EHR. Most people buy them off the shelf or adapt the portal to their own needs. Epic supplies Geisinger; Geisinger doesn't have MyChart, it has MyGeisinger, which is their adaptation of the portal that Epic provides them. Into that, they can build OpenNotes – which they're increasingly doing.

    But I want to emphasize: This is not a software package. This is a movement. This is a movement of full transparency. It's a movement to engage patients and enhance communication between patients and those that take care of them.

    We're going to target several groups of people. We're going to target CEOs, we're going to target payers. We've talked with ONC. We've talked with the American College of Physicians, who are advocates for this. We talked with provider groups of all sizes. We try to allay they fears: Try it, you may like it.

    We'll also put pressure on from the consumer side. Consumer Reports has written about us a lot, and we work with them closely. We work with the AARP. We're meeting with the Alzheimer's Association next week.

    Q: What are some other things you've noticed as OpenNotes has spread??

    A: There will be pressure on and among the providers, I think. Another thing that happens is competition. In three parts of this country we've seen a fascinating phenomenon. In Portland, Ore. and Seattle, and in the middle of Pennsylvania, we've seen organizations adopting OpenNotes because the other guy has it.

    In Portland, Ore., nine normally-competing organizations got together to work together on OpenNotes. And extraordinary thing. We call it the Portland Consortium.

    In Seattle, basically all the big players are doing it with one other thinking about doing it. University of Washington. Virginia Basin, Group Health, Kaiser Northwest. The only big outlier is Swedish Hospital, and I bet you they'll be doing it within the year. So the word gets around.

    The registrations on our portal here are way up since we started OpenNotes. It brings patients to the portal. It keeps patients in the institution. It's a way of both attracting and retaining patients. That's one of the business cases for it.

    It's the right thing to do, and there's also a business case as (providers) compete in a crowded market. That's one of the reasons we think we're spreading so quickly.

  • 09 Jan 2015 11:45 AM | Anonymous
    During the week of April 26 through May 1, 2015, a second sample group of providers will have the opportunity to participate in ICD-10 end-to-end testing with Medicare Administrative Contractors (MACs) and the Common Electronic Data Interchange (CEDI) contractor. The goal of end-to-end testing is to demonstrate that:
    • Providers and submitters are able to successfully submit claims containing ICD-10 codes to the Medicare Fee-For-Service (FFS) claims systems
    • Centers for Medicare & Medicaid Services (CMS) software changes made to support ICD-10 result in appropriately adjudicated claims
    • Accurate remittance advices are produced
    Approximately 850 volunteer submitters will be selected to participate in the April end-to-end testing. This nationwide sample will yield meaningful results, since CMS intends to select volunteers representing a broad cross-section of provider, claim, and submitter types, including claims clearinghouses that submit claims for large numbers of providers. Note: testers who are participating in the January testing are able to test again in April and July without re-applying.

    To volunteer as a testing submitter:
    • Volunteer forms are available on your MAC website.
    • Completed volunteer forms are due January 21.
    • CMS will review applications and select the group of testing submitters.
    • By February 13, the MACs and CEDI will notify the volunteers selected to test and provide them with the information needed for the testing.
    If selected, testers must be able to:
    • Submit future-dated claims.
    • Provide valid National Provider Identifiers (NPIs), Provider Transaction Access Numbers (PTANs), and beneficiary Health Insurance Claim Numbers (HICNs) that will be used for test claims. This information will be needed by your MAC by February 20, 2015, for set-up purposes; testers will be dropped if information is not provided by the deadline.
    An additional opportunity for end-to-end testing will be available during the week of July 20 through 24, 2015. Any issues identified during testing will be addressed prior to ICD-10 implementation. Educational materials will be developed for providers and submitters based on the testing results.

    For more information:

    Keep Up to Date on ICD-10
    Visit the CMS ICD-10 website for the latest news and resources to help you prepare. Sign up for CMS ICD-10 Industry Email Updates and follow us on Twitter.

    Retrieved Jan 9, 2015 from

  • 08 Jan 2015 3:22 PM | Anonymous
    First health information exchange in the country to tap its data to improve patient care
    PORTLAND, ME | January 7, 2015  | Retrieved from

    Knowledge is power. The folks who run Maine's statewide health information exchange have been keenly aware of this adage for some time – focused on not merely delivering information, but also on putting the vast amount of data they collect to work on helping providers give the best care they can.

    With their partners at HBI Solutions in Palo Alto, Calif., HealthInfoNet, which operates the statewide HIE, is helping hospitals, ACOs and physician practices put the power of near real-time data to work on improving patient care.

    The HIE has plenty of data to work with. HealthInfoNet’s comprehensive clinical data repository contains records for nearly all of Maine’s 1.3 million residents. It collects clinical information from 32 of the State’s 36 acute care hospitals and 326 ambulatory locations including primary and specialty care practices and long-term care facilities.

    Today, according, to its CEO, Devore Culver, HealthInfoNet has contracts for its predictive analytics package from five hospitals and the state's Pioneer accountable care organization. The HIE is the first in the country to adopt this type of model. And, from the trials that took place before the contracts were signed and the work the predictive analytics make possible today, it's a model that's mighty.

    Customers can use the analytics and predictive tools to study market share, clinical performance, population health and patient risk, all in real-time.

    St. Joseph Healthcare in Bangor, the first organization to use the new tools, is focused on cutting its 30-day readmissions rate.

    Jessica Taylor, RN, is a care manager in the organization’s internal medicine practice.
    “It’s easy to capture the patients that we know need a lot of help," Taylor said. "My goal was to reach those patients that are doing OK but might be getting into trouble and get them the help they need.”
    Sometimes a simple early intervention, like timely home care services for someone with congestive heart failure, can prevent a hospitalization, she explained.
    "Jessica is a long time user of the exchange," Culver told Healthcare IT News. "She is focusing on the patients that have not yet gone south – people who show signs of getting worse, catching people that otherwise would have fallen through the cracks," he said, noting that the predictive data helps caregivers identify patients who are at risk before their condition gets worst.
    "Every night we run all the transactions from the previous day, so we're never more than 24 hours behind," Culver said. "So that really is part of the power, is that its very, very, very current. In running that update of the data, HBI is recalculating the risk scores every day, too, based on the data. So it really is incredibly immediate, incredibly powerful."
    HBI Solutions President Eric Widen noted that automated close to real-time patients assessments eliminates 15-20 minute manual assessments: "We completely eliminate that work and save the organization thousands of hours of manual time by just automating the risk scores within that."

    Claims data, at best is 90 to 120 days old, Widen pointed out.

    "At worst, ours is going to be 24 hours old," he said. "You basically get a comprehensive risk profile on a patient updated every day. It provides risk of many different things, which helps the care manager understand what else the patient might be at risk for – risk of ED admission, risk of disease, its kind of a dashboard of risks."

    In addition to selling the service to HIE customers in Maine, HealthInfoNet is partnering with HBI Solutions to help exchanges outside of Maine set up similar tools for their customers. The two companies have met with a number of statewide and private HIEs in the past few months.
    “HealthInfoNet has been a leader in the HIE space for sometime and feel we have a lot to offer other HIE organizations as they set up similar services,” said Culver. He added that an HIE needs to provide additional value to its customers in order to be sustainable.
    “We believe this type of service is an important piece of the sustainability pie for the HIE and its customers," Culver said.
    In the case of Maine's HIE, "the stars aligned," Culver said. "Two organizations who are generally pretty forward thinking found each other and discovered that each had an asset the other one needed.
    "We had a lot of data, but not necessarily a way of doing this kind of stuff with it," he added. "HBI had a really interesting tool they'd been working on as a product of trying to predict variation of the genome and they thought they could apply to anything medical. And, lo and behold, we think we've proven that's true."

  • 08 Jan 2015 2:55 PM | Anonymous
    JASON Report Part II was released at the end of November, titled Data for Individual Health. The report aims to examine how to create a health information system that focuses on the health of individuals. The report focuses heavily on the critical need for the adoption of open APIs to foster interoperability. Claims are made in the report that the health data infrastructure does not have the capability to make the data accessible in a usable form or to represent it in an atomic format.

    The ONC has spent considerable time and money trying to foster interoperability through Meaningful Use the past several years. Putting the infrastructure in place to support CCD and CCR was the main focus of interoperability for Stage 1. Then Stage 2 introduced Consolidated CDA along with the Direct Project, which was touted to be a secure and simple protocol that would be easy to implement. So what does the JASON Report have to say about CDA and the efforts made towards interoperability so far?

    The report indicated that as a document standard that CDA did possess some “desirable characteristics.” There are three areas of the CDA approach that received positive comments in the report:
    • The CDA Header, one of the six key characteristics of a CDA document as defined by HL7, sets context for the entire document.
    • The human readability component of CDA was viewed as a positive feature. Human readability is also one of the six key characteristics of a CDA document.
    • Level 3 Semantic Interoperability. CDA documents which apply Level 3 Semantic Interoperability with full coding of the entries were seen as “a good example of an open standard that can be further evolved.”
    This is where the compliments end, which is not exactly a glowing endorsement of CDA.

    The chief complaint with CDA is that it is “really only a container for the information.” The report focuses in the importance of having open standards which embrace the concept of atomic data. While the report concedes that XML will allow for the parsing of the data to be used in an atomic way, they comment that disaggregating the data in this way “is made quite difficult.”

    The report does not go into details as to why the parsing of the data has been so difficult, but there have been obvious difficulties for each stage of Meaningful Use:

    Meaningful Use Stage 1. The requirements for Meaningful Use Stage 1 called for the infrastructure to be in place to send a CCD or CCR document. In a previous blog, I discussed how vendors would chose to test with CCR instead of CCD because it was simpler. The CCD of Meaningful Use Stage 1, the C32 version, had multiple sources of truth requiring anyone who wanted to understand the standard to go to multiple implementation guides. This did not make it easy to embrace the standard.

    Meaningful Use Stage 2. The requirements for Meaningful Use Stage 2 called for the use of C-CDA. The C-CDA standard aimed to solve the multiple sources of truth by combining the standards of nine different common document types into one C-CDA implementation guide. One of those nine document types was CCD. But, curiously, the ONC chose to utilize none of those nine document types, but rather four additional document types. These document types are structured using the C-CDA standard, but are not one of the included nine defined types. Needless to say, this adds to the difficulty of disaggregating the data as pointed out in the JASON report.

    If CDA is not an adequate standard for leading the industry to utilize atomic data, then what would be better? The report spends many more pages talking about the possibilities than they do rehashing what went wrong in the past. After the discussion of CDA the report analyzes the emerging HL7 FHIR standard, and details how REST and FHIR could become the foundation for the future of the health IT system. Look for future blogs that focus on FHIR. I look forward to your comments below [ click here to view / comment ].

    By Rob Brull | Retrieved from
    January 8, 2015

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