Having announced the Stage 1 Meaningful Use rules this past summer, the U.S. Office of the National Coordinator for Health Information (known to most people as the ONC) did not wait long to start work on stage 2 and stage 3 Meaningful Use rules. Earlier today, David Lansky, Chair of the Quality Measures Workgroup, posted a request for comments on proposed new clinical quality measures. These measures were developed by five tiger teams, each focused on different measure domain:
- Patient and Family Engagement,
- Clinical Appropriateness/Efficiency,
- Care Coordination,
- Patient Safety, and
- Population and Public Health.
The resulting measures were reviewed and consolidated by the Quality Measures Workgroup which is now calling for public comment. In addition to general comments, the Quality Measures Workgroup also seeks specific examples of measure for each measure concept.
Comments will be accepted until December 23, 2010 [which, by the way, also happens to be my oldest son's birthday ]
Interested in personal health records (PHRs)? So is the US Congress. Section 13424 of the HITECH Act directs the Office of the National Coordinator (ONC) for Health IT to conduct a study and make recommendations related to the application of privacy and security requirements to “non-HIPAA Covered Entities”, with a focus on PHR vendors and related service providers.
To collect information related to the mandated study, the ONC is hosting a PHR Roundtable on December 3rd, 2010. According to the ONC website for this event, the Roundtable will “address the current state and evolving nature of PHRs and related technologies (including mobile technologies and social networking), consumer and industry expectations and attitudes toward privacy and security practices, and the pros and cons of different approaches to the requirements that should apply to non-CE PHRs and related technologies.”
The roundtable will include “four panels of prominent researchers, legal scholars, and representatives of consumer, patient, and industry organizations.” These panels will include:
- PHRs: Origins, Developments, Privacy and Security Practices
- PHRs and Related Technologies: New Forms, New Audiences, and New Challenges
- Privacy and Security of Identifiable Health Information in PHRs and Related Technologies: Expectations and Concerns
- Perspectives on Privacy and Security Requirements for PHRs and Related Technologies
The ONC will begin accepting public comment at the beginning of November.
I have been watching with great interest the development of the US EHR strategy, spurred, in large part, by stimulus funding through the HITECH. I recently came across a succinct and insightful summary of this strategy written by John Glaser, VP and CIO at Partners Healthcare in Boston and soon to be CEO at Siemens Health. What I thought was particularly insightful and perhaps even profound was Mr. Glaser’s views on the uncertainity associated with the US strategy:
“It is not possible to launch this much activity of this scope with this many actors and have great certainty about the outcome. This uncertainty will be magnified by the evolving actions of the private sector—hospitals, health plans, suppliers and others that are engaging in a diverse array of often very imaginative implementation activities.
The implementation plans are good plans. Change of this magnitude will bring very real progress, but it will also bring a period of time that is likely to be bumpy.
The federal electronic health record strategy has been formed, and the country is at the start of its implementation. The strategy is ambitious, multifaceted and sophisticated. This journey faces many uncertainties and will not be easy. However, the strategy has a high likelihood of causing many health care organizations to make meaningful use of EHRs and improving the health care delivered in this country.”
Sometimes it is simply not possible to predict with any accuracy how change will play itself and being too prescriptive is a recipe for disaster. I think that the US approach will generate sufficient activity that there will more successes than failures and a natural momentum will be created that will carry the eHealth agenda forward in that country.
I have been following the US “meaningful use” debates quite closely and regularly listen in on committee and working group sessions related to this topic that are broadcast over the Internet. Another venue for public participation in the debate is through a web-based discussion forum:
An example of the type of comments posted on this site is a letter from signed by Massachusetts senators Paul G. Kirk Jr. and John F. Kerry. They ask that “meaningful use” criteria require “the inclusion of a physician narrative beyond the template text”. They argue that such narrative “enables medical providers to explain their thought processes, including issues such as why they recommended one treatment over another”.
I continue to be amazed at the degree to which the debate on “meaningful use” is made public. My sense is that this level of openness and transparency is not only leading to a more robust definition of “meaningful use” but is also contributing to a more constructive and respectful debate.
COACH, Canada’s health informatics association, has raised the alarm about a potential shortage of qualified healthcare IT professionals. Given this concern, I was intrigued to read about one US approach to dealing with a similar shortage:
This approach takes advantage of the skills people already while giving people not yet ready to exit the workforce new opportunities. Clearly a win / win situation, one that we might want to consider in Canada.
Mark and I have written in the past year about the concept of “meaningful use” associated with EHR funding in the US and the open and transparent process by which “meaningful use” is being defined. At the very end of last year (still hard to remember that it is now 2010), two documents were posted that, among other things, offer an initial definition of “meaningful use” and describe the process by which the definition was conceived:
Three stages of meaningful use are specified:
- Stage 1 (beginning in 2011): The proposed Stage 1 meaningful use criteria “focuses on electronically capturing health information in a coded format; using that information to track key clinical conditions and communicating that information for care coordination purposes (whether that information is structured or unstructured, but in structured format whenever feasible); consistent with other provisions of Medicare and Medicaid law, implementing clinical decision support tools to facilitate disease and medication management; and reporting clinical quality measures and public health information.”
- Stage 2 (beginning in 2013): CMS has proposed that its goals for the Stage 2 meaningful use criteria, “consistent with other provisions of Medicare and Medicaid law, expand upon the Stage 1 criteria to encourage the use of health IT for continuous quality improvement at the point of care and the exchange of information in the most structured format possible, such as the electronic transmission of orders entered using computerized provider order entry (CPOE) and the electronic transmission of diagnostic test results (such as blood tests, microbiology, urinalysis, pathology tests, radiology, cardiac imaging, nuclear medicine tests, pulmonary function tests and other such data needed to diagnose and treat disease). Additionally we may consider applying the criteria more broadly to both the inpatient and outpatient hospital settings.”
- Stage 3 (beginning in 2015): CMS has proposed that its goals for the Stage 3 meaningful use criteria are, “consistent with other provisions of Medicare and Medicaid law, to focus on promoting improvements in quality, safety and efficiency, focusing on decision support for national high priority conditions, patient access to self management tools, access to comprehensive patient data and improving population health.”
The rules in which the meaningful use criteria are incorporated will be published in the Federal Register by mid January and will be subject to a 60-day comment period effective. The interim final rule will become effective 30 days after publication.
According to an iHealthBeat article (http://www.ihealthbeat.org/Articles/2009/9/14/Prospect-of-Stimulus-Funds-Helps-Drive-Up-Health-IT-Stock-Prices.aspx), “the promise of new funding has helped fuel recent growth in the market for health information systems”. The article notes that “Health IT stock prices increased by 30% during the first half of 2009, compared with a 2% gain by Standard & Poor’s 500 index and a 16% growth in the Nasdaq stock market, according to a July report by Healthcare Growth Partners”.
Amazing what senior political belief in the power of IT to help transform healthcare can do
As the U.S. moves aggressively to drive the adoption of healthcare IT, the Agency for Healthcare Research and Quality commissioned a project to explore whether consumers felt that they should have “a role in determining how health IT is designed and used”. The final report of this project can be found at:
Through a series of focus groups across the United States, consumers expressed the following views:
- “… participants were optimistic that health IT would benefit health care quality. They thought that computers may add efficiency to health care and reduce medical errors, such as those associated with illegible handwriting.”
- “…some participants were concerned that health IT might make providers more impersonal, devoting more attention to the computer screen and less to the patient.”
- “Privacy and security were the main concerns of a large majority of the participants. A substantial proportion felt that health care consumers owned their data and needed a role in ensuring that those data were secure and used only in ways that they authorized. The participants were concerned that hackers or other individuals might gain inappropriate access to patient data. They were also concerned that their data might be shared with persons who want to use the data for their own purposes, rather than to provide care.”
- “The participants did tend to support the idea that health care consumers should be asked for their consent before their medical data are stored electronically. Many participants felt that consumers should be able to elect to leave their data in paper format. The participants tended to feel that each individual provider should ask each patient for permission to store the patient’s data electronically and to share the data with other providers. Patients should be able grant permission to one provider but deny it to others, in the opinion of many in the focus groups. In this way, the participants felt that health IT restrictions should be set individually for each consumer, rather than by general rules applied to all consumers.”
- “The participants were divided on the issue of how electronically stored data could be used for medical research and for market research by pharmaceutical companies.”
- “…there was a great deal of disagreement about the role of government. Some felt that government should not concern itself with health IT at all, saying that market forces should guide those decisions. Others thought that elected officials and government agencies would protect the interests of health care consumers.”
Supporting a key theme that I have been harping on for the past few months, “… public education about health IT is needed. The education might address how health IT will affect the experiences of all health care consumers. It might also show the public how patients and consumers can have an influence on how health IT is designed, implemented and/or used.” I think that such education is part of larger eHealth leadership issue, one that we (in Canada) are not addressing in the current climate of eHealth spending concerns. While we are getting better at engaging the clinical community, we still have a long way to go in engaging a critical important constituency … the people to whom care is provided!
It appears that the US eHealth market is heating up.
Although 2008 was worst year in the past seven years for clinical information system sales, market research firm KLAS predicts that “”Next year will be a boom year, and so will the next”". This growth will be largely driven by financial incentives from the American Recovery and Reinvestment Act.
Mark, do you see any similar increase in eHealth sales in Canada? What will be the impact of the $500M investment announced in the last budget for Infoway? Will the eHealth “scandal” have an opposite impact to ARRA in the US?