Clinical IT Governance Update

I've written many posts about the importance of IT governance to set priorities, align stakeholders, and allocate budgets.

Today, I will meet with the Clinical IT Governance Committee to discuss the 5 major IS projects in the BIDMC Annual Operating Plan, brief them about the Meaningful Use Stage 2 NPRM, and discuss 2012 State HIE initiatives.

Here's an overview of what I'll say

*Electronic Medication Administration Records - at BIDMC, we wanted to eliminate all handwritten orders in every care setting, so we aggressively implemented CPOE before automating Medication Administration Records.   Now that we have 100% electronic ordering, we're implementing projects that close the loop - checking patients, medications, staff ID, and active orders when medications are given to the patient.   We've developed a scope, a timeline, and a workflow that embraces both fixed bedside devices and mobile technology to document when, where, and how medications are administered, reconciling orders and doses given.   We buy technology when it is mature and robust.   In this case, we'll need highly innovative, integrated technology supporting a unique workflow, so we're building it.

*Clinical Documentation - at BIDMC, our ambulatory documentation is entirely electronic.   In our monitored units, all flowsheets are electronic.  On our wards, progress notes are still written on paper.   In 2012, we're designing inpatient clinical documentation to align with the needs of our ICD10 project.  We'll use templates, macros, and free text input to support computer assisted coding, reducing the burden on clinicians and coders who need to pick the right code from 68,000 diagnosis and 87,000 procedure choices.  

*ICD10 - Although Secretary Sebelius has announced an intent to delay ICD10 enforcement dates, the project is such an enormous undertaking requiring policy change, workflow change and technology change that we're continuing full steam ahead.   We're executing a multi-phase project that includes current state documentation, a gap analysis, and a remediation plan.

*Personal Health Records - Patientsite, our PHR, is used by over 60,000 people every month.   Since its inception in 2000, Patientsite has not had a major upgrade.   This year, we're enhancing the look and feel, adding Open Notes (patients viewing all notes written about that), and creating a mobile friendly version.

*Standardized project management including a single intake process - among the many departments of BIDMC, different techniques are used for project charters, Gantt charts, issue logs, status reports, and project intake.  This year, we plan to create a single set of uniform project management artifacts that can be used by all business owners on IS related and other projects.

In addition to ICD-10, future stages of Meaningful Use Stage 2 will require multiple years of technology and policy work.   I'll present a summary of the challenges ahead based on the Stage 2 NPRM requirements .

Finally, in October of 2012, the Massachusetts Statewide HIE will go live and we'll use the infrastructure to enhance data sharing with payers, providers and patients.   At the same time we'll want to share more, compliance requirements will suggest further restrictions on data flows.   It will be a delicate balance.

I look forward to the meeting tomorrow.  Being a CIO means there's always new challenges and life will never be boring!

Provider Directory Strategies

The Office of the National Coordinator asked me to present the Massachusetts Provider Directory approach to the Provider Directory Community of Practice (CoP) on March 21.

Here's the powerpoint that I'll present tomorrow.

It highlights the decisions we had to make (Entity v. Individual, Central v. Federated, web API verses LDAP, etc)

Issue: Should we include organizations, individuals or both in the provider directory?
Answer: The directory should have a schema that enables lookup of entities (e.g., Organizations, Departments, State Agencies, Payer Organizations, Patient Health Record services) AND an individual's affiliation with an entity trusted by the HIE.  You can lookup John Halamka to discover that I'm affiliated with BIDMC, then lookup BIDMC to determine how to exchange data with my organization.

Issue: Should the Provider Directory be centralized or federated?
Answer:  The Provider Directory should be centralized at the State level, given lack of proven scalable approaches to federated provider directories standards and architecture.  However, Public Key Infrastructure can be federated based on the Direct DNS specification for certificate exchange.

Issue: How should we expose Provider Directory services to the Internet?
Answer: A SOAP-based web services API will support query/response, add/change,  and delete operations over the Internet.  An LDAP approach will support directory access for applications behind the MassHealth firewall.

Issue: How should we populate the provider directory?
Answer:  Commercial databases often lack timely updates.   In Massachusetts, we have several existing data sources to leverage including those used by payers for quality reporting, those used by provider organizations, and those used by the regional extension center.

Issue: How will we integrate this service into EHRs?
Answer: We will work with EHR vendors via a centralized program management office to procure software components that integrate provider directory and HIE transport services into the workflow of the EHR itself.  We will not force clinicians with certified EHRs to use a disconnected portal outside of their the EHR.

I look forward to speaking with the Provider Directory Community of Practice (CoP) to hear about approaches in other states and share lessons learned.

popHealth

While in Chicago last Thursday, I was asked how we validated our quality measures when we moved from chart abstraction to automated computation of PRQS, Meaningful Use, Pioneer ACO, and Alternative Quality Contract measures via the Massachusetts eHealth Collaborative Quality Data Center (QDC).   This is an important question because Meaningful Use Stage 2 enables easy use of modular components outside the EHR such that data can be captured in the EHR and sent to a cloud based analytics engine via standards such as CCD/C32 for content and Direct for transport.

Initially we did spot checks to validate the integrity of the Continuity of Care Document data flows from electronic health records to the normalized QDC schema.

When Mitre Corporation offered to test their popHealth tool against 2 million BIDMC patient records to validate the Meaningful Use quality measures computed by our QDC, we jumped at the opportunity.

First, we ensured appropriate business associate agreements were in place to protect the privacy of patient data.   Next, we required all work to be done on site in the Quality Data Center to protect the security and integrity of clinical summary data.

Mitre ran the tool against 2 million BIDMC Continuity of Care Documents and compared the results to the reports generated by the QDC.

The results were enlightening.

The computations aligned well for most quality measures, justifying our early manual validation.

However, Mitre discovered ambiguities in the CCD specification itself that led to some differences in the calculations.     This was despite our use of this CCD implementation guide  which provides even greater specificity than the HL7 standard.

For example, the CCD does not specify an allergy vocabulary.   At BIDMC we use First Data Bank to codify medication allergies.   PopHealth expects RxNorm, the vocabulary standard required for exchanging medication history.   Even the Stage 2 NPRM does not specify an allergy vocabulary and we recognized the need to enhance the Stage 2 to include RxNorm for medication allergies (Penicillin VK),  NDF-RT for categories of medication allergies (all Penicillins and Cephalosporins) and SNOMED-CT for non-medication allergies (food and environmental agents).

I'll post other pertinent findings from the Mitre analysis after next week's debrief meeting.

Mitre demonstrated their work at HIMSS in the interoperability showcase as illustrated in the photograph above.

BIDMC and MAeHC were proud to participate in this event, which we hope provided lessons learned for other provider, payer, and government stakeholders wanting to compute quality measures in the cloud using popHealth.

The Chicago Healthcare Information Exchange

On Thursday, I met with the Chief Medical Officers working group of the Metro Chicago Healthcare Council to discuss Healthcare Information Exchange strategy in a world rapidly moving toward accountable care organizations, patient centered medical homes, and global capitation.

Chicago has created a consolidated summary record for patients using technologies from Microsoft (aggregation and analytics) and HealthUnity (master patient index services).   CSC provides Systems Integration and Program Management.

Importantly, they've built governance, trust, a policy framework, engagement, and commitment from stakeholders in the greater Chicago metro area.

Their architecture is a bit different from the Massachusetts approach and it will be very interesting to compare lessons learned over the next year.   They are receiving HL7 feeds from participating hospitals, matching identical patient records together, and  aggregating the data using the kind of data-atomic attribute-value pairs suggested by the President's Council of Advisors on Science and Technology Healthcare IT report.

The centralized/consolidated summary record can then be accessed by authorized clinical users such as primary care physicians, hospitalists, and emergency departments.

The Chicago HIE will also offer secure messaging to support the kinds of push use cases we've discussed in Massachusetts i.e.

Referral/Consult
Admission notification
Post-encounter summary
Discharge Summary/Instructions
Lab Order/Results
Public health (SS, Imm., ELR)

They've worked hard to engage the Chief Medical Officers of the region's hospitals and to create patient demand for HIE services via consumer education.

A great group of people and definitely an HIE to watch!

Our Cancer Journey Week 13

It's week 13 since diagnosis and Kathy's will receive the 7th cycle of chemotherapy tomorrow. (3rd cycle of Taxol)

Kathy's hematocrit continues to trend downward (from 42 at diagnosis to 29 last week), her nails have turned black/brittle, and her eyelashes have disappeared, but the worst is over.   She's feeling fine, the tumor is undetectable, and she's tolerating Taxol very well.

Taxol typically does not cause a drop in hematocrit, so why the gradual downward trend over the past few weeks?  

Kathy received Neulasta as part of her 4 cycles of Adriamycin/Cytoxan.  Neulasta is a colony-stimulating factor  that encourages hemopoietic stem cells to produce white blood cells, avoiding the neutropenia and susceptibility to infection that was previously a serious problem with chemotherapy.   One issue with Neulasta is that it may encourage so many stem cells to differentiate into white blood cells that fewer red blood cells are produced, leading to a mild anemia.    Over the next few weeks, her bone marrow should return to normal and her hematocrit should rise.   The only consequence of a low hematocrit for Kathy has waning energy mid-day that necessitates a 15 minute nap.   Otherwise, her activities of daily living (including packing the house for our upcoming move) remain unchanged.

Her hair is beginning to grow back.  She wears head wraps for warmth around the house and while sleeping.   When we go out to dinner, she wears a wig (interestedly termed a "hair protheses" for reimbursement purposes) that is so attractive, her friends and family have grown accustomed to the style.  When her hair grows back, she'll likely get the same cut.

One unexpected consequence of having breast cancer is that Kathy has stopped eating Tofu and soy products that are estrogenic, given that her tumor is Estrogen Receptor positive and is "fueled" by estrogen.   Minimizing estrogenic foods seems reasonable.   She continues to get her protein from vegetable sources, but has also added eggs - remaining vegetarian but not vegan.    Given that we'll soon have a coop of chickens on our new farm property, having at least one person in the family who eats eggs makes sense.

Thus, her trajectory is positive, her clinicians are optimistic, and we're pressing forward with life, balancing the needs of our personal lives, family lives, and work lives.   We're in control, not the cancer.

Will Payers be the Business Intelligence Services of the Future?

What is a payer/insurer?

Typically, payer organizations collect premiums from employers and individuals, process claims, and engage in a variety of case management/disease management activities to encourage the appropriate use of medical resources.   If they collect more premiums than claims paid,  their medical loss ratio is less than 100% and they earn a profit.

In a world of accountable care organizations and healthcare reform, new reimbursement methods will include global payments to providers, which implies the risk of loss will shift from the payer to hospitals and clinicians.   Payers will no longer need their large claims processing staff, nor create complex actuarial models.   They'll become very different organizations.

How different?

My prediction is that payers will become the health information exchange and analytics organizations that help hospitals and clinicians manage risk in a world of capitation.

I've said before that ACO=HIE+Analytics.

The payers are already making strategic acquisitions to build these new business models

Aetna acquired Medicity to gain expertise in healthcare information exchange.  Aetna had already acquired Active Health to gain access to its CareEngine analytics platform.

United acquired Axolotol to gain expertise in healthcare information .   United already had a comprehensive suite of analytic capabilities via its Ingenix subsidiary.   United rebranded the combination of HIE plus analytics as OptumInsight

Three of the nation's largest Blue Cross plans acquired Navinet for its real-time communication network that links physicians, hospitals, and health insurers.

Humana acquired AnvitaHealth for its real time analytics and decision support capabilities.

The next several years will be interesting to watch as the country gains experience from Pioneer ACOs (7 of the 32 are in New England and 5 in Massachusetts).

Watch the payers carefully.   As they acquire more HIE and Analytics businesses, I believe you'll see a shift from claims processing to wellness management and cloud-based provider services.

Surescripts Clinical Data Exchange

Yesterday, Surescripts announced a national approach to sharing clinical summaries and public health data via its Clinical Interoperability Network:

"WALGREENS AND SURESCRIPTS IMPROVE COORDINATION OF CARE BY ELECTRONICALLY DELIVERING IMMUNIZATION AND PATIENT SUMMARY RECORDS TO PRIMARY CARE PROVIDERS

Surescripts Network Accelerates Interoperability Between Physicians, Pharmacists and Take Care Health Providers by Making It Easier to Supply Information Often Missing During Patient Visits"

According to the release, the Surescripts Clinical Interoperability Network supports all federal and state policies and standards for health information exchange, including privacy and security standards (such as HIPAA and state law), technology interoperability standards (such as Direct) and various message types.   The service is being rolled out to 500 hospital labs to connect to public health under a grant from the Centers for Disease Control and Prevention, and is also being used by physicians for physician-to-physician communication and care coordination.

I asked for further details about the transport, content, and vocabulary standards they plan to use.   Here's their response:

"Currently, we’re delivering PDFs over a REST-based protocol or Direct - whatever manner we have connectivity. We’re also faxing and mailing while vendors work on their connectivity modules. We’re in the process of determining which profile in terms of CCD/CDA will be the easiest for most vendors to receive. We’re targeting implementation later this summer.

When we start reporting to state registries, we’ll be sending the records in the most modern standard the states are ready to implement. We hope to see the majority of registries stepped up to HL7 2.5.1, Release 1.3 and August 2011 CVX code sets. But if a state isn’t quite ready, we’ll connect to what they have and upgrade the transport/content when they’re ready."

Massachusetts and other HIEs are implementing Direct for the summary and public health transactions.   With State HIE and national Healthcare Information Service Providers like Surescripts, we'll connect every payer, provider, and patient in time for Meaningful Use Stage 2 requirements.