Tuesday, July 27, 2010

Energy and Commerce Committee Hearing on Health IT

The Subcommittee on Health of the House Energy and Commerce Committee held a hearing on Tuesday, July 27, 2010, in 2322 Rayburn House Office Building entitled “Implementation of the Health Information Technology for Economic and Clinical Health. Reported Emily Long at NextGov:
Members of the House Energy and Commerce Health Subcommittee questioned whether health care providers will run out and purchase new technology knowing that the certification program won't be up and running until 2012. Providers who don't demonstrate meaningful use by 2015 could face penalties.
According to Blumenthal, The Office of the National Coordinator has in place a temporary certification program, but it doesn't include all the criteria that providers will have to meet in the long run.The certification standards are entirely new because they must reflect the requirements of meaningful use, he said, adding, "We don't want to create the impression for providers that something they're using now will be capable of meaningful use."
Testifying at the hearing were:
  • David Blumenthal, M.D., National Coordinator, Health Information Technology, U.S. Department of Health and Human Services
  • Anthony Trenkle, Director, Office of E-Health Standards and Services, Centers for Medicare and Medicaid Services
  • Frank J. Vozos, M.D., FACS , Executive Director, Monmouth Medical Center, New Jersey Hospital Association
  • Gregory D. Starnes, CEO, Fayette County Hospital
  • Christine Bechtel, Vice President, National Partnership for Women & Families
  • Roland A. Goertz, M.D., M. B.A., President-Elect, American Academy of Family Physicians, Heart of Texas Community Health Center
  • Dr. Matthew Winkleman, M.D., Physician, Primary Care Group,
  • Glen E. Tullman, CEO, Allscripts
  • Peggy C. Evans, Ph.D., CPHIT, Director, Washington and Idaho Regional Extension Center, Qualis Health
The Briefing Memo is below with video and testimony beneath that and then some interesting bits from the question and answer. The entire hearing is embedded at the end of the post.

Testimony of David Blumenthal

Testimony of Anthony Trenkle

Testimony of Frank J. Vozos

Testimony of Gregory D. Starnes

Testimony of Christine Bechtel

Testimony of Roland A. Goertz

Testimony of Matthew Winkleman

Testimony of Glen E. Tullman

Testimony of Peggy C. Evans

Below are some interesting segments from the Q and A.



Sunday, July 25, 2010

Liberating the NHS

As the Unites States moves towards a more centralized government role in healthcare, Great Britain is beginning to move in the other direction. The new coalition government has proposed some quite radical plans for the National Health Service (NHS) by shifting control of the $160 billion annual health budget from a centralized bureaucracy to local physicians while also promising to put more power in the hands of patients.

The paper (embedded below) states:
"The current architecture of the health system has developed piecemeal, involves duplication and is unwieldy. Liberating the NHS, and putting power in the hands of patients and clinicians, means we will be able to effect a radical simplification, and remove layers of management."
Some of the main points in the paper include:
  • The retention of national and regional commissioning, which will come under a new NHS Commissioning Board
  • The recognition that research is vital in order to identify new ways of preventing, diagnosing and treating disease
  • The commitment to shared decision making and the recognition that it results in a better quality of care
  • Increased patient access to information, including increased control over their records and more information on research
  • Integration of health and social care by creating a system that works more effectively across boundaries

Thursday, July 22, 2010

eHI Releases "The State of Health Information Exchange in 2010: Connecting the Nation to Achieve Meaningful Use"

The eHealth Initiative (eHI) released a new report entitled "The State of Health Information Exchange in 2010: Connecting the Nation to Achieve Meaningful Use." The report identifies significant growth in the industry, as well as rising concerns related to new government policies, and an increased focus on patients. The report was shared with several hundred state and industry leaders during the National Forum on Health Information Exchange in Washington, DC. The eHealth Initiative has been tracking the progress of health information exchange initiatives for seven years. This year, eHI identified 234 active health information exchange initiatives across the country and 199 organizations responded to the annual survey.

Several key findings emerged from the survey results:

Despite recent funding, significant challenges exist to supporting provider attainment of meaningful use.

The survey revealed that despite expanding capabilities, the ability of HIEs to support providers as they become Stage 1 meaningful user will be challenged by the current number of operational exchanges and current capacity of health information exchange initiatives.

"From the results, it is clear that health information exchange initiatives are focused on supplying the services that will help providers reach their targets," Commented Micky Tripathi, Ph.D., President and CEO of Massachusetts eHealth Collaborative. "While we're on the right track with the service offerings, we still haven't achieved the necessary critical mass of participation."

More research is needed to determine the key characteristics of sustainable systems.

The report confirms that sustainability remains one the key challenges before the initiatives. The State Designated Entities (SDEs) are new entrants in the field, and it is not clear what will be their impact on the initiatives.

"The State Designated Entities (SDEs) are poised to foster growth across the field of health information exchange," said Dr.Marc Overhage, Director of Regenstrief Institute and CEO of Indiana Health Information Exchange. "Among other challenges, the SDEs are going to face the question how to keep the doors open once the federal funding ends. Failure to sustain the SDEs may hinder the overall advancement of health information exchange."

New challenges are rapidly emerging related to federal policy and governance of the health information exchanges.

131 initiatives cited addressing government policy mandates as a major challenge.

More organizations are reporting cost savings through reductions in staff time and redundant testing through the use of health information exchange.

More initiatives reported health information exchange had reduced staff time spent on clerical administration and filing (33); reduced staff time spent on handling lab and radiology results
(30); and decreased dollars spent on redundant tests (28).

Health information exchange initiatives have increased their focus on patients.

Initiatives are providing greater access to patients to not only view (44 in 2010 up from 3 in 2009), but to also update their health information (31 in 2010 up from 7 in 2009).

"There is definite progress here, but it doesn't mean we can rest on our laurels," noted Jennifer Covich Bordenick, CEO at eHealth Initiative. "More initiatives and providers need to document cost savings, and promote services that involve patients in their healthcare."

The report and an interactive map of health information exchange activity are available on the eHI website at:

The HIE I am working on, Gorge Health Connect, Inc. is here:

Open Source Solutions for Healthcare

With the health information technology industry ramping up to help physicians and hospitals meet meaningful use, there is opportunity to bring open source solutions to bear. At the intersection of health care, government and open source, these three have a unique perspective on how to address the pressing needs within health care.

If you have not had a chance to see the interview on Radar with Brian Behlendorf, Arien Malec and David Riley check it out at

Tuesday, July 20, 2010

Congressional Testimony on Meaningful Use

The House Ways and Means Subcommittee on Health held a Hearing on Efforts to Promote the Adoption and Meaningful Use of Health Information Technology on July 20, 2010. Text of the testimony provided at the meeting is below the videos:

Testimony By David Blumenthal M.D.

National Coordinator for Health Information Technology
U.S. Department of Health and Human Services

Testimony By Tony Trenkle

Office of E-Health Standards and Services
Centers for Medicare & Medicaid Services

Testimony By Christine Bechtel

Vice President
National Partnership for Women and Families

Testimony By Phyllis Teater

Chief Information Officer
Ohio State University Medical Center, Columbus, Ohio

Testimony By Eugene Heslin M.D.

Saugerties, New York

Testimony By Charles W. Jarvis

Vice Chair
Health Information and Management Systems Society (HIMSS)
Electronic Health Record Association (EHRA), Chicago, Illinois

Testimony By Jonathan P. Hare

Resilient Network Systems, Inc.,
San Francisco, California

Monday, July 19, 2010

OpenNotes© Study Launches

With patients across the country voicing a growing desire for greater engagement in and control over their medical care, a new study involving patients in Boston, Pennsylvania and Seattle will examine the impact of adding a new layer of openness to a traditionally one-sided element of the doctor-patient relationship—the notes that doctors record during and after patients’ visits.

Funded through a $1.4 million grant from the Robert Wood Johnson Foundation (RWJF) Pioneer Portfolio—which supports innovative ideas and projects that may lead to important breakthroughs in health and health care—the 12-month OpenNotes© project will evaluate the impact on both patients and physicians of sharing, through online medical record portals, the comments and observations made by physicians after each patient encounter. Approximately 100 primary care physicians and 25,000 patients at Beth Israel Deaconess Medical Center (BIDMC) in Boston, Geisinger Health System in Pennsylvania, and Harborview Medical Center in Seattle will participate in the 12-month trial.

“Patients remember precious little about what happens in the doctor’s office,” says Tom Delbanco, M.D., a primary care physician at BIDMC and the Richard and Florence Koplow-James Tullis Professor of General Medicine and Primary Care at Harvard Medical School. “We expect OpenNotes will improve patient recall, help patients take more responsibility for their care, and offer an opportunity for avoiding potential medical errors as patients and families monitor and think about their care in a much more active and knowledgeable way.”

That premise is based in part on a recent study by Delbanco and Jan Walker, R.N., M.B.A., instructor in medicine in the Division of General Medicine and Primary Care at BIDMC and Harvard Medical School. As reported in the Journal of General Internal Medicine, Delbanco and Walker found that most consumers want full access to their medical records.

The study also found that consumers expect computers to play a major role in their future medical care, even substituting for face-to-face doctor visits.

“We learned that, for the most part, patients are very comfortable with the idea of computers playing a central role in their care,” Walker says. In fact, patients said they not only want computers to bring them customized medical information, they fully expect that in the future they will be able to rely on electronic technology for many routine medical issues, she says.

“Doctors have strong differences of opinion about giving patients access to their notes. However, the debate is largely uninformed by evidence,” says Stephen Downs, assistant vice president at RWJF and member of the Foundation’s Pioneer Portfolio. “In the context of a physician’s day-to-day work, opening up notes is a subtle change—but it could reposition notes to be for the patient instead of about the patient, which might have a powerful impact on the doctor-patient relationship and, in the long run, lead to better care.”

To collect evidence, physicians and patients will fully share, through a simple one-step intervention, all encounter notes online. By contrasting the experience of trial participants with unenrolled physicians and patients, the researchers hope to measure the impact of OpenNotes through online surveys of both groups of doctors and patients.

“While this intervention potentially could disrupt the current flow of primary health care, it holds considerable potential to transform the doctor-patient relationship,” says Delbanco. “By enabling patients to read their clinicians’ notes, OpenNotes may break down an important wall that currently separates patients from those who care for them. It may promote insight and shared decision-making by bringing closer together the unique expertise of the clinician and the unique understanding of himself or herself that each patient possesses.” (via

This summer, a team of 100 primary care physicians across the country will embark on the “OpenNotes” initiative. OpenNotes will give 25,000 patients the chance to read doctors’ notes on their medical records via a secure Internet portal.

“I think patients will not be very surprised by what they see”
The OpenNotes pilot program is designed to determine if access to doctors’ notes will result in improved doctor-patient communication. For doctors, notes serve as a reminder of the unique characteristics of the patient, their medical history, and their care. For patients, doctors’ notes may help to clarify issues or explain care approaches. The hope is that inviting patients to review their notes could improve their understanding of their health, foster productive communication, stimulate shared decision making, and ultimately lead to better outcomes.

“I think this may be a real step in transforming the patient and provider relationship,” said Tom Delbanco, MD, Professor, Harvard Medical School and Physician (Former Chief) Division of General Medicine & Primary Care, Beth Israel Deaconess Medical Center in Boston.

Some fear that patient access to physicians’ notes could have negative consequences, such as confusing or worrying patients.

“I think patients will not be very surprised by what they see,” said Dr. Delbanco. “In many ways, the note is supposed to mirror what happened in the encounter. But patients will probably get insight into what’s worrying their doctor and what their doctor’s intentions are. They also may find things for which they want more explanation. We don’t know exactly what will happen. But we are excited to find out if OpenNotes can improve care from both the physician and the patient perspective,” said Dr. Delbanco.

The program will be evaluated primarily through web-based surveys. Researchers believe that if the pilot goes well, OpenNotes could become the standard in years to come.

The full report is available here:


Mirth Demonstrates Health Information Exchange

Mirth Corporation, the leader in commercial open source healthcare information technology, successfully powered the nation's first publically staged multi-organization demonstration of NHIN Direct standards and technologies. The demonstration included secure clinical information exchange between healthcare providers across three prominent California-based Health Information Exchanges. It took place on July 9th at Redwood MedNet's 4th Annual HIE Conference in Santa Rosa, CA, 50 miles north of San Francisco.

Organizations participating in the landmark demonstration included the pioneering Redwood MedNet Health Information Exchange, as well as the Western Health Information Network from Long Beach, CA, and Physicians Medical Group of Santa Cruz. Technology partners supporting the initiative -- in addition to Mirth Corporation -- included Harris Corporation, MedPlus, creator of Care360, and Microsoft, developer of HealthVault, a personal health technology platform.

"Microsoft has been participating in the NHIN Direct effort because we believe connecting providers with each other and their patients is critical to driving improvements in the quality of care delivery," said Sean Nolan, chief technology architect in Microsoft's Health Solutions Group. "We were delighted to support this landmark demonstration and show that healthcare interoperability can be a reality today, thanks to technologies like Mirth and HealthVault."

The Nationwide Health Information Network (NHIN) represents a set of federally architected standards for health information exchange, as well as "on ramp" tools to enable healthcare organizations to exchange health information more easily. NHIN Direct, a companion project sponsored by the department of Health and Human Services, seeks to enable simple, secure transport of health information between healthcare providers -- including summary care records, referrals, discharge summaries and other clinical records.

Redwood MedNet, which operates a health information exchange (HIE) service in Northern California based on the Mirth open source software, conceived and managed the NHIN Direct demonstration. "NHIN Direct as a project is designed to accelerate adoption of HIE services," said Will Ross, Project Manager for Redwood MedNet. "We produced the live demonstration of NHIN Direct at our conference in order to highlight how transformative health information exchange technology can be. Broad adoption and use of these tools is not a question of 'if' but rather is only a question of 'when' agile electronic exchange of patient data will become the dominant paradigm."

Mirth continues to focus its energy and innovation on making interoperability tools widely and inexpensively available to healthcare organizations and providers," said Jon Teichrow, president of Mirth Corporation. "This successful demonstration -- using production code on real use cases with real physician users -- shows that the Health Internet can be a reality today. The implications are profound: when healthcare providers and organizations can get on the same page around patient information, good things happen in terms of safety, quality and cost," added Teichrow.

The demonstration used fictitious patient records to avoid any disclosure to the 200+ attendees, but used real system and production code, as well as "hands on" participation by physicians who helped narrate the demonstration. It took advantage of the widely used Mirth technology as well as NHIN direct standards that enable provider-to-provider exchange of clinical records using a secure email-like approach, with SMTP as the message protocol. It showed how electronic records and messages can support the care of a patient who presents in a hospital emergency department hundreds of miles from home -- and be safely and rapidly treated by an emergency physician who can access his medication records, allergies, as well as his primary physician for consultation.

For more information about the demonstration, please visit:


Friday, July 16, 2010

Study Like a Scholar, Scholar

Student employees and Brigham Young University video staff created this Old-Spice-themed ad for Brigham Young University's Harold B. Lee Library. This is really quite funny and creative...

Tip of the hat to

PCAST Report on Health Information Technology

Watch this report on Health Information Technology to the President's Council of Advisors on Science and Technology (PCAST) during their July 16, 2010 meeting:

The report has been released. You can view the report and video at the PCAST Report on Health IT post.


Thursday, July 15, 2010

Defining moment for meaningful use

We have reached a fulcrum point in the history of health care in our country. The announcement on Tuesday of the final rule establishing Medicare and Medicaid incentive programs for the meaningful use of electronic health records (EHR) creates a framework for change that will have reverberations throughout the health care industry. An important companion rule (pdf) was also released that establishes standards, specifications and certification criteria for EHRs.

David Blumenthal, the national coordinator for health information technology at Health and Human Services (HHS), and Marilyn Tavenner, principal deputy administrator of the Centers for Medicare and Medicaid Services (CMS), published an overview of the meaningful use rule in the the New England Journal of Medicine. John D. Halamka, of both Harvard Medical School and Beth Israel Deaconess Medical Center, wrote an excellent analysis of the final standards rule on his blog. I expect in the coming months there will be a great deal of parsing of the language of these two rules, which total 1,092 pages.

For my initial analysis, see the post on O'Reilly Radar ~ Analysis: A defining moment for "meaningful use"

The rule has added the recording of advanced directives and a provision for providing patients with educational materials, which were not included in the proposed rule. However, the proposed rule's requirement to provide an electronic copy of a patient's medical record is maintained in the final rule. This record must contain diagnostic test results, problem list, medication list, medication allergies, and for hospitals, discharge summary and procedures for at least 50 percent of patients within three business days. This requirement may prove to be one of the most difficult to achieve, but as Regina Holliday's poignant testimony during the press conference proves (video below), it is vital to include consumers in the process.

Regina Holliday is a 37-year old mother of two and an art teacher. Last summer, her husband, Fred, died from kidney cancer at the age of 39. She writes at the Medical Advocacy Blog and tweets at @ReginaHolliday.

Tuesday, July 13, 2010

Meaningful Use Announcement

Health and Human Services Secretary Kathleen Sebelius announced final rules to help improve Americans' health, increase safety and reduce health care costs through expanded use of electronic health records (EHR).

- Kathleen Sebelius, Secretary, US Dept of Health & Human Services (HHS)
- Dr. Donald Berwick, Director, Center for Medicare & Medicare Services (CMS)
- Dr. David Blumenthal, Director, ONC for Health IT
- Dr Regina Benjamin, US Surgeon General
- Reginal Holliday, patient advocate

Microbiome: passenger or vehicle?

Remember how you learned in BIO 101 that many fluids in the human body are normally sterile? And you know how you laugh with condescension when someone dares to question this dogma? After all, we know that the gut and the skin are full of microorganisms, but the lung? The bladder? This is inconceivable, heretical!

Well, actually, this, like many other dogmas that seemed like God's word at the time, has been broken open by some very interesting research emerging from multiple laboratories around the world. I was first stopped in my tracks about a year ago, while listening to an NPR story in my car and learning that the number of bugs we carried on and in us was about 10-times greater than the number of our own cells. Then, in a farm house in Cornwall a couple of weeks ago, while on vacation, I read an article in an October 2009 issue of Eureka, The Times monthly science magazine, which once again made me ponder our sojourns in life, the bacteria that cohabitate with us. And finally, today I saw this story in yesterday's NYT, which galvanized me into writing action. This grabbed me in particular:
Scientists are even discovering ecosystems in our bodies where they weren’t supposed to exist. Lungs have traditionally been considered to be sterile because microbiologists have never been able to rear microbes from them. A team of scientists at Imperial College London recently went hunting for DNA instead. Analyzing lung samples from healthy volunteers, they discovered 128 species of bacteria. Every square centimeter of our lungs is home to 2,000 microbes.
It grabbed me for two reasons:
1). I am a lung doctor, and a lot of the research that I do centers around lung infections. One type of this infection, ventilator-associated pneumonia or VAP, is the subject of much scrutiny by policy makers and payers, and is emerging as a quality indicator. There are many challenging issue in VAP, not the least of which is its treatment: because it is likely to be caused by an antibiotic resistant organism, and because at least one-half of all cases of suspected VAP never grows out a specific microbe, the recommended empiric treatment is with broad-spectrum drugs. The clinician treads a fine line between undertreating the patient at the expense of increased mortality or overtreating and promoting antibiotic resistance.
2). I have already written here about my thoughts on evidence and how we tend to approach our knowledge with the arrogance that blinds us to the possibility of being either under-informed or plain wrong. Well, here is the case where we were so convinced of what we knew, yet it was plain wrong! With the scientific skepticism and appropriate tools we are learning something completely opposite to what we thought we knew.

Taking this line of thinking one step further, can we now conceive of the possibility that what we expose our bodies to actually plays a role in our long-term health? To be specific, I mean something as simple as food and the way our food is produced. Monoculture and food engineering have become staples of our food production. Animals are raised in CAFOs in conditions requiring them to be on antibiotics to ward off infections and to help with growth. Additionally, to leverage the subsidized and abundant corn supply, food animals are forced into diets completely unnatural to them. Cows, for example, evolved over millennia to be ruminants meant to eat grass and hay, are fed a corn-based grain diet, which, by altering their gut environment, makes them much more likely to carry toxigenic E. coli. Although there is much nay-saying about whether antibiotics (and hormones, by the way), are passed on to humans through meat or milk, I have never seen any convincing scientific evidence to the contrary. So, if we eat meat that is microbiologically altered, and may also be exposed to antimicrobial residues that may in turn change our own native microbiome, is it possible that at least some of the emerging health issues are due to the travesty of monoculture production?

I am not saying that I have all the answers -- clearly, this research has a long way to go to establish causal pathways and potential points of intervention. But let's exercise our common sense and at least ask the questions. Do it early and often. And let's please agree that there is a certain burden of proof here that resides with the food production oligopoly. Oh, yeah, and let's not forget to continue limiting the use of antibiotics in human health too. And have a little bit of dirt... for lunch... every day...  

A Meaningful Definition

The Office of the National Coordinator for Health Information Technology (ONC) issued a final rule defining meaningful use requirements to qualify for incentive payments under the HITECH portion of the ARRA. The final rule for meaningful use is embedded below (it is temporarily available at the Public Inspection Desk, but this link will expire after the rule is actually published) and it is scheduled to be published in the Federal Register July, 28 2010. The rule definitively outlines all the specifics of Stage 1 meaningful use and clinical quality measure reporting to receive the incentive payments in 2011 and 2012. The final rule builds on the notice of proposed rulemaking (NPRM) released December 30, 2009.

The definition of meaningful use attempts to harmonize criteria across other CMS programs as much as possible and coordinate with quality initiatives. It also is closely linked to the certification standards criteria in development by the Office of the National Coordinator (ONC) and provides a platform for a staged implementation over time. The temporary certification final rule was published in the Federal Register June 24, 2010. The final rule on Initial Set of Standards, Implementation Specifications, and Certification Criteria is below the meaningful use rule.

Initial Set of Standards, Implementation Specifications, and Certification Criteria