Meaningful Use to become a "political football"?

From Government Health IT's

"5 nagging questions about meaningful use Stage 2"

3. Will MU become just another political football? Hatch and company being Republicans and the Obama administration being decidedly not, some observers are afraid that meaningful use may end up impeded by the gridlock that seems to define so many other debates in the nation’s capital these days. And yet the gridlock, one could say, only reflects the fact that there are no easy answers concerning how to move forward. “If the existing meaningful use deadlines and eventual outcome milestones get extended, critics of the Obama administration get to point to yet more healthcare dollars spent on Obama's watch with too little to show for it,” one observer noted. “If Meaningful Use doesn't get extended, hasty implementations could lead to a series of embarrassing headlines and, in a worst-case scenario, HIT-triggered preventable patient deaths.”

Well... got me reaching again for Photoshop.

Again, given the angry political fixation on "ObamaCare" (now in full throat at many congressional recess Town Halls), I'm just not seeing much significant headway across the next year or two for the anti-HIT crowd. There will, of course, be smoke (e.g., the rapidly molding "REBOOT" and its progeny), but no fire. NERF football, this is, IMO. If that. Maybe badminton would be a more pithy metaphor.

That's not to argue that there are no glaring problems with HITECH.
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FARZARD EXIT WATCH

Mostashari's departure creates concern among mHealth advocates
Eric Wicklund - Editor, mHealthNews

The impending departure of Farzad Mostashari, MD, the nation's National Coordinator for Health IT, caught everyone by surprise – none more so than mHealth advocates.

Mostashari announced on Tuesday, August 6, that he will leave the ONC this fall after four years in the office and two as its leader. His departure comes at a time when the ONC is in the midst of a study of the nation's healthcare IT system, a crucial issue facing the mHealth industry as it awaits federal direction on the regulation of mobile medical apps.

"A leadership change at ONC will come at an awkward time for the timely completion of the FDASIA 618 committee work and sorting out the confusion over the regulation of mobile health and clinical decision support software," said Robert McCray, president and CEO of the San Diego-based Wireless Life Sciences Alliance.  "For the sake of consumers and patients we urge (Health and Human Services Secretary Kathleen Sebelius) to quickly identify a knowledgeable replacement with consensus-building skills and a desire to unleash the power of technology in healthcare, including self care."

The FDASIA 618 committee was created by the Food and Drug Administration Safety Innovation Act of 2012 and charged with reviewing the nation's HIT regulatory framework. The committee's study is expected sometime this fall, at which time the HHS will work with the ONC, FDA and Federal Communications Commission to draft a report for Congress that outlines a proposed strategy for regulating health IT, including mobile technology.

mHealth advocates say Mostashari's departure will create transition issues in the ONC that may affect its participation in the FDASIA study. In addition, it comes as another regulatory agency, the FCC, searches for a new leader to replace the departed Julius Genachowsky...

Mobile portends to be a huge component of Health IT going forward, one rife with special problems. We will need competent and steady hands at the helm here.
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ONC MEANINGFUL USE PROGRESS INFOGRAPHIC

Interesting.

But, looking ahead...

As if the turbulence of July 2013 on healthcare IT wasn't bad enough, last week things got arguably worse.

First, Farzad Mostashari, director of the Office of the National Coordinator (ONC) for Health IT at the Department of Health and Human Services, announced he is resigning, staying on just long enough for a replacement to be found.

Then, one of ONC's major projects of 2013, a strategy by CMS and ONC to promote interoperability in an industry that desperately needs it, made its underwhelming debut, overshadowed as it was by Mostashari's resignation, which hit during the same 24-hour news cycle.

How underwhelming was the ONC/CMS plan, itself a response to comments on an earlier request for information? Highlights of the initiative related to health information exchange tell the story:

• Accelerating Interoperability and Electronic HIE through Payment Models Require electronic HIE in all advanced payment models and Medicaid waivers
• Extend Center for Medicare & Medicaid Innovation (CMMI) efforts
• Include Long-term care and post-acute care (LTPAC) and Behavioral Health (BH) in State Innovation Models (SIM) grants
• Direct incentives for LTPAC and BH providers
• Explore additional reimbursement codes for care coordination via telehealth, e-visits, radiology queries, and Evaluation & Management
• Require electronic HIE standards as regulatory requirements for quality measurement and conditions of participation
• Extend Regional Extension Center (REC) support
• Extend Stark and Anti-kickback exceptions for donations of EHR software

The RECs are doing fine work, and it's all well and good for CMS and ONC to want to extend support for their work in the hopes of moving health IT interoperability forward and provide necessary training, but that will require Congress to act to extend that funding...

There will be no more REC funding. Period, IMO. I have opined at length across prior posts on the short-sightedness of this (and I no longer have no personal dog in that fight, having retired from my REC), but Congress is not going to appropriate any more REC money.

Scott continues, to conclude:

...the dog days of summer 2013, a good time for healthcare CIOs to take a break if they can, if they believe that things will turn around when they return in September. Meanwhile, I do wish ONC and HHS leadership all the luck in the world. Losing Mostashari now is the last thing they need.

ARCH-IT UPDATE

One of the more notable failures of the short-lived REC era. If they're doing anything of substance (or anything at all) in the Beltway on behalf of the ONC Regional Extension Centers, it must be a closely held secret.

The 10 RECs (out of 62) who bought into this scheme seem to have gotten played. Probably with taxpayer money.

UPDATE

"2014 brings a perfect storm of regulatory compliance issues for family physicians that, we fear, may derail health information technology (IT) adoption and substantially interfere with our shared progress toward achieving better care for patients, better health for communities and lower costs through improvements to the health care system."

- AAFP Board Chair Glen Stream, M.D., M.B.I., AAFP Proposes Revised Meaningful Use Stage Two Compliance Timeline

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OOPS

apropos of my August 4th post:

From Salon.com
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More to come...

The future of the PPACA explained in one small jpeg

I loves me Photoshop.
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ONC Chief Dr. Mostashari calls it quits

One of my shots of Farzad at HIMSS13 in NOLA

From: Mostashari, Farzad (HHS/ONC)
Sent: Tuesday, August 06, 2013 10:23 AM
To: OS – ONC Feds

Subject: Announcement

My Dear ONC’ers,

On a pre-dawn morning in June 2009, I paced helplessly outside my Mom’s hospital room as alarms beeped and the monitor showed the most recent run of life-threatening heart arrhythmia. I had screwed up my courage to ask to see the paper chart, but I couldn’t even read the cardiology consult’s name. After her discharge it was also very difficult to get her records; she didn’t get needed follow-up and required emergency surgery. The complications, which weren’t supposed to happen, indecently increased the hospital’s revenue.

I joined ONC a week later. This office had a daunting task ahead of it. Working backwards from the outcomes we hoped to enable, we had to define ’Meaningful Use’ of electronic health records, establish a new certification program, endorse national standards, design and set up a slew of new grant programs to assist in health IT adoption, exchange, workforce, research, and privacy. There were 32 staff members.

You will remember the successive sprints ’ to recruit and establish the Regional Extension Centers and collaborate with newly appointed Health IT coordinators in every state. The ’Office of No Christmas’ moniker that we earned for yuletide rulemaking. Trudging 4 miles through the blizzard–to a hotel that still had power– for Beacon application reviews.

And then came an intense focus on implementation and integrity of our grant programs. Accelerating consensus around healthcare standards through an innovative new open source community paradigm in the Direct Project and its successor Standards and Interoperability Framework. Coordinating policy with our federal partners. Adding a new focus on consumer eHealth, and giving consumers access to their own data through the Blue Button. Creating a Health IT safety program.

We gradually assembled within ONC a microcosm of the diverse and passionate Health IT community itself. Implementers, doctors and nurses, software developers and project managers, privacy experts, proud standards geeks, patient advocates, public health workers, researchers and data analysts. And we added strength, integrity and resilience by recruiting a core of civil servants who are dedicated to lifelong public service.

You each brought to ONC your own personal commitments and your community’s perspectives, and we unified those divisions through our shared goals: A better health system– that truly knows and cares for all of its patients- through application of information and learning. You nurtured a culture of commitment to American innovation, and an essential optimism that healthcare’s best days are ahead of us.

Regional extension centers have assisted 140,000 providers- over 40% of all primary care providers in the country and over 80% of critical access hospitals- the largest medical technical assistance project in history. Nationwide, adoption of health records has tripled in doctor’s offices and increased five-fold or more in hospitals. Over half of prescriptions are now electronic. New functionalities essential for population health management are increasingly available and used. National standards and protocols for information exchange and interoperability are being implemented throughout the industry. Over the next 12 months we will see a great democratization of health information as individuals become empowered to download their own health information, and venture capital investment in new tools to help us manage our own health and healthcare are skyrocketing. Meanwhile, hospital readmissions are dropping, healthcare cost inflation is at historic lows, and the movement towards payment that rewards quality and value is gaining speed.

My mom has recovered now. Her hospital is working to implement new systems to provide accountable care. Her prescriptions and health records are electronic and can be shared across the state. Like 37 million other elderly Americans, we can access her medical history with her Medicare Blue Button records on her mobile phone.

There are formidable challenges still ahead for our community, and for ONC. But none more difficult than what we have already accomplished. In these difficult and challenging times, your work gives us hope that we can still do big things as a country. That government and the private sector working together can do what neither can do alone. We have been pioneers in a new landscape, but that landscape is one changed for ever, and for better.

It is difficult for me to announce that I am leaving. I don’t know what I will be doing after I leave public service, but be assured that I will be by your side as we continue to battle for healthcare transformation, cheering you on.

Best wishes to you all,

Farzad

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Aug 7th: Well, what are we to make of this? Resigning without a new gig in hand? If he is to be taken at his word, what does that say of the situation at ONC? Who of equivalent stature is around to succeed him and take in the increasing political anti- Health IT pushback? Who of such clinical and political cred would even want to?

Below, no mention of any of this today on the ONC blog site.

The Health IT press this morning is dripping with fulsome praise for Dr. Mostashari personally, and for the progress ONC has ostensibly made during his tenure, but little in the way of departure analysis above the fold just yet. The only thing I can find is in the Healthcare Informatics article linked here:

Upon the announcement by Health and Human Services Secretary Kathleen Sebelius on August 6 that Farzad Mostashari, M.D. was planning to leave his post as National Coordinator for Health Information Technology, Russell P. Branzell and George T. Hickman issued a joint statement regarding the departure, representing the Ann Arbor, Mich.-based College of Healthcare Information Management Executives (CHIME), the nation’s CIO association. Branzell is president and CEO of CHIME, and Hickman, excecutive vice president and CIO of Albany (N.Y.) Medical Center, is CHIME’s  board chair.

“Through Dr. Farzad Mostashari’s leadership, we saw the Office of the National Coordinator lead our nation’s providers through the first gates of measured, meaningful use of electronic health records, and address in reality those initial standards that make our health information portable across the U.S. healthcare system,” the statement said.

“Any CIO will tell you that implementing technology in the face of cultural resistance and process redesign is a monumental challenge,” Branzell and Hickman continued. “ONC’s task was to help guide such implementations in over 5,000 hospital settings and with nearly 400,000 physicians and clinicians.  Today’s health delivery system is fundamentally different than it was five years ago when HITECH was passed, but it’s not because Congress simply passed a law.  It’s because ONC and CMS, in partnership with the private sector, designed an implementation strategy that tried to align various stakeholders and make the spirit of HITECH a reality.”

And, they concluded, “CHIME appreciates the partnership forged under Dr. Mostashari’s tenure and his commitment in furthering the development of widespread health IT adoption. We wish him continued success in his future endeavors...”

[Russell P. Branzell]
Why do you think Dr. Mostashari is leaving right now?

He told me that he thought this was the time for him; he’s been there since 2009, and he just thought this was a logical and appropriate time for him to transition. And I’ll tell you, we’re very appreciative of everything he’s done. One of things he’s done is to bring in the voice of the community—CIOs, physicians, and nurses—to be part of the process. And one of the things I asked him was what he’d like to see in his successor; because we’d like to see a CIO or physician or nurse, someone who’s worked with some of the requirements of Stage 2 meaningful use, placed into that office.

So you’re not necessary arguing for David Muntz or Judy Murphy [Judy Murphy, R.N., Deputy National Coordinator for Programs and Policy] to succeed Dr. Mostashari?

Oh, absolutely, either David or Judy could succeed him; both of them do have that provider-organization experience, and both would be logical and highly qualified candidates. Now whether or not they’re interested, is a different question. This is very highly stressful work. If either of them would throw their hat into the ring, we would be very strong supporters...

BLOOMBERG TAKES A SWIPE

BUT, THEN...

www.healthcareitnews.com

...As National Coordinator he brought energy, enthusiasm, and momentum to healthcare IT. He inspired, challenged, and influenced with informal authority, never a heavy hand. Hundreds of people volunteered to support his vision out of respect for his ideas and a sense that it was the right thing to do.

Some people seek fame and fortune. Some just want to make the world a better place. In all the years I've worked with Farzad, I've never sensed any self-interest. He has been mission driven.

Washington is a hard place to work. Some say that no one is your friend (except your dog). Hours are long, pay is poor, and travel is overwhelming. Burn out is hard to avoid when you've cleaned the Augean Stables and your only feedback is that you missed a spot...

SILENCE ON THE HITRC

Real beehive of up-to-date activity and information, that ONC HITRC (Health Information Technology Resource Center).

Nothing about Dr. Mostashari's departure. Nothing else much of recent dates, either, though.
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More to come...

The "Do Nothing Congress" heads home for six weeks to prepare for the assault on ObamaCare

Forget "HIT." Forget "Meaningful Use" and "REBOOTING" (or just "BOOTING") it. Forget "HIE." Up next? "HIX" -- the PPACA "Health Insurance Exchanges" that comprise a critical next step in the operational implementation of "ObamaCare" (or, as I sometimes call it, "AHIPcare," which is what it mostly is).

Hard right "Republicans" have vowed to obstruct (or, preferably, kill) the ACA, vowing to cause a federal debt default and government shutdown on October 1st if necessary to "defund ObamaCare" -- which, tactically at this point means, as a priority, throwing truckloads of sand in the HIX gears and cause insurance exchange failures at every turn.

Should be "interesting."

I would think that, for now, Health IT is off the radar, "REBOOT" Congresscritters notwithstanding. HIT is chump change relative to the money at stake in the PPACA.

Below, a concise HIX infographic (click image to enlarge).

Above, the Teabagger wet dream. I loves me Photoshop.
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Groups go door-to-door to encourage enrollment in Obamacare
By Sandhya Somashekhar, Washington Post

MIAMI BEACH — Her clipboard said the man who lived in the pink stucco apartment building a few blocks from the hotel-lined beach might not have health insurance. So Laura Botero climbed the darkened staircase to the second floor and knocked on the door.

Eduardo Devine, 49, an unemployed beach waiter in black, square-framed glasses, peeked into the dim hallway. He confirmed he had been without coverage since he was laid off a month ago, and his face lit up when Botero mentioned “Obamacare.”

“I just heard about it on the news, but I don’t know how it works,” he said, taking a pamphlet. “It will help. That’s all I know.”

It was a small but critical victory for Botero, a volunteer for Enroll America, a nonprofit group that is fielding a small army to spread the word about Obamacare. In recent weeks, President Obama’s signature health-care law entered a new phase as hundreds of advocates began the arduous task of identifying the uninsured and coaxing them, one by one, to sign up for coverage.

For the law to succeed, groups such as Enroll America, whose officials include several veterans of Obama campaigns, will need to cajole millions of Americans, including many healthy ones, to enter the insurance market. It could be a tough sell. Confusion about the law is rampant. The online insurance sites, which open for enrollment Oct. 1, could be tricky. Some people who rarely need medical care might view even low-cost health plans as too pricey...

Wouldn't surprise me if PPACA opponents mount a counter-campaign to challenge ObamaCare HIX signups. Similar to their initiatives to challenge voter registrations in many states.

Meanwhile, HHS is ramping up at HealthCare.gov.

The HHS explanation of the "fee" for not complying with the "Individual Mandate."

What if someone doesn't have health coverage in 2014?

If someone can afford it but doesn't have health insurance coverage in 2014, they may have to pay a fee. They must also pay for all of their care.

When the uninsured need care
 
When an uninsured person requires urgent—often expensive—medical care but doesn't pay the bill, everyone else ends up paying the price.

That's why the health care law requires all people who can afford it to take responsibility for their own health insurance by getting coverage or paying a penalty.

People without health coverage will also have to pay the entire cost of all their medical care. They won't be protected from the kind of very high medical bills that can sometimes lead to bankruptcy...

The fee in 2014 and beyond

The fee in 2014 is 1% of your yearly income or $95 per person for the year, whichever is higher. The fee increases every year. In 2016 it is 2.5% of income or $695 per person, whichever is higher.

In 2014 the fee for uninsured children is $47.50 per child. The most a family would have to pay in 2014 is $285.

It's important to remember that someone who pays the fee won't get any health insurance coverage. They still will be responsible for 100% of the cost of their medical care.

After open enrollment ends on March 31, 2014, they won't be able to get health coverage through the Marketplace until the next annual enrollment period, unless they have a qualifying life event...

OK, let's say you're a "young invincible" median income earner. Round number $50,000. You opt to decline and pay the "fee" of $500 (rising to $1,250). You're betting that the "fee/fine/penalty" will be cheaper than buying "minimum essential coverage" from a legitimate insuror.

Keyword "legitimate." There will no doubt be all manner of scammers out there conveniently pricing "coverage" for less than the "fee."

Coverage that will be declined when you actually try to use it.

CALLING ALL RUGGED INDIVIDUALISTS!
BURN YOUR OBAMACARE DRAFT CARDS!

 Above, from "A Health Plan for Rugged Individualists" on THCB.

Below, the FreedomWorks "ObamaCare Draft Card."

How witty and original.
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“We are on target and ready to flip the switch on Oct. 1,” [Kathleen] Sebelius, secretary of the U.S. Department of Health and Human Services, told reporters. The markets “are already increasing competition and giving consumers a better deal.”

THE EQUALLY HATED "EMPLOYER MANDATE"

Those who follow the PPACA wrangling will know that the Obama administration has pushed compliance with the ACA "Employer Mandate" back by a year, until 2015. Many pundits conclude that this tactic is designed to get it off the mid-term elections radar.

But, here's an interesting view from Elizabeth Lee Vliet:

The employer mandate requires that businesses with more than 50 full-time employees must provide health insurance for all employees, and that insurance must meet the new standards set forth in the new law. Businesses that do not comply must pay a financial penalty for each employee, which for large companies can run into the millions of dollars annually.

To understand the reason for this "selective enforcement," we must first understand this fact: President Barack Obama wants a single-payer healthcare system in the U.S. This is not a secret. In 2003, he said: "I happen to be a proponent of a single-payer healthcare system for America, but as all of you know, we may not get there immediately." In 2007, he said: "But I don’t think we will be able to eliminate employer-based coverage immediately. There is potentially going to be some transition time."

...By forcing individuals to purchase compliant healthcare plans but not forcing employers to provide those plans, Obama is creating a swell of 10 million to13 million workers that must enroll in health insurance, but cannot obtain it from their employers. These workers thus have no choice but to use the government-controlled health insurance exchanges, or else pay a financial penalty. This will double the number of workers forced to get health insurance on the exchanges. That, in turn, leads to massive cost-shifting onto the backs of taxpayers subsidizing the health insurance exchanges, rather than having businesses pay for employees’ health insurance.

Higher taxes are the result. Individuals are also facing 20 percent to 100 percent increases in their private health insurance premiums for 2014 to pay for the expanded mandates of Obamacare required coverage. That means workers no longer getting health insurance from their employer will be paying far more for individual coverage. Squeezed from both directions, it is obvious that all this will collapse on itself. At that point, there will be no other option but for the government to step in and save the day, which is what the Obama administration wanted all along.

...Obama and his party advocates sold the healthcare "reform" to the public by saying "reform" would increase competition and patient choice. But the perverse incentives, draconian regulations, and massively complex and unworkable law is a clever disguise for the real goal: to drive people out of private, employer-provided insurance, as a stepping stone to a government-run, single-payer system. Once we know the ultimate goal, the purpose behind the delay of the employer mandate seems clearer — to hurry the "transition time" away from employer-based health insurance and push more workers into the arms of government control to reach their dream of a single-payer system.

Hmmm... Obama's Cleverly Disguised Machiavellian Master Plan.
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MILEPOST

I'd like to think I've added some value to the Health IT space from an REC grunt perspective.

IN OTHER HEALTH NEWS...

LOL.

MEANWHILE, BACK AT THE MEANINGFUL USE CORRAL

Meaningful Use progress 'uneven' for hospitals
August 5, 2013 | By Marla Durben Hirsch

The attestation outlook for hospitals is not quite as sunny as the government has indicated, with smaller, more rural hospitals struggling to meet Meaningful Use and at risk of incurring penalties, according to a new study in the August issue of Health Affairs.

The researchers, from Mathematica Policy Research and elsewhere, found that there was a "significant" increase in the percentage of hospitals receiving incentive payments for achieving Meaningful Use between 2011 and 2012--from 17.4 percent to 36.8 percent.

However, the majority of eligible hospitals still did not achieve Meaningful Use in the first two years of the program, according to the researchers. Moreover, hospitals are making "uneven" progress, typically associated with the "digital divide," with larger, teaching, for profit and Northeast hospitals the most successful...

The inpatient setting is unsurprisingly difficult.

BREAKING

Mostashari to step down as ONC chief
HHS Secretary announces Mostashari's planned leave-taking in a memo to staff

n a letter to HHS staff, Secretary Kathleen Sebelius said that Farzad Mostashari, MD has said he intends to step down from the national coordinator post this fall.

Mostashari spent four years with ONC, first as a deputy national coordinator, then taking over as the National Coordinator in 2011...

Well, I hate to see him go. From Politico:

“It is difficult for me to announce that I am leaving. I don’t know what I will be doing after I leave public service, but be assured that I will be by your side as we continue to battle for healthcare transformation, cheering you on,” he [Farzad] wrote.

His departure comes at a critical time in the world of health technology. The government has pumped billions of dollars into more advanced health systems since the 2009 stimulus law, and the administration only upped those efforts in the Affordable Care Act. Hundreds of thousands of doctors and other health care providers have updated their practices to include health technology, earning incentive payments from the federal government.

According to HHS, Medicare and Medicaid have paid more than $12 billion in those payments as of February [$15.5 billion in the latest report -BG] to encourage the adoption of electronic health record systems.

The results have been mixed. A study published in Health Affairs on Monday suggests that smaller hospitals have struggled to adopt electronic records because their smaller cash flow prevents that kind of large-scale investment. They also might have a harder time attracting IT staff and competing for limited vendors.

HHS Secretary Kathleen Sebelius sent her own email to staff, hailing Mostashari’s work and describing him as “an important adviser” to her and the agency.

“His expertise, enthusiasm and commitment to innovation and health IT will surely be missed,” she wrote...

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More to come...

54 Days and counting. Time to get on the Omnibus

Meaningful Use may at this point be up in Congress, it may be down, its fate may be inscrutably uncertain.  PPACA may at this point be up, it may be down, it may be inscrutably uncertain. Maybe the GOP will make good on their extreme right wing's threat to shut down the federal government on October 1st.

One thing is certain, though. You have until Monday, September 23rd, 2013 to be documentably in compliance with HIPAA as amended by HITECH -- the "Omnibus Rule."

If you have yet to start on this, I rather doubt you'll make it on time, even with a full-bore effort starting today. There will be no backdating of compliance records. Yeah, you may not get audited until well into 2014, but if you are either a CE (Covered Entity) or BA (Business Associate of a CE) and cannot satisfy HIPAA regulators that your full compliance ensued on or before September 23rd, you will come to rue that circumstance. HHS has declared that HIPAA audits will be "self-funding," i.e., the settlement fines will pay for the compliance program.
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My former HealthInsight REC colleague Carlyn Choate has been on a tear lately, giving numerous webinars and writing about HIPAA related topics (PDF).

What are Risk Assessment, Risk Analysis, and Risk Management?
In order to understand Meaningful Use Core Measure 15, first you need to understand the difference in Risk Assessments, Risk Analysis, and Risk Management. Many individuals use these terms interchangeably, however there are significant differences in each of these.

• Risk Assessment: A risk assessment is a term used to identify the overall risk analysis process. This consists of the evaluation of the environment and assesses the potential threats to the organization.
• Risk analysis: A risk analysis is the detailed granular process of identifying the weaknesses that make the organization vulnerable to threats.
• Risk management: This is an ongoing maintenance process that includes the practical application and implementation of making corrections, developing policies and procedures, monitoring, evaluating and communicating risk.

Each of these terms is the stepping stone for the other; for example, you cannot “analyze” a situation without first “assessing” what it is you want to analyze, and you cannot “manage” something without knowing what it is you are trying to control and prevent.

Below, Are You Ready For Some Football? Gotta love the cute copywriting analogies. "Offensive Plays." "Defensive Plays." Special Teams."

They provide free stuff -- with registration required, though. Good looking material.

BELOW: AN OOPSEY

Every morning I read the latest postings on The Health Care Blog.

I would expect that they will clear this up pronto.
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More to come...

Meaningful Use Payments Update

$15.5 Billion paid out to date. Not much of an increase over the May numbers. To be expected, I guess.

More reporting:

Majority of hospitals, docs have received EHR incentives
By Joseph Conn

Eight out of 10 eligible hospitals and 58% of eligible physicians and other medical professionals have received payments totaling $15.5 billion under the federal electronic health record incentive payment program, according to the latest CMS data.

Through June, 4,024 hospitals have shared nearly $9.2 billion dollars to adopt, implement, upgrade and/or meaningfully use certified EHRs under the Medicaid and Medicare EHR incentive payment programs created by the American Recovery and Reinvestment Act of 2009.

In addition, 305,778 physicians and other eligible professionals have been paid more than $6.3 billion under the Recovery Act’s Medicaid, Medicare and Medicare Advantage EHR incentive payment programs, the CMS report said.

There are 4,477 hospitals that have registered for the programs, which leave just 11% of the 5,011 eligible hospitals that have not registered. Meanwhile, 400,960 physicians and EPs have registered, which leaves 24% of the estimated 527,200 eligible physicians and other EPs that have not registered.

"4,024 hospitals have shared nearly $9.2 billion dollars to adopt, implement, upgrade and/or meaningfully use certified EHRs"

Note the weasely boolean "or." "AIU" (Adopt, Implement, or Upgrade to an ONC CHPL Certified EHR system) has been viewed by many skeptics as the "free money" part of the MU program -- a year one "baby steps" initiative for the more marginal Medicaid cohort. On the ambulatory side, if, say, you're a Medicaid Peds or OB provider, sign up for the "free" Practice Fusion and collect $21,250 year one AIU money per doc just for attesting "AIU"
-- without having to meet or exceed the MU Stage 1 criteria (and, notably, without having to comply with that pesky and onerous Core 15 ePHI Security measure set forth in 45 CFR 164.308 et seq).
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Well, how are the RECs stacking up? From data I downloaded into Excel off the snazzy ONC Regional Extension Center Dashboard. M1 = you signed up an EP or EH, M2 = they began using an ONC Certified EHR, and M3 means they successfully attested and got paid.

Raw ordinal ranked data are only marginally useful. A variety of weightings would be needed (e.g., outlay per M3, total #of EPs in the state vis those who signed up for REC, REC time in the program, etc) to make better sense of these (and maybe they're mining this stuff internally at ONC, but they aren't publishing any findings publicly). For starters, these are state based data, and a number of REC contracts are multi-state / territory (e.g., two RECs in PA, Several in CA, Qualis covers WA and ID, and tight-lipped Hawaii has to deal with the far-flung Pacific Islands territories). 

My own REC exemplifies the problem. The high and mighty Health IT-leading Utah is #5; its bordering red-headed stepchild anarchic Nevada is 50th (49th, discounting DC) -- but, they are the same HealthInsight REC contract. But Utah, home to Intermountain Healthcare (IHC), is a largely homogenous state that has been an aggregate "early adopter" of HIT going all the way back to DOQ-IT and before. Nevada, on the other hand, is Ground-Zero of the late 2000's financial meltdown and foreclosure crisis.

I'm sure it cheeses certain Utah HealthInsight management to no end that Nevada is "dragging us down" (there's some vestigial QIO chafing there; NV was acquired by UT just prior to my first QIO tenure in 1993). Were one to pool UT and NV REC performance data into one REC contract look, HealthInsight would be solidly and unremarkably mid-pack in a raw data ordinal ranking.

AND, NOW -- BECAUSE IT'S MY BLOG -- 

A GRATUITOUSLY OFF-TOPIC DIVERSION FOR YOUR ENTERTAINMENT ENJOYMENT

I had no idea about Robert Downey Jr's vocal chops.

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More to come...

An EPIC Tale. Portending an EPIC Fail?

One of my compadres sent me this link the other day.

BOSTON HIE AND THE 'ERA OF EPIC'
SOURCE: JOHN HALAMKA, MD DATE: JUL 25, 2013

In the Boston marketplace, Partners Healthcare is is replacing 30 years of self developed software with Epic. Boston Medical Center is replacing Eclipsys (Allscripts) with Epic. Lahey Clinic is replacing Meditech/Allscripts with Epic. Cambridge Health Alliance and Atrius already run Epic. Rumors abound that others are in Eastern Massachusetts are considering Epic. Why has Epic gained such momentum over the past few years?

Watching the implementations around me, here are a few observations:

1. Epic sells software, but more importantly it has perfected a methodology to gain clinician buy in to adopt a single configuration of a single product. Although there are a few clinician CIOs, most IT senior management teams have difficulty motivating clinicians to standardize work.  Epic's project methodology establishes the governance, the processes, and the staffing to accomplish what many administrations cannot do on their own.

2. Epic eases the burden of demand management. Every day, clinicians ask me for innovations because they know our self-built, cloud hosted, mobile friendly core clinical systems are limited only by our imagination. Further, they know that we integrate department specific niche applications very well, so best of breed or best of suite is still a possibility. Demand for automation is infinite but supply is always limited.   My governance committees balance requests with scope, time, and resources. It takes a great deal of effort and political capital. With Epic, demand is more easily managed by noting that desired features and functions depend on Epic's release schedule. It's not under IT control. 

3. It's a safe bet for Meaningful Use Stage 2. Epic has a strong track record of providing products and the change management required to help hospital and professionals achieve meaningful use. There's no meaningful use certification or meaningful use related product functionality risk.

4. No one got fired by buying Epic. At the moment, buying Epic is the popular thing to do. Just as the axiom of purchasing agents made IBM a safe selection, the brand awareness of Epic has made it a safe choice for hospital senior management. It does rely on 1990's era client server technology delivered via terminal services that require significant staffing to support, but purchasers overlook this fact because Epic is seen in some markets as a competitive advantage to attract and retain doctors.

5. Most significantly, the industry pendulum has swung from best of breed/deep clinical functionality to the need for integration. Certainly Epic has many features and overall is a good product. It has few competitors, although Meditech and Cerner may provide a lower total cost of ownership which can be a deciding factor for some customers. There are niche products that provide superior features for a department or specific workflow. However, many hospital senior managers see that Accountable Care/global capitated risk depends upon maintaining continuous wellness not  treating episodic illness, so a fully integrated record for all aspects of a patient care at all sites seems desirable. In my experience, hospitals are now willing to give up functionality so that they can achieve the integration they believe is needed for care management and population health...

I have to say that, given that my particular REC project turf was almost exclusively small doc shop outpatient EPs, I've never gotten to kick the Epic tires or even watch it in action. It may be a perfectly fine, usable, featiure-rich project with great vendor support behind it for all I know.

Critics are not difficult to unearth, though. Foremost among the high-profile target is the Epic CEO herself, an Uber-geek straight out of Central Casting, but all the more notable for her gender.

An Interview With The Most Powerful Woman In Health Care
Zina Moukheiber, Forbes Contributor

Judy Faulkner might not be a household name yet, but in the health care industry, she’s simply known as Judy. She is the founder and chief executive officer of Epic Systems, a privately-held $1.5 billion (2012 revenue) company that sells electronic health records—a position that makes her one of the few self-made women on the Forbes billionaires list. Her customers are top medical centers, such as Cleveland Clinic, Geisinger Health System, and Johns Hopkins. She wields enormous influence. Almost half of the U.S. population will have its medical information stored in Epic digital records when hospitals finish installing them.

Faulkner, rarely, if ever, grants interviews. A year ago when I profiled her, she refused to speak. Because Epic shuns publicity and press releases, it is perceived as aloof; and criticism leveled at Epic regarding its business strategy is rarely challenged by the company. In a phone interview from Epic’s seat in Verona, Wisconsin, Faulkner acknowledged that.

Forbes: A year ago, you declined to be interviewed, what made you decide to talk now?

Faulkner: I’m recognizing that when we were small, we could stay under the radar, but now it’s harder. I get so many requests for interviews. If I talk to everyone, we can’t do our job with our customers and work on our software. It would be hard to stay focused.

I was an undergrad math major, and a grad student in computer science. I’m hugely introverted, not atypical of math majors. It’s not something I love [being in the public eye]; it’s a personality thing. I like to go around, and people not knowing who I am. I like to keep some privacy, be a normal person.

Forbes: With success comes visibility, plus you’re a woman who’s a computer scientist, who coded the original software for Epic. It makes for a good story.

Faulkner: If you line up the CEOs of major [electronic health record] companies, the CHEESI group–I came up with that to remember them all: Cerner CERN -1.97%, HBOC (now McKesson MCK +5.29%), Eclipsys (now Allscripts), Epic, Siemens , IDX (now part of General Electric GE -0.16%), what’s the primary difference? It’s funny, visually I’m the one woman, but I’m the only one with a technical background. That’s the main difference.

Forbes: Many things are said about Epic by competitors, but also by customers. One of them is that Epic is a closed system: it’s difficult to exchange patient information with other electronic health records; it’s hard for third-party vendors to integrate with Epic, and the technology is old. Is this totally wrong?

Read on...

The hits just keep on coming.

Judy Faulkner: Criticism that Epic system stymies interoperability 'unfair'
May 17, 2013 | By Dan Bowman

Responding to criticisms that Epic's electronic health record systems are closed and, thus, difficult to integrate with third-party vendors, CEO Judy Faulkner, in a rare interview granted to Forbes, called such accusations "totally wrong."

In fact, Faulkner referred to Epic as "the most open system I know," saying it's designed as a database management system.

"Database management systems need to allow their users to mold it to what they need," Faulkner told Forbes. "We interface with speech recognition, imaging, medical devices, lab, patient education content, user authentication and hundreds of different vendor systems."

Faulkner said claims that the company does not value interoperability are "unfair," adding that Epic systems were interoperable before government regulation came into play.

She also took a jab at the recently formed CommonWell Health Alliance in the Forbes interview.

Faulkner raised concerns about CommonWell at a Health IT Policy Committee meeting last month, saying that not initially being invited to be part of the alliance caused her to have doubts about its motives.

"What is it?" Faulkner, a policy committee member, asked rhetorically at the meeting. "Is it a competitive business? Is it a service? Will it be favoring those who started it and using those who did not start it as the means to feed the business? What components of business will be in it? Will it sell the data? Will there be patents?"...

Faulkner referred to Epic as "the most open system I know," saying it's designed as a database management system. "Database management systems need to allow their users to mold it to what they need."

OK, so, does this mean you'll share your RDBMS database dictionary with everyone?

Didn't think so.
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Interesting Forbes article comment here in the wake of "Who Says Chief Information Officers Can't Lose By Choosing Epic?"

John Stokes: I think you are only beginning to scratch the surface of the difficulties providers and institutions face with regards to making a rational, informed decision about EHRs, and about the true, long-term total cost of ownership.

For any new EHR installation there is at least some form of “double hit”: The product cost and the lost productivity cost.

In contrast to the comment above that “there are literally thousands of other causes of decreased revenue immediately following ANY [EHR] implementation”, Epic stands out as the only EHR for which there is now a track record of failing hospitals immediately following their EHR implementation. A mere coincidence? No. It is because Epic’s execution and business strategy imposes and requires new, permanent, and massive increase in the fixed cost of operations of the organizations that they partner with. These are simply not sustainable. What are two of these “hits”?

The Epic product cost: The software and licensing is only a small part of this. The major costs come is in the massive time and funds spent on training, support, configuration, updates, and salaries of a large number of new full-time staff that the institution has to hire permanently (50 new FTE for a small hospital; 150+ new FTE for a large academic institution). At 100k with benefits, that is 5 to 15 million a year in new fixed operational costs.

The Epic productivity cost: No other EHR other than Epic requires 18 to 24 hours of full-time training for highly educated physicians to become ‘basic’ end users. This is a huge loss of time (two to four days) that physicians are not compensated, nor taking care of patients. As the prior commenter stated “Any responsible EMR vendor will suggest a lighter schedule in the first few weeks of a new system to allow staff to get acclimated”. To be precise, Epic recommends a 50% reduction in clinical workload during this “acclimation”, and then recommends a 25% reduction for at least several more weeks. Epic states that providers should be back to their baseline productivity after six months to one year. However, the reality is that after a year of using Epic, most physicians never recover their full level of efficiency, and are experiencing at least a 10% productivity hit. What are the financial costs of this?

A typical physician will see 40 to 50 patients a day, or 5-6 per hour in clinic. That leaves about ten minutes per patient for an entire encounter, including history, examination, prescription writing, and counseling the patient (including the new Meaningful Use required data entry requirements, etc.). So even as little as one or two minutes more per patient adds up quickly – lengthening the workday by one to two hours. With a loss of productivity of only one hour per day (above) at $100 per visit, that represents six patients, or $600 /day. At that rate the physician is losing $10k/month. Multiply that by the number of physicians working in your practice group or community hospital and you get millions in losses each month.

This loss of physician time may also be measured as an opportunity cost of seeing an additional five to ten patients per day. With all of the strains on the healthcare system, a shortage of primary care doctors (made acutely worse by an influx of 38 million newly ‘insured’ patients entering the system under the ACA) – can we really afford to waste the most valuable and essential asset of the entire healthcare system: physicians’ time?

Note that most of the 5800 hospitals in the US are not large, well endowed academic medical centers with both alumni and government giving billions to prop them up. Epic’s market is only those hospitals with at least 100 million to spend, which is some 200+ hospitals in the US. The remaining 5500 hospitals? They run on a razor thin margin of 1-2%, and where a few million here or there is enough to put them deep into the red. Epic is very selective in picking clients only that fit their one and only criteria: deep pockets.

It would be convenient to dismiss Epic’s role in the financial demise of a growing list of hospitals in the United States. Unfortunately, these are not coincidences. This is a real and consistent pattern, and correlates the physicians comments and surveys on usability. [Ignore the trade association surveys sponsored by the vendors under HIMSS and KLAS - these are meaningless technical specifications and laundry lists of features].

The arguments that Epic provides for failure is that is was ultimately the end-users fault. Yes, those stubborn, unteachable doctors who went through 24 years of formal education – through college, graduate, and postgraduate study and training – who happily use their smartphone, tablet, and laptop to do manage virtually every aspect of their life on the web. But we can’t get those doctors to learn how to use a 1992 vintage thick client with nested dropdown menus seven layers deep. Will Epic lead the way and take usability seriously? Or it will it continue to be a risk to the financial health of the institutions it is supposedly helping?

We live in dangerous times in HIT. In a few years, when the $27 billion subsidy program for EHRs dries up and the mad gold rush for EHR implementation is over – it will expose many more hospitals that over-extended themselves with their choice of Epic. I must concur with Ryan Champlin. That is a dangerous choice.
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John Stokes: After reading my followup post here comparing the cost of two statewide hospital networks (Maine with Epic at $366 million; West Viginia with VistA at $8 million) there must be some fundamental reason that CIOs are willing to spend thirty times more for a product than another product.

Is Epic actually “better” than any other EHR? What do the end users have to say about Epic?

http://www.americanehr.com/about/News/13-03-05/Survey-of-Clinicians-User-satisfaction-with-electronic-health-records-has-decreased-since-2010.aspx

This survey on usability is directly from physicians (not via a vendor-sponsored surveys such as KLAS or HIMSS that emphasize vendor attributes such as ease of implementation, or length of feature lists).

These are ordered from lowest to highest rating.

EHR Overall Usability Rating (number of raters)

AHLTA 2.64 (49)
http://www.americanehr.com/find-an-ehr/ehr-product/54/ahlta-us-military-system/101/ahlta-us-military-system.aspx
Siemens Soarian 2.73 (15)
http://www.americanehr.com/find-an-ehr/ehr-product/254/siemens-medical-solutions-usa-inc/256/soarian-clinicals-inpatient-by-siemens.aspx
Cerner 2.93
http://www.americanehr.com/find-an-ehr/ehr-product/70/cerner-corporation/16/cerner-millennium-powerchart-powerworks.aspx
GE Centricity Enterprise 2.96 (57)
http://www.americanehr.com/find-an-ehr/ehr-product/88/ge-healthcare/219/centricity-enterprise-inpatient-by-ge.aspx
McKesson 3.1 (88)
http://www.americanehr.com/find-an-ehr/ehr-product/113/mckesson-provider-technologies/57/practice-partner-by-mckesson.aspx
Allscripts 3.06 (3)
http://www.americanehr.com/find-an-ehr/ehr-product/203/allscripts-eclipsys/203/allscripts-sunrise-clinical-manager-eclipsys.aspx
Meditech 3.08
http://www.americanehr.com/find-an-ehr/ehr-product/235/meditech/235/meditech-advanced-clinical-systems-client-server.aspx
Partners Healthcare 3.34 (25)
http://www.americanehr.com/find-an-ehr/ehr-product/134/partners-healthcare-system/99/partners-healthcare-longitudinal-medical-record.aspx
EpicCare 3.51 (148)
http://www.americanehr.com/find-an-ehr/ehr-product/86/epic-systems-corporation/217/epiccare-inpatient.aspx
Greenway 3.83 (69)
http://www.americanehr.com/find-an-ehr/ehr-product/93/greenway-medical-technologies/37/primesuite.aspx
VistA: 4.06 (124)
http://www.americanehr.com/find-an-ehr/ehr-product/75/cprs-vista-federal-open-source/96/cprs-vista.aspx

This survey shows that usability of EHRs has gotten *worse* since Meaningful Use regulations came into effect in 2010. One factor may be that EHR vendors have focused their development efforts to satisfy these requirements rather than the requirements of their end users.

Note also that survey results of VistA were mostly from the VA, where they are using a non-Meaningful Use certified EHR. It appears that while commercial EHRs devote their energy to winning the buzzword compliance awards from KLAS, VistA remains steadfast on its commitment to its physicians.

Now, to your question. VistA is the #1 ranked EHR and more cost effective by a factor of twentyfold.

I can only guess that the reason CIO’s choose any system over VistA:

(1) lack of information: the VA does not have a marketing department
and get and and publicize its system.
(2) lack of vision: an institution does not see the value in open-source, in taking ownership of their own intellectual property and information infrastructure, in building internal capacity to support this, and in supportin their own user-driven innovation. They would rather outsource this to a proprietary vendor.
(3) lack of name brand recognition: The CIO does not want to get blamed for a failure, so chooses a big name company. (This is obviously untrue: how can you say the VA and its 1400 clinics and hospitals running VistA is not a large enterprise)
(4) lack of clinical and technical expertise: The CIO does not have the combined technical and clinical knowledge to appropriately assess EHRs, and therefore has to depend on superficial demos, marketing materials, word of mouth, or responses to RFI (which are simply marketing brochures, sans slick pictures).

Again, these are only guesses, but based on many observations. 

Whatever one thinks of this commenter's views, they comprise a refreshing, considered respite from the endless onslaught of bumper sticker quality anti-Health IT naysayers.

Epic's "Usability" assessment in the America EHR survey.

Interesting. a 4.01 high for "Document a progress note for each encounter."

You have to register an account with American EHR (free) to get at the full report for all surveyed systems.
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BUT WAIT! THERE'S MORE!

Why Epic's market dominance could stifle EHR and health IT innovation
Brandon Glenn

Epic has attracted several notable critics, who warn that its market dominance could have harmful effects on the future of health information technology, EHRs and even patient care. Worse, these critics warn, Epic has achieved much of its market dominance on the backs of taxpayers.

Epic is the nearly undisputed king of the electronic health records world.
About 40% of the U.S. population has its medical information stored in an Epic electronic health record (EHR), and the company often sits atop research firm KLAS' rankings of best-available EHR systems.

Epic has plenty of big-name clients who've spent tons of money installing its expensive systems: $700 million from Duke University Health System; $700 million from Boston's Partners Healthcare; $150 million from the University of California, San Francisco; and $80 million from Dartmouth-Hitchcock Medical Center in New Hampshire, Forbes reported last year.

So it's not surprising that such a high-profile company has attracted several notable critics, who warn that its market dominance could have harmful effects on the future of health information technology, EHRs and even patient care. Worse, these critics warn, Epic has achieved much of its market dominance on the backs of taxpayers - courtesy of $35 billion in federal subsidies paid to hospitals and doctors to purchase EHR systems...

Aside from the taxpayer subsidies Epic has indirectly received, what really rankles the company's critics is Epic's lack of interoperability with other EHR systems, meaning that's it's a "closed" system that doesn't share patient data particularly well with doctors or hospitals who don't use Epic's software.

"If Epic (already based on an antiquated technology -- MUMPS) decides to maintain an essentially closed system, and to drive all innovation internally, this could prove stultifying, limiting the development of novel ideas, and forcing the many high-profile adopters of Epic to accept stagnation or pay the staggering costs of switching," wrote physician-scientist David Shaywitz in Forbes.

In other words, the "closed" nature of Epic's systems - coupled with its dominant market position - could mean that Epic ends up setting the defacto standards for EHR systems, effectively stifling innovations that its competitors might develop in the EHR market. That, in turn, could lead to Epic's big hospital customers - and those hospitals' patients - being frozen out from advances in EHR technology. ..

Then there's the question of to what extent American taxpayers are helping to subsidize Epic's market grab, courtesy of EHR incentive payments outlined in the Obama administration's 2009 stimulus bill. It's not a coincidence that the privately held company's sales have been skyrocketing in recent years, up to $1.2 billion in 2011, double what they were four years prior, according to Forbes.

It's also no coincidence that Epic and other major EHR players lobbied the federal government hard for the subsidies, and those companies "have reaped enormous awards because of the legislation they pushed for," The New York Times reported earlier this year.

Executives at smaller EHR companies say the legislation cemented the established companies' leading positions in the field, making it difficult for others to break into the business and innovate, according to The Times...

??? Ya think? I don't think Judy does.

Helping enrich Faulkner is ... a piece of government legislation [Meaningful Use] that subsidizes the adoption of electronic medical records, by paying millions to qualifying hospitals... Faulkner is also the only head of a company to sit on a government-appointed policy committee that makes recommendations on standards for the exchange of patient information.
- Epic Systems Tough Billionaire

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ERRATA

Google "Epic EHR." Here are the first, above-the-fold responses I got.

Gotta love it. Paying for positioning. I bet Judy Faulkner could care less about all these ankle biters.

Below, gotta love this stuff as well (rolls eyes).

Yeah.

New on SBM

[T]he new CAM buzzword these days to explain why quackery “works” is epigenetics. Basically, whenever a proponent of alternative medicine uses the word “epigenetics” or “quantum” to explain why an alternative medicine treatment “works,” what he really means is, “It’s magic.” This is a near-universal truth, and even the most superficial probing of such justifications will virtually always reveal magical thinking combined with an utter ignorance of the science of quantum mechanics or epigenetics.

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More to come...