Memorial Day

What little I really know of our military comes from my infrequent stops at a Starbucks in Clarksville, Tennessee. There, men and women from Fort Campbell sit with their children and family and, it seems, live within a context most of us have not experienced.

While most of us go about our business as if our military and our country is not at risk; while news channel "situation rooms" fill our plasma screens with collages of talking heads arguing about tie pins, clergy endorsements, misspoken words, and the attitudes of retirement home residents in Florida, these courageous families go about their errands in Clarksville, simply hoping and praying that their family members return. They wonder if the sacrifices they and their military family members are making will be recognized by the Congress and the public through a commitment to provide the mental and physical care that will be necessary to heal bodies and minds subjected to the trauma so many of the rest of us simply choose to ignore.

This essay will not address the anomalies of military health care and the odd administrative silos created through Department of Defense and Veterans Affairs facilities. The issue for Memorial Day is not to argue on behalf of one mechanism of support over another; our obligation is not just to pay tribute to the Fallen; more deeply, our responsibility is to plead for broader recognition of a remarkably brave and deserved body of American citizens whose primary concern is supporting one another through difficult times as those they love serve in foreign and often lethal venues.

Let us hope this Memorial Day that we remember not just the Veterans of our past great wars - Europe, the Pacific, Korea, Vietnam - but also those who have only recently fallen and those many hundreds of thousands of people who either current serve in the military or support someone who does; let us hope for the physical and psychological recovery of those who pay a dear price for their military service; let us hope that our Nation wakes up to their daily effort.

When my father and his generation speak of the war through the dimming memories of decades, it seems increasingly like a myth. When you buy a cup of coffee in the Clarksville Starbucks, you see the present with a poignant clarity not usually found on television; it's just real people, living real lives, hoping for a good outcome.

And if you make it to the Clarksville Starbucks, think about picking up the tab for the mother, grandmother, or grandfather in line behind you. Odds are someone they love is making a far greater sacrifice than most understand. Let's do more to hold up our end of the bargain these strong families have made.

Thanks to those who serve or who have served; those who love them; and those who care for them.

Memphis Health Information Exchange Beginning 3rd Year of Clinical Operations

On May 3, 2008, our Memphis-based health information exchange has been in operation for two years. Funded by AHRQ, the State of Tennesse, and Vanderbilt and governed by the non-profit MidSouth eHealth Alliance, the Exchange has come a long way

The Exchange currently has 356 people using the system for clinical care.

• Physician / Provider roles - 199
• Nurse roles - 109
  
• Registrars and unit clerk functions - 48

These numbers will change as the last major system goes "near real time" in the next few weeks and as more ambulatory care providers are introduced to the program. The number of clinicians will increase and the number of registrars and unit clerks will decrease dramatically.

Data are accessed by authorized personnel in 30 sites, including 11 emergency rooms, 15 primary care clinics, and 4 hospitalist groups. Expansion to other emergency department settings is taking place in May and June of 2008. Access is only through two-factor authentication and secure Web browsers in restricted settings. 100% of access transactions undergo some form of audit. Use is restricted to clinical settings. No aggregate data or metrics are kept. Patients may "opt out" at the institutional level.

The Exchange grants secure access to almost 3 million patient encounters.

• Total number of unique individuals - 1,050,000
• Total number of unique individuals with clinical data (not
  just claims) - 809,000

Our latest inventory of data elements from the two-years of operation counts:

• Over 64 million laboratory tests (growing at an average of 88,000 test results a day).
  
• 1.3 million radiology reports (growing at almost 2,000 per day)
  
• Over 16 thousand dictated discharge summaries
• Over 218 thousand anatomic pathology reports
• Approximately 40 thousand other clinical notes

(Follow this link to compare with our February 2008 update)

More data and implications will soon be found at our Regional Informatics Site

The Microsoft HealthVault Be Well Fund

On February 25, Microsoft announced a $3 million dollar effort called the Microsoft HealthVault Be Well Fund. The initiative is designed to "empower providers with targeted funding to stimulate the research and development of online tools that improve health." Microsoft expects to fund approximately 20 qualified institutions with an average award of $150,000 (maximum of $500,000). Indirect costs are not funded by the Microsoft proposal. Proposals must be submitted by May 9, 2008 12:00 (noon) PST and notification will occur no later than July 1, 2008.

• Follow this link for the Microsoft Press Release
• Follow this link for the Microsoft HealthVault Be Well Fund FAQ sheet
  
• Follow this link for the HealthVault Be Well Fund RFP
• Follow this link for the HealthVault Software Developers Kit (SDK)

Microsoft envisions a range of application areas, including but not restricted to (quoting):

Primary Prevention Applications (Track 1)
Proposals targeting primary prevention could help people and caregivers create and maintain strategies that prevent or delay onset of disease by reinforcing healthy lifestyle factors and addressing modifiable risk factors such as hypertension and weight.

Secondary Prevention Applications (Track 2)
The identification of major modifiable risk factors (such as dyslipidemia, hypertension, smoking, obesity and inactivity) is a prerequisite to the implementation of preventative interventions — known as secondary prevention. Proposals in this category could help people and their caregivers measure things such as blood pressure, lipid profile components (LDL and HDL cholesterol and triglycerides), diet and nutrition, weight, smoking, and activity level to create the optimal plan to prevent or delay morbidity and acute care.

Acute Care Applications (Track 3)
Certain conditions require immediate diagnosis and treatment, whether at the doctor’s office or in an urgent care setting. Proposals targeting acute care scenarios might track progress, improve communication and share data between the silos in the healthcare system, providing caregivers with a longitudinal view of a patient’s health history that ultimately may lead to superior outcomes.

Juvenile Disease Management Applications (Track 4)
Health conditions in children often require specialized detection, diagnosis and treatment. Parents typically become eager partners in the plan of care, and seek information specifically related to their child’s condition. Proposals focusing on juvenile disease management might provide age-appropriate tools to help children, parents and caregivers understand and manage their conditions.

Women’s Health Management Applications (Track 5)
Women’s health issues can be complex and are often influenced by biopsychosocial and environmental factors. Proposals targeting this track might choose to create online tools or services that help manage health within the context of lifestyle and family.

Community and Social Health Applications (Track 6)
Patients and caregivers dealing with illness or people interested in wellness are increasingly sharing information and support with each other through various Web-based social applications. Proposals targeting this category might include applications for health in areas such as collaboration, communication and the use of social relationships to improve care.

Universal Internet Connectivity

Today AT&T announced a major program with the State of Tennessee.

Pertinent links:

• AT&T Press Release (February 25, 2008)
• San Antonio Business Journal (February 25, 2008)
• Tennessean (Nashville) article (February 25, 2008)
  
• Tennessee eHealth Council
• TN eHealth physician connectivity grant page
• Sample grant contract

Here's a portion what the AT&T press release said:

AT&T is actively engaged with the state and health care providers statewide in building the eHealth Exchange Zone. Plans call for eHealth applications to be phased in as participation by health care providers grows.

The AT&T solution features a secure online collaboration center — a Virtual Private Network (VPN)-based portal — designed to safely and securely enable such applications as:

• Prescribing pharmaceuticals online (also known as "ePrescribing").
• Securing clinical messaging among the state's health care providers.
• Sharing high-density images, including X-rays, MRIs and CT scans.
• Exchanging patient information via portable health records, which provides patient profiles, medical history, prescriptions, etc.
• Delivering telemedicine applications for remote diagnostics and care.
• Accessing Tennessee Department of Health applications, including the immunization registry, disease registries, death certificate applications and processing and medical license renewal.
• Accessing other health care applications and systems, including laboratory systems.

The network has an added component especially for protecting health information provided by the Covisint OnDemand Platform. The platform is a hosted solution that provides dual-factor authentication of health care providers using the VPN-based portal, which supports HIPAA privacy requirements. It also centralizes, automates and streamlines the access to information across health care communities statewide by giving physicians the ability to use many health-information applications with a single sign-on. The platform from Covisint, a division of Compuware Corporation (NASDAQ: CPWR), provides an on-demand, industry-leading infrastructure for secure collaboration and interoperability among health care providers.

Reading carefully, the AT&T announcement does not declare an intention to become the "exchange zone," to provide health care applications, or do more than two very important things: 1.) establish Internet connectivity for providers who do not have this capabilities because of locale; 2.) work with Covisint to provide dual-factor authentication - a critical aspect of any future health care application (don't you want to be sure that clinicians accessing your personal health information are who they say they are?) Covisint has been active in this area. See, for example, the testimony of their Chief Security officer to the U.S. Senate Judiciary Committee on the Future of e-Prescribing of Controlled Substances.

Reading carefully, the AT&T announcement does not seem to be exclusive, but potential grants from the state may be available to those who wish to use this network or switch to AT&T from their current means of Internet access.

According to the TN eHealth Council physician connectivity grant Web site, the State of Tennessee will distribute through intermediary organizations connectivity grants designed to "offset the costs offset the costs of connecting health care providers to Tennessee eHealth resources" including "hardware, software, peripherals, broadband connectivity, and HIPAA compliant authentication." The grant contract funding includes $3,500 per actively practicing physician as well as $6,000 per site.

This is a boon especially to rural practitioners who at this date do not have access to high-speed internet services in their community. It is not clear how much practitioners will be charged for this connectivity, nor is it clear how the Covisint authentication will work, but both seem to be good ideas in selected circumstances.

But what are the requirements?

Excerpting from the sample grant contract at the TN eHealth site one notes the following conditions:

• A.3.d Grantee agrees, for a period of two (2) years, to actively participate in electronic prescribing (ePrescribing) and capturing prescription information to populate a patient’s medication history as directed by the eHealth Council. Grantee should use a software application with SureScripts and/or RxHub certifications.
• A.3.d.1. Electronic prescribing, as defined by the National Council for Prescription Drug Programs (NCPDP), is two way [electronic] communication between physicians and pharmacies involving new prescriptions, refill authorizations, change requests, cancel prescriptions, and prescription fill messages to track patient compliance. Electronic prescribing is not Faxing or printing paper prescriptions. ePrescribing also includes the potential for information sharing with other health are partners including eligibility/formulary information and medication history.
• A.3.e. Grantee agrees to participate in discussions with any health information exchange “HIE” or regional health information organization “RHIO” operating in that geographic area.
• A.4. Grantees, who are TennCare providers, must adopt the health information technology in accordance with TennCare metrics. When serving TennCare patients, Grantee agrees to use an electronic medical record to document and track pertinent preventive health services (e.g. immunizations, pap smears, mammograms) and/or access and populate (as appropriate) a claims-based electronic health record for the same purpose.

What are the implications of these provisions? Here's one person's guess:

A.3.d
This measure will ensure that e-prescribing is adopted in a way that ensures security and authentication. This measure will place practitioners ahead of the curve - particularly if controlled substances and stronger authentication are required. One problem with the current system: It is not clear how many rural pharmacies are ready to accept e-prescriptions. Progress in the chains is striking and growth of adoption in independent pharmacies is rapid, but some communities may have to await new initiatives by independent pharmacists to achieve Internet connectivity and upgrade their systems.

E-prescribing brings new opportunities to communities. Because the linkages are between the prescriber and the pharmacy (with eligibility checks via RxHub or SureScripts in some instances), there is the potential for a leaner system and new methods of ensuring better compliance with needed medications. Remember, the real "quick win" with e-prescribing may be simplifying refills and ensuring that patients take the meds required to avoid long-term complications.

One unknown: it is not clear what "population of a medication history" means. This will be resolved. But clearly both providers with e-prescribing and plans have these data and additional overhead does not seem warranted.

A.3.e
This caveat seems to urge collaboration but does not impose additional burdens on practitioners. It is not clear which "RHIOs" are really valid here - and which are even exchanging data. It is assumed that the list includes initiatives in Memphis, Knoxville, the Tri-Cities area, and the Shared Health Initiative.

A.4.
This clause focuses on TennCare. It is not clear what "TennCare metrics" are, but the need to document care for these patients is acute. One requirement is that for TennCare patients, providers must "use an electronic medical record to document and track pertinent preventive health services (e.g. immunizations, pap smears, mammograms) and/or access and populate (as appropriate) a claims-based electronic health record for the same purpose."

Optimists can read this as a means of enabling choice among ambulatory care systems, although it's not clear how such systems will transmit "TennCare metrics" to the State. The only "claims-based electronic health record" available is Shared Health. Cynics can argue that such a requirement limits choice. In reality, it all depends on the extent to which the state encourages open choices among exchanges. The objective - improving the care of TennCare patients - seems a good one.

The Suggestion of a Framework

There are several different components that are alluded to in these documents:

• The "back end" - a database that TennCare uses to document care and quality
• One or more "health information exchanges" - the means by which health care providers (and someday consumers) communicate their information among authorized parties
• Authentication mechanisms - means by which one can be sure of valid communications
• Authorization - means by which policies and technologies ensure that the person authenticated is authorized to transmit or receive information
• The "front end" - the means by which data are captured by clinicians, consumers, and fiscal intermediaries

Aligning all of these moving parts is complex and involves assuring that components at each layer are able to communicate with others. Such "interoprability" is important so that each consumer and provider can chose systems best suited for these needs. (Example: as much as we Tennesseans like Nissan, I don't think we all want to drive a Tundra, nor do we want excessing intrusion into our auto purchasing decisions.)

Unanswered Questions

This program seems worthy of strong consideration by practitioners who do not at present have access to the Internet. Among the unanswered questions are:

• Internet connectivity is essential to health care delivery. But what of those who already have such access by some other means? In essence, receiving grant funding would require them to change carriers to AT&T. And what about pharmacies, nursing homes, and other essential care sites? Ultimately, every care provider is going to have to pay their way, so understanding the total cost of participation - over a 5 year period - would be valuable.
  

• Authentication is a vital service. Can a physician gain access to these services without using AT&T? Is there any grant funding for this? Will other means of authentication be developed over time, or is Covisint the only authorized authentication broker?
  

• Choice is important. Many practices are adopting comprehensive electronic medical record systems? How will these systems interact with the authentication mechanisms proposed? How will exchanges collaborate? How will the public's concerns over privacy and confidentiality be addressed?

Each of these topics has been the matter of hard work and collaboration. It may take time for answers to emerge.

This announcement should be viewed as a part of a broader framework enabling better care. Putting the pieces together will be somewhat a process of trial and error; that's the price a state pays for staying ahead of the curve.

The Economy - February 24, 2008

At times, articles randomly perused give the appearance of deeper linkages. Such is the case when comparing two front-page articles on Sunday February 24 from the St. Louis Post Dispatch and the New York Times. The Post's article is entited "Recession resilient: why we may be able to bounce back faster this time around." It's sub-title in the back pages sums up the picture: "More jobs in service sector weather a downturn." It highlights a wide range of individuals who are pursuing careers in nursing.

The New York Times front-page article is entitled "Once immune, Utah is feeling economic dip." This article mentions that Utah's relatively lower rate of retiree emigration anti-recessionary "non-wage" spending patterns of this demographic. Utah also recently cut its 2008 job projections by a third (to 2% annual growth). But the treatment of health care is the most compelling contrast to the St. Louis Post article. Quoting:

"And in what is perhaps the cruelest paradox of all, Utah spends less on health care than its neighbors, according to Headwaters, with health habits, fewer old people, and abstention from alcohol and tobacco by practicing Mormons the biggest factors. Health care spending is usually one of the most stable sectors of all in a downturn."


A table created from the St. Louis Post and other sources summarizes the change in the St. Louis economy. Several things are apparent about the St. Louis picture. First, manufacturing has diminished. The acquisition of McDonnell Douglas by Boeing is but one indicator. Similarly, one sees consolidation of some industries (groceries, telecommunications, retail) and dispersal of others (Unity health system). The percentage growth rates are also of interest, but difficult to interpret without some unit of output. It may be rather easy to calculate the efficiency per worker of a McDonalds or Wal-Mart, but more difficult for BJC and Washington University.

• Follow this link for the table

What does this all mean? Extrapolated to an extreme, we may some day be a country where the economy can best be described a population of health care workers employed caring for a population of agricultural and fast food workers. Extrapolated to an extreme, we become a country that not only makes fewer things but given the relative diminution in engineering and scientific talent also realizes fewer ambitions and ideas.

Looking at the recent issue of Health Affairs also emphasizes the degree of direct financial input by government. We are told that in 2005 Medicaid paid for 20% of the 39 million hospital stays in that year. Adding Medicare almost doubles that. Adding Medicaid managed care adds 25 - 50% to the Medicaid spend. Entitlements and defense, it seems, drive the country's economic engine, all fueled by bonds held by others. Sobering stuff.

MidSouth eHealth Alliance Update - February 2008

The MidSouth eHealth Alliance published its first newsletter in January of this year. The newsletter provides some background on the Alliance's recent work and data on our health information exchange in Memphis.

Additionally, the CHCF report was cited today by the Health Affairs blog and makes mention of our work in Memphis.

• Follow this link to the Midsouth eHealth Alliance Newsletter
• Follow this link to the Health Affairs Blog reference

What can be said of the Exchange in early 2009?

• Security and confidentiality remain paramount. Use and participation is governed by patietn consent, data sharing agreements, and user agreements
• Information from the secure Web browser is used to care for 100 - 200 individuals today in most of Memphis' major emergency departments and a growing number of ambulatory settings.
• Over 2 million events can be accessed on over 1.3 million medical records or demographic files from over 900,000 unique individuals.
• Over 50 million laboratory tests are available, as well as discharge summaries, radiography reports, some medications, and a range of other clinical data elements.
• Annual costs are less than $3 per person per year.
• The Exchange remains committed to the care of every consenting individual without regard to health care coverage.

What are priorities for the year?

• The Exchange continues to work through integration with an array of ambulatory care systems and providers.
• The Exchange seeks to follow national guidelines to foster collaboration with other systems and exchanges in the region, the state, and the country.
• The focus of the Exchange remains identification of ways to improve the quality of care provided to individuals both by presenting valuable clinical information and studying. consumer-driven "version 1.0" markets where patients and providers can focus first on their care and secondarily on the complexities of reimbursement.

GAO: Awaiting a Strategic plan from the Office of the Network Coordinator

The considerable progress in health information technology correlated with the HHS Office of the Network Coordinator is summarized in the most recent GAO report on this office. This report describes a "numerator" of programs funded by ONC, but fails to include the "denominator" that would include the far greater degree of innovation congruent with the Secretary's vision but equally the product of thousands of professionals and consumers across our country who - on their own and without strong government mandate - have concluded that a more effective health care technology infrastructure is essential to any improvements in our ailing health care system.

A "coordinator," one could argue, should address how the growing momentum created by all of these myriad programs can be harnessed to a greater social good. This writer remains a cautious optimist in this regard.

In testimony before the Senate Committee on the Budget on February 14, Valerie C. Melvin of the GAO summarized the overall HHS efforts, urging again for a national strategy.

• Follow this link to the report (GAO-08-499T)

The report describes the considerable progress achieved . And it concludes with mention of the strategic planning process underway by the relatively new leadership at ONC.

The report states:

The National Coordinator ...told us that HHS intended to release a strategic plan with detailed plans and milestones in late 2006. Nonetheless, today the office still lacks the detailed plans, milestones, and performance measures that are needed. According to its fiscal year 2009 performance plans, the Office of the National Coordinator has prepared a draft health IT strategic plan, which it intends to release in the second quarter of 2008. If properly developed and implemented, this strategy should help ensure that HHS’s various health IT initiatives are integrated and effectively support the goal of widespread adoption of interoperable electronic health records.

The current GAO report builds on previous reports cited and provides a high-level overview of budgets, progress, and challenges. The report repeatedly makes statements like "HHS has not yet defined detailed plans and milestones for integrating the various initiatives, nor has it developed performance measures for tracking progress toward the President’s goal for widespread adoption of interoperable electronic health records by 2014. "

Since 2002, ONC has received about $200 million and has made considerable progress along several critical areas. Cited in the report are details on the progress made in:

• Advancing the implementation of both outpatient and in-patient electronic health records
• Recognition by the Secretary of some interoperability standards
• Trial "NHIN II" implementations
• A toolkit and report on the extensive privacy and security efforts at the state and national level

One could challenge the impact of some of these efforts. This writer is of the belief that the NHIN I initiate was conducted in too much haste over too short a time to achieve its true impact. The GAO report states (p 10) that "according to HHS, in early 2007 its contrators delivered final prototypes that could form the foundation (emphasis added) of a nationwide network for health information exchange. The NHIN I summary report cited 24 "core services" 12 "common transaction features," and 14 "annexes on common themes like identity arbitration, consumer data-sharing permission, and data routing. Among these 50 "things" (not counting the many other features and specifications decried by the use cases, one hopes that some immediate and fundamental high priority steps will emerge as initial steps in the road map. This writer believes that about 12 of the core services lists are "must do" high priorities, but that many others may best be left for later consideration.

The report later states (p 11) that at the end of the first contract year (September 2008), "HHS intends for the nine organizations and the federal agencies that provide health care services to test their ability to work together and to demonstrate real-time information exchange based on the nationwide health information exchange specifications they define." The specifications and test materials will be placed in the public domain so that "they can be used by other health information exchange organizations to guide their efforts to adopt interoperable health IT." These documents will be valuable. (One hopes that the NHIN I materials will someday be more easily accessed as well.)

But how should - and how can - even an organization as talented as ONC develop a national strategy. This writer has a few suggestions:

Look to the successes, not just NHIN contractors. A lot is going on in health care delivery organizations, health plans, and exchanges that are funded by AHRQ, private resources, and other sources. Indeed, many of the largest and most vibrant exchanges have chosen not to participate in NHIN at this juncture.

• Build on the idea - first raised by the Commission on Systemic Interoperability - that strongly suggested the availability of a medication history for every American as a top priority
• If a second "quick win" is desired, focus the same approach on clinical laboratories
• Create guidelines for identity management. This is a critical topic for consumers, for e-prescribing, and for other applications. If e-prescribing is expanded to include controlled substances, identity management will become even more pressing
• Focus on simple core guidelines for confidentiality and privacy that transcend applications that that can serve as a basis for new and revised legislative and policy remedy
• Focus - as HHS is - on incentives to adopt helpful technologies that foster a more effective system of care
• Table or adjourn 50% of the discussions taking place on topics that are not "foundational." To paraphrase Governor Phil Bredesen's remarks at the 2007 HIMSS meeting, don't try to build version 6.0 before you've got version 1.0 working.

The literature - and our experience - are full of examples of successful approaches to strategy. Such a strategy is possible in a way that transcends the transfer of power at the executive branch of the federal government and the ongoing changes in states and communities. Central to every approach is a realistic set of expectations, focus, and incremental steps.

Governor Bredesen Mentions Memphis in his Annual Address to the Legislature

Four years ago - Feburary, 2004 - Governor Bredesen made note of a newly-formed collaboration between the Regional Medical Center in Memphis and Vanderbilt University. This collaboration led to the AHRQ initiative governed by the MidSouth eHealth Alliance and managed by the Vanderbilt Regional Informatics Group.

On January 28, 2008 the Governor returned to the Memphis project briefly in his address to the legislature.

He made two remarks that are relevant to the direct health care value of the Exchange as well as a way it may be used as part of the State's emergency preparedness efforts.

The Governor’s talk:

http://www.tennesseeanytime.org/govfiles/2008-SOS-Address.pdf

Security and preparedness. This is a bedrock responsibility of any Governor. This past summer Tennessee was named by the U.S. Department of Homeland Security as one of the ten states in the nation to achieve their highest ranking for our disaster response plans. And we were one of eight states to get a perfect score--10 out of 10--from the Trust for America's Health for emergency preparedness. To David Mitchell and Jim Basham and Gus Hargett and Susan Cooper, and to all your supporters in the General Assembly, thank you.

.............

Education, safety, jobs, employees. I'd like now to address the subject of health.
We have a lot of things underway in the health field.

I'm particularly proud of the efforts that our state is making to fight some of the underlying causes of serious health problems, particularly in the areas of obesity and smoking. This is the real frontier in public health, and we're starting to show some real successes here; the smoking rate in middle school has declined from 17% to 10% over the past year, for example. That 10% is still 10% too high.

We are also a national leader in e-health, in the use of electronic data and communication technology to maintain and make accessible to providers a person's health records. There are advantages to both the cost and quality of health care that flow from this use of technology. We have paid a great deal of attention to the privacy and security of these records as we have proceeded. The initiative we have developed in conjunction with Vanderbilt University in the greater Memphis area is frequently held up as one of the two or three top e-health efforts in the nation.

CMS, DRGs, and Hospital-acquired complications

PLEASE REFER TO MY NEW BLOG SITE

The Federal Register (Vol. 72, No. 85) of Thursday, May 3, 2007 has a 457-page listing of proposed changes to the hospital inpatient prospective payment system for the 2008 fiscal yer. These proposals affect 42 CFR Parts 411, 412, 413, and 489.

This is essential reading. The posting of these proposed changes is a watershed event with implications that may extend far beyond the altruistic intentions of CMS.

• Follow this link for the Federal Register pages
• Follow this link for commentary sumitted to CMS
• Follow this link to the specific Federal Register pages (pdf)
• Follow this link to Mark's HTML summary pages
  

Page 24716, Section F begins a lengthy discussion of how CMS proposes to reimburse hospital-acquired conditions, including infections. The changes are revolutionary and will have a tremendous impact on how hospitals - and other organizations - manage health information.

CMS has proposed some target conditions. At least to this writer's limited understanding, if one of these conditions is developed during a hospitalization, CMS would not reimburse for any higher DRG rates but instead would reimburse for the DRG that is not associated with the complication. Proposed conditions include:

• Catheter-associated urinary tract infections.
• Pressure ulcers
  
• Air emboli resulting from injection
• Stephylococcus septicemia
• Erroneous transfusion with the wrong blood type
  
• Ventilator-associated pneumonia.
• Infections relating from intra-vascular infection
  
• Clostridium difficile-associated gastrointestinal infections
  
• Drug-resistant staphyloccocus infection
  
• Surgical site infections.
• Wrong surgery.
• Falls

The legislative authority is clear. Quoting from the Federal Register:

Section 5001(c) of Pub. L. 109–171 requires the Secretary to select, by October 1, 2007, at least two conditions that are
(a) high cost or high volume or both,
(b) result in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis, and
(c) could reasonably have been prevented through the application of evidence-based guidelines.
For discharges occurring on or after October 1, 2008, hospitals will not receive additional payment for cases in which one of the selected conditions was not present on admission. That is, the case will be paid as though the secondary diagnosis was not present. Section 5001(c) provides that we can revise the list of conditions from time to time, as long as the list contains at least two conditions. Section 5001(c) also requires hospitals to submit the secondary diagnoses that are present at admission when reporting payment information for discharges on or after October 1, 2007.

The mere targeting of this vital issue may transform both the means by which data are collected in the hospital and the means by which the status of a patient must be determined prior to hospitalization (the "present on admission"indicator becomes crucial). It will lead to better health care, greater systemic application of best practices, greater complexity, higher administrative costs, and perhaps add additional weight to the arguments made by proponents of global capitation or a single-payer health care system.

---

Aside: What is the Present on Admision indicator? Maybe this quote from the Register can help - or at least demonstrate again how health care is mired in the complexity business.

The current electronic format used by hospitals to obtain this information (ASC X12N 837, Version 4010) does not provide a field to obtain the POA information. We are in the process of issuing instructions to require acute care IPPS hospitals to submit the POA indicator for all diagnosis codes effective October 1, 2007. The instructions will specify how hospitals under the IPPS will submit this information in segment K3 in the 2300 loop, data element K301 on the ASC X12N 837, Version 4010 claim.

Now, isn't that clear?

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The intent of these regulations is laudable. Who, after all, should be responsible for the costs incurred when the wrong limb is amputated, when a sponge is left in a body, when the wrong type of blood is transfured, or when a catheter is left too long unattended and leads to septicemia? That said, some of the areas are far more problematic. Complications - including septicemia, C. difficile happen under the best of practices. Where decubitus ulcers are concerned, determining the onset of these conditions is problematic - particularly in the case of patients who are bedridden or largely sedentary prior to admission.

In addition to the obvious coding and IT implications, these regulations may have other implications:

• A far more extensive investigation for pre-existing conditions at the time of admission - expect every patient to have a more extensive set of tests and perhaps photographic documentation of state of skin care. Expect a tension between those who "up code" at admissions and those who suspect fraudulent behavior.
• An escalation of the "blame game" between long-term care facilities and hospitals
• A significant financial impact on hospitals as the same regulations are adopted by commercial health plans
• A new basis for malpractice claims

There are other, perhaps unlikely long-term implications. As our system becomes more and more complex and as more and more dollars go towards coding and assigning blame rather than treating, at the same time providers will be adopting health care guidelines with greater enthusiasm, payers will be revolting over the escalation in costs associated with documentation rather than care. Proponents of single-payer systems - long arguing that the administrative costs of health care in America are prohibitive - will have a new and powerful arrow in their quiver.

The Best Healthcare System in the World - Sometimes

PLEASE REFER TO MY NEW BLOG SITE:
posted at http://www.markfrisse.com/policy/

An August 12 Editorial in the New York Times reviews the findings from a recent Commonwealth Fund report on the relative performance of the U.S. health care system when compared with other countries.

• Follow this link to the NY Times editorial (subscription may be required)
• Follow this link to the Commonwealth Fund home page for the study mentioned
• Follow this link for the Commonwealth Fund's Commission on a High Performance Health System

Let's start with the good news. According to the report and the editorial, our Nation ranks very high in following certain guidelines for preventive care. The Times states that three-fourths of Americans "rate their medical care as excellent or good, so it could be hard to motivate these people for the wholesale change thought by the disaffected." The Commonwealth Fund polls, the editorial states, rate U.S. opinions as very negative stating that a third of the "adults surveyed called for rebuilding the entire [health care] system, compared with only 13 percent who feel that way in Britain and 14 percent in Canada."

In the "Dark Ages"

The editorial emphasizes what we already know: "despite our vaunted prowess in computers, software and the Internet, much of our health care system is still operating in the dark ages of paper records and handwritten scrawls. American primary care doctors lag years behind doctors in other advanced nations in adopting electronic medical records or prescribing medications electronically. This makes it harder to coordinate care, spot errors and adhere to standard clinical guidelines." Admittedly, these claims must be considered in light of the correlation between payer complexity and automation and the reports of dissatisfaction and information technology snafus in the U.K. and elswhere, but it does seem unconscionable for a sector controlling this much of the GDP to have allowed such neglect in our infrastructure.

Other issues

The editorial adds to a long list of factors that we as citizens ought to weigh when we consider the state of our health care in the present and for our Nation's children and grandchildren. These include:

• Access. Try to find care on a weekend. The editorial and report point out we as a nation are les likely to have a long-te3rm doctor, less able to see a doctor on the day when sick, and less apt to get our questions answered.
• Disparities. Try to find care on a weekend if you have no insurance
• Insurance coverage. It is difficult to say anything new here.
• Life and death. We score high in some critical areas
• Healthy lives. We have a shameful infant mortality rate, but we seem to neglect our own care as well as that of our infants; we rank very low in healthy life expectancy at age 60.
• Quality. The report mentions our inability to coordinate the care of our chronically ill, emphasizing again that our "system" of care arguably forces silos of care to compete - to the disadvantage of our own care. This writer believes such coordination can only be realized if we address the information technology infrastructure in the right way.
  

Everyone reads what they believe in such reports. Some may focus on the higher out-of-pocket expenses Americans pay for health care. This claim should be placed in context with the higher out-0f-pocket expenses the middle and upper classes incur for plasma TVs, automobiles, and consumer debt.

No answers or even firm opinions are offered here, but one should ask the broader question - what is the total cost for our social safety net if we include employer tax deductions and other hidden "taxes" we as citizens pay. Perhaps the challenge is to make the true cost of this sincere but faulty system more transparent. The challenge, perhaps, is to lay out the facts in a way that makes the real decisions more apparent. It may be that we are reaching a point where we cannot make any decisions other than painful ones (much as the Romans, no doubt, did not "decide" to let the Goths invade their failing empire.)

For this reason, the issue is not a partisan one but more one of first creating a spirit of true "transparency" in our health care system - something Secretary Leavitt strongly supports. With a more transparent system based on useful data, we can debate our different views on equity, self-reliance, and role of both government and the individual.

The system is broken. Some make the analogy with a trauma patient on life support who will not recover from a their injuries. Some would argue we should work even harder at saving this life as it is currently organized. Others would argue it is time to let this soul go and to start thinking about how to harvest organs. A crude choice, perhaps, but in the end the editorial is not just about ideas, it is about the savage reality of life and death.

Following Intel's CEO

What follows is a compendium of postings from my other sites concerning Intel's visionary CEO. This observer heard his September 2006 address and thought his remarks put our health care delivery crisis in the right context. Enclosed as well are subsequent postings and links.

Barrett, September, 2003

On September 26 at 8:30 am, Intel CEO Craig Barrett spoke at the eHealth Initiative Health Information Technology Summit. He preceded Secretary of HHS Michael Leavitt.

• Follow this link for an unofficial transcript (PDF) of Barrett's talk.
• Follow this link for a transcript of Secretary Mike Leavitt's talk.
  

He prefaced his remarks by emphasizing both his support for the political process but also his frustration with the pace of change and leadership "around the margins." He mentioned in a positive sense his participation in the American Health Information Community.

But Barrett's words were strong and, in the view of this observer, dead on.

Among his comments:

• U.S. jobs will continue to move offshore at a rapid pace unless corporate America exerts its power to force the health care industry to adopt systems that will cut costs and improve efficiency. "Every job that can be moved out of the United States will be moved out ... Because of health care costs," which on the average were in excess of $6,300 per person in 2004.
• "The system is out of control, it's unstable, it's basically bankrupt, it gets worse each year and all we do is tinker around the edges when what we need are major fixes"
• Asking "who should pay for it" is the wrong question. No one can pay for it.
  Even if one makes a massive, one-time change in the chronic care disease management, unless the trend is toward continual improvement, the costs will inexorably climb.
• "Every other industry has adopted this technology and (the health care) industry continues to sit here and debate"
• Why does the health care industry expect subsidies to pay for health care technology? Every other industry makes these investments as a matter of survivability?
• Employers should demand that hospitals select standardized record systems to lower costs or take their company's business elsewhere
• Companies should only do business with health care providers who meet certain standards, including fully electronic patient records and published "best practices" for patient treatment
• Price transparency is critical to employer and consumer engagement. How many other industries can't tell you what a service will cost or explain their charges in a simple way?
• Hospital networks could and should be transformed into "competitive centers for excellence" that are paid to keep employees healthy.

Wal-Mart Stores Inc. Executive VP Linda Dillman joined Barrett on the stage and spoke of Wal-Mart's costs as an employer and their innovative approach to providing health care in pilot settings.

• Barrett said the health care industry could learn from the efficiency of Wal-Mart.
• He claimed Wal-Mart was an information technology company that sells what it tracks and excels by its ability to employ IT in conjunction with effective business models and great customer service

• Follow this link for AP coverage of this presentation
• Follow this link for a Health IT World News article on the talk
• Follow this link for a related posting on this Blog that references Health Affairs articles
• Follow this link for my comments on a NY Times editorial concerning health care costs
• Follow this link to a July 2004 discussion involving Craig Barrett and addressing global competition

---

Barrett (November, 2006)

In a September 29 posting to this site, this writer quoted from a presentation given by the CEO of Intel to the eHealth Initiative meeting. Warning of the crisis in health care delivery, he assured the public that large employers will take action.

In a November 29 article in the Wall Street Journal by Gary McWilliams, Barret's "jolt to the health care system" is describe in greater detail. mcWilliams states that in the coming week, Intel, Wal-Mart, British Petroleum, and others will disclose a plan to provide digital health records to their employees "and store them in a multimillion-dollar-data warehouse" linking hospitals, doctors, and pharmacies. (This writer believes the actual technology will be an exchange with strong privacy protections and not a giant data warehouse; a clarification will assuage public concern).

Craig R. Barrett, Intel's chairman, calls this effort part of a "building-block to modify the U.S. health industry" and he doubts that "the industry is capable of modifying itself."

The costs projected for the project seem low; the article claims a contribution of 1.5 million each from 10 employers. The model appears to let "consumers and insurers...evaluate price and performance data from millions of employees." Eliminating duplicate tests and erroneous or lost information would also slash administrative overhead, accounting, according to the article, for up to 40% of medical costs. An appeal to reduction of adverse drug events is also made.

Functionality includes an ability for doctors to "measure which treatments worked best for chronically ill groups of patients" and the ability to prescribe electronically.

The article raises some points that will draw concern. Quoting:

"Coalition members believe that giving consumers control over their own records would help get around the technical and cost issues. But the idea of portable medical records and a massive repository still faces hurdles. Privacy advocates worry that digital records will be misused by employers and insurers to deny jobs or health-care coverage. The watchdog group Patient Privacy Rights Foundation urges employees to shun the approach until there are adequate protections. 'The system is leaking information,' says Chairwoman Deborah C. Peel, a practicing psychiatrist. 'Once out there, it's like a Paris Hilton sex video. It's [there] for the millennium.' "

Other features:

• The employers will insist that health-care providers adopt electronic records and prescribing as a condition of future business.
• Wal-Mart will apply its purchasing power to get bar codes on products intended for hospitals and clinics.
• Employers will expect employees to pick doctors willing to use and update their records, though employee compliance is voluntary.
• The "records will be the property of the employees, and the data will be mined by insurers and others only after the patients' identity is stripped off."
  

Linda Dillman, who was on the stage with Barrett at the eHealth Initiative meeting in September, states that they are "trying to bring all the right people to the table and show them what can be done."

The article also elaborates on some sobering costs, claiming that "Intel figures its health-care spending will be as much as a fifth of its research and development costs by 2009. Wal-Mart says the costs for its 1.3 million U.S. employees, if unchecked, will climb $1 billion annually for the next five years."

The final feature - patient "ownership" will be an interesting driver. Quoting from the article:

The Intel-Wal-Mart plan to offer employees medical records and automatically update those records with hospital, doctor and pharmacy detail "is very ambitious," says Dr. Greenfield, an adviser to Care Focused Procurement LLC., a nonprofit putting together an HMO claims database. "We love the patient as the agent."
"It has always seemed unusual to me that the medical record is seen as the property of the medical system," adds Donald Berwick, chief executive of the Institute for Health Care Improvement, Cambridge, Mass. Tests are duplicated and information lost in the handoff between physicians or clinics. "The best integrator in the end is the patient," Dr. Berwick says.

One expects reaction to be rather diffuse until more clarification is obtained. The "disruptive" element of this plan is note employer drive for digital health as much as, this writer suggests, it will lead to alternative care delivery models. Something that our Nation dearly needs.

Follow-up stories and links

• Follow this link for a December 4 Information Week article by J. Nicholas Hoover
• Follow this link for a December 6 article describing the Omnimedix relationship
• Follow this link to access the Omnimedix dossia site

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Barrett (July 2007)

• Follow this for an even later (summer, 2007, link)

Commonwealth Fund Report

A January 2007 document published by Davis et. al. of the Commonwealth fund addresses means to achieve savings and better value through more efficient and effective health care and insurance systems.

• Follow this link to the report home page. The 33-page report is in PDF format

Entitled "Slowing the Growth of U.S. Health Care Expenditures: What Are the Options?" the report focuses on six strategic areas:

1. Increasing the effectiveness of markets with better information and greater competition
2. Reducing administrative overhead and developing competitive pricing structures
3. Incentives promoting efficient and effective care
4. Patient-centered primary care;
5. Health information technology and other infrastructure approaches
6. Strategic investments to improve access, affordability, and equity.

Medicare - Senate Budget Committee - January 30,2007

Dr. Robert Reischauer (Urban Institute and former chief of the CBO) and colleagues presented details of the implications of the current Medicare Budget. Sen Conrad opened with a statement quoting the Chairman of the Federal Reserve.

Buried within the discussion was a heightened degree of skepticism about the economic value of information technology. To this reader there was no sense of discouraging health IT, just an added emphasis on the importance of doing it right and that the purported economic benefits might not be as great as claimed - and certainly not sufficient to "solve" any of these problems.

• Follow this link for Senator Conrad's statement
• Charts used in the Fed Reserve Chairman's January 18 presentation
• Follow this link to Bernanke's January 18 testimony
• Follow this link for the Reischaur testimony
• Greenstein testimony
• Stuerle testimony

California Healthcare Foundation's Most Popular Reports, 2006

A January 2007 posting from the California HealthCare Foundation lists the 10 most popular reports accessed during the last year. There are some expected titles (e.g., health care costs, MediCal, Part D) and some surprises (e.g., open source software).

• Follow this link for all CHCF publications

Follow these links for the Top 10

• The Guide to Medi-Cal Programs
• Snapshot: Health Care Costs 101
• Open Source Software: A Primer for Health Care Leaders
• Health Care in the Express Lane: The Emergence of Retail Clinics
• IT Tools for Chronic Disease Management: How Do They Measure Up?
• Medi-Cal Facts and Figures: A Look at California's Medicaid Program
• Consumers in Health Care: Creating Decision-Support Tools That Work
• Guide to Health Programs in English
• The Medicare Drug Benefit: How Good Are the Options?
• Snapshot: Employer-Based Insurance: Coverage and Cost

HHS Medicaid Transformation Grants

On January 25, 2007, HHS released notification of awards to 27 states to fund new ways of improving Medicaid efficiency, economy, and quality of care through the development and enhancement of "innovative systems to get more value out of the money they [the states] spend providing care to their low-income elderly, chidren and disabled citizens."

Among the "permissable" uses of grant funds were:

• Reducing patient error rates through the implementation of technology (electronic health records, clinical decision support tools or e-prescribing programs).
• Improving rates of collection from estates of amounts owed under Medicaid.
• Reducing waste, fraud, and abuse under Medicaid, such as reducing improper payment rates. Increasing the utilization of generic drugs through education programs and other incentives.
• Improving access to primary and specialty physician care for the uninsured using integrated university-based hospital and clinic systems.
• Implementation of a medication risk management program as part of a drug use review program.

The primary source links are:

• Follow this link for the HHS press release of 25-January
• Follow this link for the details (some of the URLs are not accurate as of 1-26-07)
• Follow this link for the zip file for states A-I
• Follow this link for the zip file for states J-R
• Follow this link for the zip file for states S-Z
• Follow this link for a nice table and discussion from the Commonwealth Fund
  

The proposals are an interesting mix. Many emphasize health information exchange and some of these link such proposals with e-prescribing. The dominant health information exchange proposals include:

• Arizona - $11,749,500
• Connecticut - $5,000,000
• DC - $9,864,000
• Kentucky - $4,987,583 (primarily claims-based systems)
• Wisconsin - $3,043,272
• Total - $34,644,355
  

Others emphasize this topic to lesser degree - and some - like New Mexico and Tennessee - are restricted to e-prescribing.

Summary of grants from the CommonWealth Fund States in Action (March / April, 2007)

Focus of Grant	Number of Grants	State Grantees
Electronic medical records or health information systems and exchanges	13	AL, AZ, DC, HI, KY, MI, MN, MT, NM, TX, WV (2), WI
Pharmacy HIT tools	7	CT, FL, NM, ND, TN, UT, WV
Electronic verification of citizenship	4	AR, MA, MI, RI
Promoting good health and personal responsibility	2	WV (2)
Predictive modeling system	2	IL, KS
Program integrity (fraud reduction)	2	MD, NY
Medical information for children	1	NJ
Health provider credentialing	1	MI
Medicaid estate recovery	1	IN

A complete table listing can be found at the link above and is included below.

State Name	Project Name	Total Funded
Alabama	Together for Quality - Health Information Systems	$7,587,000
Arizona	Medicaid Health Information Exchange Utility Project	$11,749,500
Arkansas	Electronic Verification of Proof of Citizenship	$285,513
Connecticut	Health Information Exchange and e-Prescribing	$5,000,000
DC	Comprehensive Medicaid Integration (Patient Data Hub)	$9,864,000
Florida	GenRx Expansion	$1,737,861
Hawaii	Open Vista ASP Network	$3,188,535
Illinois	Predictive Modeling System	$4,849,200
Indiana	Medicaid Estate Recovery Centralization and Automation Project	$124,880
Kansas	Using Predictive Modeling Technology to Improve Preventive Healthcare in the Disabled Medicaid Population	$906,664
Kentucky	Health Information Partnership	$4,987,583
Maryland	Automated Fraud and Abuse Tracking	$576,228
Massachusetts	Secure Verification of Citizenship through Automation of Vital Records	$3,950,440
Michigan	One Source Credentialing	$5,208,759
Michigan	Expansion of Vital Records Automation and Integration Into Medicaid	$3,929,317
Minnesota	Communication and Accountability for Primary Care System (CAPS)	$2,843,340
Mississippi	As One - Together for Health	$1,688,000
Montana	Enhancing EHR - Clinical Decision Making	$1,481,152
New Jersey	Medical Information for Children	$1,516,900
New Mexico	e-Prescribing	$855,220
New Mexico	Electronic Health Record Project	$712,301
New York	Fingerprint Authentication at Point of Service	$5,500,000
North Dakota	Web-based Electronic Pharmacy Claim Submission Interface	$75,000
Rhode Island	IT Infrastructure Transformation	$725,253
Tennessee	Electronic Prescription Pilot Project	$674,204
Texas	Electronic Health Passport for Foster Care	$4,000,000
Utah	Developing a Pharmacotherapy Risk Management System with an Electronic Surveillance Tool	$2,881,662
West Virginia	Healthier Medicaid Members through Personal Responsibility	$1,937,110
West Virginia	Healthier Medicaid Members through a Stronger Medicaid Program	$1,731,680
West Virginia	Healthier Medicaid Members through Health Systems Improvement	$3,895,730
West Virginia	Healthier Medicaid Members through Applied Technology	$1,766,280
West Virginia	Healthier Medicaid Members through Enhanced Medication Mgmt	$4,287,110
Wisconsin	Health Information Exchange Initiative	$3,043,272
Total		$103,559,694

Center for Health Care Strategies and Return-on-Investment

The Center for Health Care Strategies (CHCS has recently published an ROI analysis on integrated substance abuse treatment and medical care management. Of greater acute interest is their recent announcement of a Return on Investment Purchasing Institute designed to help states understand the return on investment (ROI) of various care management iniatives. Quoting from the announcement: "Through this 12-month initiative, up to eight states will receive focused training paired with intensive technical assistance around concepts and methodology for calculating ROI. Participants will evaluate the ROI potential for specific quality initiatives, analyze the implications of ROI analyses for program planning, and package ROI forecasts for use in budget requests. "

On February 16, CHCS announced its eight states.

• Arizona
• Colorado
• Connecticut
• Idaho
• Louisiana
• Oklahoma
• Pennsylvania
• Washington

• Follow this link for the CHCS home page
• Follow this link to the integrated substance abuse treatment ROI page
• Follow this link to the Return on Investment Purchasing Institute announcement
• Follow this link to a summary of the forcasting calculator instrument (pdf)
• Follow this link to the CHCS announcement of the eight states
  

CHCS was established 1995 with support from the Robert Wood Johnson Foundation. Current supporters include:

• Agency for Healthcare Research and Quality
• The Annie E. Casey Foundation
• The California HealthCare Foundation
• The Commonwealth Fund
• The David and Lucille Packard Foundation
• Kaiser Permanente
• Robert Wood Johnson Foundation
• Schaller Anderson, Incorporated
• United Healthcare/Evercare
  

The home page describes the mission as follows:

CHCS advances its mission by working directly with state and federal agencies, health plans, and providers to design and implement cost-effective strategies to improve health care quality. We help these Medicaid stakeholders implement eight Quality Action Steps that are critical to chronic care improvement. These quality strategies form the foundation of CHCS’ core initiatives — the CHCS Purchasing Institute, Best Clinical and Administrative Practices (BCAP) workgroups, and multi-stakeholder collaboratives. These collaborative-learning activities provide unique venues for state Medicaid agencies, health plans, and providers to share best practices and to work together to design programs that reward high quality care.

A Busy Month in DC: January, 2007

Congress has been busy, but the plans for health information technology remain undetermined. Privacy and confidentiality are the primary topics of discussion but more changes to Medicare and Medicaid may be in the works.

Most of the activity is in HHS. In particular, there are three meetings of note.

AHIC - the January meeting will address a wide array of topics.

• Follow this link for the AHIC agenda

The National Health Information Infrastructure Prototype demonstrations - it will be interesting to see what has - and has not - been accomplished in a year. It is difficult to imagine completely engaged communities in a short period of time, but results are demonstrable. Given the expertise of the contractors, a clearer understanding of the costs and benefits should ensue and this alone will be a valuable contribution.

• Follow this link for more information on the NHIN demonstrations

The inaugural meeting of the State Allliance for eHealth - conducted by the National Governors Association.

• Follow this link for more information about the State Alliance for eHealth

Tax Relief and Health Care Act of 2006

The Tax Relief and Health Care Act of 2006 was signed into law on December 21, 2006.

The White House press release emphasizes the health care impact as follows:


The Act Will Help Make Health Care Affordable And Accessible For More Americans. This Act will bring Health Savings Accounts (HSAs) within the reach of more Americans. HSAs allow people to save money for health care tax-free, and to take these accounts with them if they move from job to job. This Act will raise contribution limits and make the accounts more flexible, let people fund their HSAs with one-time transfers from their Individual Retirement Accounts, allow people to contribute up to the annual limit of $2,850 regardless of the deductible for their insurance plan, and give them the option to fully fund their HSAs regardless of what time of year they sign on to a plan.

There, is, of course, much more than that. (including a section entitled "Designation of wines by semi-generic names.")

• the House version can be accessed through this link

The section addressing Medicare and other provisions is called the Medicare Improvements and Extension Act of 2006. It includes:

• One year increase in the Medicare physician fee schedul conversion factor
• Ammendments to the Social Security Act (42 USC 139w4) to have the Secretary of HHS to implement a system for the reporting by eligible professionals of data on quality measures. These measures are the measured identified as 2007 physician quality measures under the Physician Voluntery Reporting Program as published on the CMS web site.
• For 2008, the measures are to be endorsed by a consensus organization such as NQF or AQA. "Such measures shall include structural measures, such as the use of electronic health records and electronic prescribing technology."
• Registries may be used. The legislation states "the Secretary shall address a mechanism whereby an eligible professional may provide data on quality measures through an appropriate medical registry (such as the Society of Thoracic Surgeons National Database), as identified by the Secretary."
• There are limitations to administratvie and judicial review under sections 1869, section 1878 and other relvant codes, of the development and implementation of the reporting system,including identification of quality measures, registries, or identifiers.
• Provision of the appropriate quality measures may qualify practitioners and facilities for a bonus from the Federal Supplementary Medical Insurance Trust fund an amount equal to 1.5% of the estimate of allowed charges for services provided during a reporting period.
• There are definitions of the amount of services. For example if there are no more than three provided that are applicable and each has been reported by 80% of cases, one is eligible. If 4 or more, the reimbursement is allowed if one reports 80% of at least 3 measures
• There are limitations to payment. For example, not more than 300% of the average per measure payment.
• Recommendations for validation are included

As part of this legislation, Section 1848 of the Social Security act is ammended further by creating a new subsection entitled "physician assistance and quality initiative fund."

• This fund will have available funds of $1.35 billion
• the fund will be used to pay for the quality payments
• the legislation describes what will happen if there isn't enough money prior to appropriations

What does this mean?

• Quality metrics are part of the plan
• They will be based on consensus groups
• Use of EMR, e-Rx and other structural measures will be part of the reimbursement

HHS Advances Nationwide Health Information Network Initiative

After many months of speculation, it appears that there may be new life, opportunity, and utility associated with the NHIN prototypes funded through ONC.

• Follow this link to the December 8, 2006 press release
• Follow this link to the January 25-27 AHIC demonstration press release

HHS’ Office of the National Coordinator for Health Information Technology announced today that the department will support trial implementations for the Nationwide Health Information Network (NHIN). Dr. Kolodner stated by "bringing together the significant expertise and work achieved this year by the current efforts with state and local health information exchanges, we can begin to construct the 'network of networks' that will form the basis of the Nationwide Health Information Network."

In the coming months, HHS will announce details of the procurement process for the trial implementations. Proposals to create the trial implementations and work toward integrating them with the broader NHIN initiative will be solicited in spring 2007.

National Conference of Commissioners on Uniform State Laws

The National Conference of Commissioners on Uniform State Laws (NCUUSL) has been participating in some of the state-level discussions on the legal and regulatory issues related to health information exchange. W. Grant Callow, Esq, for example, has been active in the Florida HISPC deliberations.

• Follow this link to a description of the Study Committee on Health Care Information Interoperability chaired by W. Grant Callow
• Follow this link to the Florida Privacy Project

The National Conference of Commissioners on Uniform State Laws (NCCUSL) "provides states with non-partisan, well-conceived and well-drafted legislation that brings clarity and stability to critical areas of state statutory law."

"Conference members must be lawyers, qualified to practice law. They are practicing lawyers, judges, legislators and legislative staff and law professors, who have been appointed by state governments as well as the District of Columbia, Puerto Rico and the U.S. Virgin Islands to research, draft and promote enactment of uniform state laws in areas of state law where uniformity is desirable and practical. "

The Agency for Healthcare Research and Quality (AHRQ) Announces Four New Programs

The Agency for Healthcare Research and Quality has announced four new programs as part of an ambulatory safety and quality (ASQ) initiative. This posting should not be considered definitive.

• To access the four announcements, follow this link or access each individually below
• Follow this link to access the transcript of the January 4 Technical Assistance call

The four initiatives are:

1. ASQ: Risk Assessment in Ambulatory Care: This announcement has a broad view on ambulatory care that includes the ambulatory care clinician, as well as the patient cared for in ambulatory settings and across high risk transitions in care. Research will focus on assessing the risks associated with ambulatory care that have not yet been fully elucidated. Unlike the rest of the ASQ program, this announcement will not include a primary focus on health information technology.
2. ASQ: Improving Quality through Clinician use of Health IT: This announcement has a primary focus on the ambulatory care clinician. Research will focus on strategies to improve medication management and the delivery of evidence to the point-of-care resulting in improved clinical decision-making and clinical quality for priority conditions. Issues to be addressed include the relationship between Health IT and workflow redesign, systemic barriers to Health IT adoption, care for patients with multiple chronic conditions, enhanced patient-centered models of care delivery, and improved use of effective alert strategies for decision support.
3. ASQ: Patient-Centered Health IT: This announcement has a primary focus on patients and their interaction with the ambulatory health care system. Research will focus on strategies to improve the patient experience of care through the use of health IT. It will include work to improve the delivery of patient-centered health information to ensure patients and clinicians have the information they need to make better health care decisions. Specific topics to be addressed include shared decision-making and patient-clinician communication, personal health records, integration of patient information across transitions in care, and patient self-management of chronic conditions.
4. ASQ: Enabling Patient Safety and Quality Measurement through Health IT: This announcement has a primary focus on integrating patient safety and quality measurement with information technology. Research will focus on strategies to improve transparency for patients in ambulatory care through the development, deployment and export of quality measures from electronic health record systems. Issues to be addressed include measure development across episodes of care, clinical data needs for quality measurement export and reporting, and the reporting of quality data for improvement.

The Privacy Agenda

In what this writer suspects will be an opening round in a series of related articles, the NY Times writers Milt Freudenheim and Robert Pear in the December 3 issue contribute a piece entitled "Health hazard: Computers Spilling your History."

The article touches on a vast array of issues, from access within organizations to specific records (e.g., Bill Clinton's surgery) to access by employers to personal health information. Mention is made to the broad support for more health care technology while at the same time raising the very legitimate concerns over what these technologies can do to threaten personal information.

Reference is made to two surveys. The first is the 2005 California Health Care Foundation survey. The second is a recent survey by the Markle Foundation to be released soon and building on a 2005 survey conducted by the same organization.

Other topics mentioned include:

• Lack of enforcement and limitations of HIPAA
• Examples of state enforcement where federal enforcement has been less prominent
• Concerns over recent efforts to pre-empt state consumer protection laws
• The prominent role privacy may play in the congressional agenda (quoting Reps. Dingel of Michigan and Markey of Massachusetts)
• Efforts by employers to promote the use of personal health records (Harriet M. Person, IBM's chief privacy officer, is mentioned as a representative of one of "25 companies meeting...to develop a set of principles and best prac