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Finding the Leverage of Adoption

June 26, 2009
by David Raths
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With serious cash at stake, policy wonks struggle to navigate chronic disease management and chart a course on certification

Should state-level health IT leaders primarily work on increasing EHR adoption rates and creating the infrastructure for statewide data exchange?

Or should they focus on small victories with pilot projects that target chronic disease management to both help alleviate the crushing costs of Medicaid payments and help prove the value of exchanging data? Or can states do both at the same time?

We've read about intriguing state-level success stories such as the Delaware Health Information Network, but many states are closer to starting from scratch than they are to having a statewide exchange up and running. Facing all the traditional problems involving business models and governance issues, where should they start? Federal funding will kick-start HIE development, but it probably won't pay to sustain it long-term.

Mark Danis, vice president in charge of public sector health for information technology services company Keane, told me recently that he believes broader EHR usage and data exchange shouldn't be goals in themselves. Rather, state governments and public/private HIEs should work on identifying specific quality improvement projects and then make technology investments to achieve those goals.

“My concern is that a lot of energy may be expended to push for wider adoption, the network effect, when I think there should be more focus on desired outcomes from the beginning,” Danis said.

Many states have received Medicaid Transformation Grants from CMS to work on pilot projects that involve technology investments targeting Medicaid patients.

Some states have started to build systems to work with chronic disease populations, and if successful those efforts may become building blocks for broader health data exchange.

“One state we have been talking to wants to address patients who are males over the age of 47 who have diabetes,” Danis explained. By using public health databases, the state can identify that population and see if by expanding broadband access in rural areas and pushing widespread EHR and PHR usage, it can have an impact on patient empowerment both in terms of access to information, and patients taking control of their own health, he said.

Like many others, Danis believes the broader definition of “meaningful use” of health IT will ultimately have to include patient empowerment.

Leveraging IT at the Indian Health Service

Posted on: 6.3.2009 2:24:17 PM

From the department of shameless self-promotion, I'd like to point you to an article I recently wrote for a different publication, Public CIO magazine.

I recommend the article, “Government CIOs Diagnose Health Information Technology Options,not because of any great insights of mine, but because I got a chance to interview some very impressive public-sector CIOs about how the sudden increased emphasis on health IT is affecting their work. They include Chuck Campbell, CIO of the Military Health System, and Dr. Louis Capponi, chief medical informatics officer of the New York City Health and Hospitals Corporation.

My favorite conversation was with Dr. Theresa Cullen, CIO of the Indian Health Service (IHS), who described how her interest in technology grew out of her own primary-care practice on the Tohono O'odham Nation reservation in Arizona. Her commitment to the healthcare of the Indian people really came through in everything she said.

As Cullen explains in the article, IHS' fiscal and human-resource constraints forced a recognition that it needed to leverage IT better. She describes the growth of IHS' open source clinical information system called RPMS, including the 2007 rollout of a clinical decision support aid called iCare.

The HITECH Act provides $85 million for IHS to use on health IT, and Cullen talks about the pressure that puts on her.

“It is a very exciting time, but also a burden because we want to leverage these funds in a way that provides good value and helps the Indian people,” she said. “But we also have to be good stewards of the taxpayers' money in terms of application planning.”

She also said that RPMS, because it is open source, is starting to be used in other settings, such as community health centers. Is this a model that could spread? What do you see as potential benefits and/or shortcomings?

Opening Up Certification to Competitors

Posted on: 5.21.2009 9:55:13 AM

Nothing in the current debate over how to proceed on widespread EHR implementation seems to generate as much heat as the issue of certification.

If you do a Google search on the term CCHIT, you very quickly come across articles and blog posts by people who adamantly believe certifying EHR products is wrong-headed or that one organization is being given too much power. Some argue that certification should be focused at the provider level, not the vendor level. Organizations with open source variations or home-grown clinical information systems or ones cobbled together from multiple vendors wonder how they will be assessed.

Others criticize CCHIT's relationship with HIMSS (HIMSS was one of its co-founders and provided seed money, although CCHIT is now an independent entity). Still others say that it favors large vendors, who can create soup-to-nuts offerings, over smaller software companies and entrepreneurs.

One of our own bloggers, Holzer Clinic CIO Mark Harvey, argues that because general adoption rates are still far too low, setting the certification bar high initially is a mistake. “Help us digitize first,” Harvey wrote recently. “More sophisticated functionality will follow naturally.”

I have interviewed CCHIT Chair Dr. Mark Leavitt on several occasions, and he usually makes the case that the organization is evolving to meet the needs of the industry and points to the number of small vendors that have achieved certification.

I like the suggestion of a recent Markle Foundation report that responsibility for certification shouldn't reside with a single organization. The Markle report makes the case for letting a government entity such as the National Institute of Standards and Technology set the core criteria for certification of meaningful-use functionality, and then allowing multiple entities, both public and private, to do the actual certification testing.

“So long as these testing services all work on the same definition, these entities can then compete on their ability to provide value-added services above the minimum requirements,” the report continues. “Once the certification protocols are defined, the door should be left open to a plurality of private certification organizations, including ones like CCHIT, to compete for public and private sector business, as there are now for other IT products and services.”

While it wouldn't address all the criticisms of CCHIT, opening up the process of certification to multiple organizations sounds reasonable to me. It might ease the fears of a monolithic, bureaucratic organization with too much power. I would be interested to hear what others think.

The Markle report goes on to point out that there also must be a validation mechanism. Certification only checks that a system has the capability to help an organization achieve the meaningful-use objectives. HHS must now develop mechanisms to determine whether organizations are using it in that fashion.

Making sure those reporting schemes and attestations are not a huge burden on clinicians and CIOs will be a massive challenge.

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