Saturday, September 05, 2009

Electronic Health Record Data Required for Proposed ARRA “Meaningful Use” Standards

•• Update 9/5/2009: Added American Medical Association portal for physician access to HealthVault data to PHR Service Providers, Microsoft HealthVault and Windows Azure section.
• Update 9/4/2009: Added section at end on CMS PHR pilot program and EMR/EHR adoption report from the New England Journal of Medicine; updated limited linkage of RelayHealth to HealthVault. 

Nearly US$1.2 billion in economic stimulus grants are available under the American Recovery and Reinvestment Act (ARRA)’s Health Information Technology for Economic and Clinical Health (HITECH) section to help doctors and hospitals use electronic health records according to the Department of Health and Human Services (HHS) Health Information Technology (HIT) Portal.

The portal’s “Meaningful Use” topic page begins by describing the conditions for awarding grants and penalties for not implementing EHR technology:

The American Recovery and Reinvestment Act authorizes the Centers for Medicare & Medicaid Services (CMS) to provide a reimbursement incentive for physician and hospital providers who are successful in becoming “meaningful users” of an electronic health record (EHR).  These incentive payments begin in 2011 and gradually phase down. Starting in 2015, providers are expected to have adopted and be actively utilizing an EHR in compliance with the “meaningful use” definition or they will be subject to financial penalties under Medicare.

The focus on meaningful use is a recognition that better health care does not come solely from the adoption of technology itself, but through the exchange and use of health information to best inform clinical decisions at the point of care.

Meaningful Use Objectives for Engaging Patients and Families with Electronic Copies of Health Data in 2011

The following table is based on the First Iteration of Meaningful Use/User (6/18/2009) and Proposed Revisions to Meaningful Use (7/16/2009) worksheets whose source is pages 5-7 of the HHS’s Meaningful Use Matrix of 7/16/2009 worksheet. It lists the initial 2011 electronic medical record (EMR) and personal health record (PHR) objectives for eligible [health] providers (physicians, et al.):

Health Outcomes Policy Priority Care Goals
2011 Objectives
Eligible Providers
2011 Objectives
Engage Patients and Families

Provide patients and families with timely access to data, knowledge, and tools to make informed decisions and to manage their health.

Goal is to electronically capture in coded format and to report health information and to use that information to track key clinical conditions. Goal is to electronically capture in coded format and to report health information and to use that information to track key clinical conditions.



Provide patients with an electronic copy of their health information (including lab results, problem list, medication lists, allergies) upon request.

Provide patients with an electronic copy of their discharge instructions and procedures at time of discharge, upon request.



Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, allergies)

Provide patients with an electronic copy of their health information (including lab results, problem list, medication lists, allergies, discharge summary, procedures) upon request.



Provide access to patient-specific education resources

Provide access to patient-specific education resources



Provide clinical summaries to patients for each encounter


[Emphasis added.]
Note: Electronic access to and copies of may be provided by a number of secure electronic methods (e.g., PHR, patient portal, CD, USB drive).

2011 Measures of meaningful use include:

  • % of all patients with access to personal health information electronically
  • % of all patients with access to patient-specific educational resources
  • % of encounters for which clinical summaries were provided (eligible providers only)

Care Goals for 2013: Guide and support care processes and care coordination

  • Offer secure patient-provider messaging capability
  • Provide access to patient-specific educational resources in common primary languages
  • Record patient preferences (e.g., preferred communication media, advance directive, health care proxies, treatment options)
  • Documentation of family medical history
  • Upload data from home monitoring devices

2013 Measures of meaningful use include:

  • Additional patient access and experience reports using NQF-endorsed HIT-enabled quality measures
  • % of patients with access to secure patient messaging
  • % of educational content in common primary languages
  • % of all patients with preferences recorded
  • % of transitions were summary care record is shared
  • Implemented ability to incorporate data uploaded from home monitoring devices

Care Goals for 2015: Achieve and improve performance and support care processes and on key health system outcomes

  • Access for all patients to PHR populated in real time with data from EHR
  • Patients have access to self-management tools
  • Electronic reporting on experience of care

2015 Measures of meaningful use include:

  • % of patients with full access to PHR populated in real time with EHR data
  • NPP quality measures related to patient and family engagement

ARRA’s and HHS’s “carrot and stick” approach and the 2015 deadline for implementation of PHR-friendly EMR systems by eligible providers and hospitals assures a well defined market for PHR service providers.

Peter Pollack’s Stimulus Plan Will Stimulate EMR Adoption, CBO says article of 7/26/2009 for Medical Practice Trends reports:

According to a recent report from McKinsey, the US Congressional Budget Office (or CBO, always described by the media as “non-partisan”) predicts that the stimulus incentives for EMR adoption will have a significant effect on medical practices in this regard, as compared to projections without the incentives.

Part of this is due to the fact that the incentives, which may amount to as much as $44,000 per physician, would more than cover installation costs of an EMR system, particularly for web-based type systems. These systems, known as ASP (application service provider) or SaaS (software as a service), generally incur less up-front costs since they do not require on-site hosting servers and their associated infrastructure but rather reside on the vendor’s servers.

The CBO also predicts that adoption rates under the stimulus incentives will climb to 90 percent by the year 2019. The slice of the stimulus pie earmarked for healthcare IT is $40 billion. And while physicians will realize many benefits from the use of EMR, the main beneficiaries are expected to be medical payers, since the expected decrease in both healthcare costs and medical errors will improve profitability. …

InformationWeek Analytics offers a multipart Analytics Alert by Marianne Kolbasuk McGee: E-Health - One Step Closer To All Those Stimulus Bucks of July/August 2009 (site registration required) which covers the following topics:

  • Meaningful Use: The Details Worked Out
  • Obama’s Health IT Czar On Strategy And Incentives
  • Will New Certification Criteria Fuel Open Source E-Health Records?
  • E-Health Records Planned Despite Stimulus Uncertainty
  • GE Offers Stimulus Loans To Bolster E-Medical Records
  • CIO Will Advise Feds On $20 Billion Health IT Bill
  • Health IT Adoption Still Faces Big Challenges
  • Health Care IT Gets Dragged Into The 21st Century
  • Stimulus Package Aims To Spur Adoption Of E-Health Records

Evan Steele’s EMR Reform: A Plan to Spur Adoption post of 9/2/2009 includes a chart showing Desire to Participate in Government Stimulus Program as a function of familiarity with Meaningful Use requirements and contends:

The barriers to EMR adoption are not problems that government incentives can even begin to remedy. What is needed to truly drive adoption is major healthcare IT reform. Transparency and full disclosure must be introduced in order for market forces to work and for widespread adoption to occur.

Evan Steele is CEO of SRSoft, an EMR software vendor.

PHR Service Providers, Microsoft HealthVault and Windows Azure

•• Nicholas Kolakowski reports Microsoft and AMA Collaborate on HealthVault on a 6/17/2009 eWeek DevSource article:

… Microsoft is collaborating with the American Medical Association, allowing physicians to access patient records stored on Microsoft's HealthVault application via a Web-based portal. That portal, currently being beta tested, will be launched in early 2010.

The AMA is developing the portal with Covisint, a subsidiary of Compuware. HealthVault contains self-reported patient health information, which physicians will be able to access from the point of care through the portal. The portal will allow for personalized content, search capabilities and networking opportunities. …

Covisint lists its Physician Collaboration Center in HealthVault’s Web Application Directory, but there’s no mention of the AMA in the Center’s description.

PassportMD and RelayHealth are Microsoft HealthVault front-end (Web application) solution providers: PassportMD, RelayHealth. HealthVault uses Windows Azure for secure storage of personally identifiable medical data subject to HIPAA privacy requirements, according to Mary Jo Foley’s Microsoft HealthVault service sheds its beta tag post of 9/2/2009.

Barbara Duck’s Kaiser Permanente Talking Tachnology post of 9/1/2009 to the Medical Quack blog observes [emphasis Barbara’s]:

If you haven’t seen this yet, Kaiser is talking technology for patient care in their latest commercials.  Kaiser has been the forerunner in using technology combined with patient care.  In the related reading below are some additional examples.  Over 3 million people are now using “My Health Manager” the personal health records program from Kaiser, that also integrates with Microsoft HealthVault, which could really be very valuable if you are seen at a facility and by a clinician who is out of network as you could provide your entire saved record.  With all the technology Kaiser has, it leads me to ask this? 

Why Doesn’t Anyone in Congress or at the AMA Talk about their Healthcare – Do They Use Any New Technology Themselves, like a Glucose Meter or a PHR – Magpie Healthcare?

Robert N. Mitchell’s Improved Quality and Efficiency through a PHR article of 8/26/2009 for the Advance for Health Information Executives site reports:

Electronic patient records are important to the cause of advancing quality and efficiency, federal government leaders say. So, when, New York Presbyterian Hospital's personal health record (PHR) launched earlier this year, there was a huge media splash, because the hospital was reportedly the first in the country to implement a PHR portal. …

For their part, New York Presbyterian Hospital leaders believe the system -- including its software and technology platform -- is the first of its kind to be launched by a major health system, and the only such system that provides security, privacy and portability to patients from all walks of life.

The PHR also made a splash in health IT circles because of its technology platform -- Microsoft's HealthVault and Amalga technologies. HealthVault's open, security-enhanced platform allows users to create a Web-based account that can store several sets of medical records from across the health ecosystem - anything from blood tests to CAT scans, for an individual or an entire family's medical history - enabling improved health management. Amalga aggregates large amounts of clinical, administrative and financial data from disparate information systems, what are commonly referred to in health IT as "silos." Hospitals commonly have more than 100 disconnected silos of data at any given time. …

The My CVS/pharmacy Prescriptions Web application “allows you to link your CVS/pharmacy prescription records to your Microsoft HealthVault account, so that you can safely and easily manage your prescription information.”

Russel Redman reports in his Walgreens enlists HealthVault for online Rx histories article of 6/4/2009 for Chain Drug Review:

Walgreen Co. plans to offer pharmacy customers online access to their prescription drug histories through Microsoft's HealthVault platform.

Plans call for Walgreens to begin offering the service later this year.

Registered users already can access their  prescription histories for refills, tax purposes or personal use, the drug chain said. Patients who enroll in the new service will be able to securely add their Walgreens prescription histories to HealthVault, and the information will be automatically updated daily. Users will then be able to share their most up-to-date health information with their providers, helping them to get the most benefit from their drug therapy, according to Walgreens.

It’s not clear from current Web-based information about PassportMD or RelayHealth how these Web applications display or share independently added HealthVault information. It’s possible to enable synchronizing data entered in PassportMD with HealthVault data for a specific account but the process isn’t intuitive.

RelayHealth provides the following HealthVault services:

  • Blood glucose data pulled from HealthVault
  • Blood glucose data charting and graphing
  • Secure online messaging with your healthcare provider

Two way synchronization isn’t provided.

Joseph Tartakoff’s What will the stimulus do to Microsoft's HealthVault? post to the Seattle Post-Intelligencer’s Microsoft Blog recounts a March 2009 interview with David Cerino, general manager of the consumer health solutions group at Microsoft.

Centers for Medicare & Medicaid Services Personal Health Record Pilots and PassportMD

Meaningful use of an EMR by patients and families requires the capability to import health insurance claim data to establish accurate historical treatment records.  From the Centers for Medicare & Medicaid Services (CMS) Personal Health Records Overview page:

Since 2006, the Centers for Medicare & Medicaid Services (CMS) has been engaged in a number of pilot projects to encourage Medicare beneficiaries to take advantage of Personal Health Records (PHRs).  These tools, usually available through the internet, can help people track their health care services and better communicate with their providers.  The type of Personal Health Records CMS has been testing are populated with health information from Medicare claims data.  In the future, these records may be able to get information from a provider's electronic health record system, and some provider's may begin to allow patients to see the information directly from those electronic records. …

CMS Personal Health Record Pilots in South Carolina, Arizona, and Utah

CMS is currently conducting two pilots.  One called MYPHRSC in the state of South Carolina, and one called Medicare PHR Choice, in Arizona and Utah. …

Medicare PHR Choice is a pilot program for people with original Medicare residing in Utah and Arizona.  People with Medicare in those states may choose one of the participating PHRs and authorize Medicare to populate it with their Medicare claims data.  The Medicare PHR Choice pilot will continue through December 31, 2009. 

PassportMD is a participant in PHR Choice for Medicare recipients Arizona and Utah. PassportMD’s services are available at no charge to all Medicare recipients. Here’s a link to a Personal Online Health Records: Interview with CEO Steven Hacker at Microsoft Connected Conference article of 7/30/2009, which offers a 16:21 audio interview and text summary.

John Moore’s Quick Survey – CMS PHR Pilot: No Money, No Play post of 8/15/2008 notes the reluctance of PHR and Personal Health Platform (PHP) vendors to participate in the pilot without federal funding. His recommendation:

It is time for the government to stop trying to do this on the cheap and start leading by example. Let’s move beyond roundtable policy talks, promoting certification of PHRs, talking about privacy ad nauseum (this is NOT the primary issue holding back adoption, delivering value to the consumer is), all things that really do not cost the government anything.

Rather, lets see the government itself begin investing in the concept by putting some real money down, cold hard cash, and placing a few bets.

They can begin by sponsoring research that will look at the real issues regarding adoption of PHRs. As there are a number of PHRs in the market today, let’s start by taking a closer look at what is working, what is not, who is adopting, who is not, etc. Sure, there have been a few reports here and there that attempt to address  some of these questions but none have been comprehensive nor have the rigor of say the recently published EMR adoption report [Electronic Health Records in Ambulatory Care — A National Survey of Physicians] of NEJM. Such a study will prove invaluable as it can establish an adoption baseline upon which future policy initiatives are structured to address the real adoption challenges.  This report may also prove quite valuable in educating the consumer as well as addressing concerns within the physician community.

John Moore is Chillmark Research’s principal analyst. Chillmark specializes in PHR and PHP markets.

Following is the abstract of Electronic Health Records in Ambulatory Care — A National Survey of Physicians by Catherine M. DesRoches, Dr.P.H., Eric G. Campbell, Ph.D., Sowmya R. Rao, Ph.D., Karen Donelan, Sc.D., Timothy G. Ferris, M.D., M.P.H., Ashish Jha, M.D., M.P.H., Rainu Kaushal, M.D., M.P.H., Douglas E. Levy, Ph.D., Sara Rosenbaum, J.D., Alexandra E. Shields, Ph.D., and David Blumenthal, M.D., M.P.P. from the New England Journal of Medicine, Special Article, June 3, 2008:

Background Electronic health records have the potential to improve the delivery of health care services. However, in the United States, physicians have been slow to adopt such systems. This study assessed physicians' adoption of outpatient electronic health records, their satisfaction with such systems, the perceived effect of the systems on the quality of care, and the perceived barriers to adoption.

Methods In late 2007 and early 2008, we conducted a national survey of 2758 physicians, which represented a response rate of 62%. Using a definition for electronic health records that was based on expert consensus, we determined the proportion of physicians who were using such records in an office setting and the relationship between adoption and the characteristics of individual physicians and their practices.

Results Four percent of physicians reported having an extensive, fully functional electronic-records system, and 13% reported having a basic system. In multivariate analyses, primary care physicians and those practicing in large groups, in hospitals or medical centers, and in the western region of the United States were more likely to use electronic health records. Physicians reported positive effects of these systems on several dimensions of quality of care and high levels of satisfaction. Financial barriers were viewed as having the greatest effect on decisions about the adoption of electronic health records.

Conclusions Physicians who use electronic health records believe such systems improve the quality of care and are generally satisfied with the systems. However, as of early 2008, electronic systems had been adopted by only a small minority of U.S. physicians, who may differ from later adopters of these systems.

David Blumenthal, MD is the Obama administration’s National Coordinator of Health Information Technology.

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