Aetna Avant-Garde.

When I first started in health IT, I noticed that the people who used Twitter were the cool kids. So, in 2012 I made an egocentric New Year’s resolution to exceed an arbitrarily “cool kid” threshold of 100 Twitter followers. Since I’m a fan of efficiency, I decided that the best way to do this was total automation. I found a tweet scheduling platform and used an excel spreadsheet to schedule all of my tweets for the entire week on Sunday as if I was a company engaged in a massive PR effort. Over the next few months my following barely increased. I had no idea what I was doing wrong; by all accounts, my tweets were perfect - filled with descriptive words, hashtags, and links. When the HIMSS annual conference rolled around, I attended my first tweetup and people went around and introduced themselves and said why they joined Twitter – one person’s comment stuck with me – they joined because they “wanted to be part of the conversation.” Who said this? None other than Wen Dombrowski, @HealthcareWen, last year’s #HIT100 champion.  If people wanted a feed of cool articles they’d just follow Kaiser Health News or Histalk on twitter. The real value add is finding people who think the way you do (or, better yet, think opposite of you). So yes, formulaically my tweets were perfect – but they weren’t interactive. Turns out that interacting is actually what Twitter is about - relationships, not mindless self-promotion.


Ready to join the conversation and need some people to follow? Here’s some of my favs:

In a League of her own: Wen Dombrowski (@healthcarewen)

  1. Feds:
    1. Feds: Steven Posnack (@HealthIT_Policy),  Claudia Williams (@claudiawilliams), Ryan Panchadsaram (@rypan)
    2. Fed Translators: Brian Ahier (@ahier), John Halamka (@jhalamka), Mandi Bishop (@MandiBPro)
    3. ONC Alums: Rebecca Coelius (@RebeccaCoelius), Sherry Reynolds (@cascadia), Ross Martin (@RossMartin, of @Acmimimi fame), Lygeia Ricciardi (@Lygeia), Sachin Jain (@SacJai)
  2. The Technical Side: Erik Pupo (@erikpupo), Keith Boone (@motorcycleguy), Chad Johnson (@ochotex), Mark Silverberg (@skram), Greg Norman (@Raelshark), Leah Vaughn (@HealthPolicyGrp)
  3. Startup Buzz: Startup Health (@StartupHealth), Rock Health (@Rock_Health), Brian Dolan (@mobilehealth).
  4. Straight Shooters:  Matthew Holt (@boltyboy), John Moore (@john_chilmark), Henry Wei (@henryweimd)
  5. Public Health Mavens: Michelle Holshue (@PHNurseMichelle), Whitney Zatzkin (@MsWz), Nina Jolani (@ninajtweets, runs #phtweets chat under @PublicHealthTalks).
  6. Big Data Evangelists:  Aman Bhandari (@ghideas), Fred Trotter (@FredTrotter), John Brownstein (@johnbrownstein).
  7. #TheWalkingGallery: Regina Holliday (@ReginaHolliday), Ted Eytan (@TedEytan), Donna Cryer (@dcpatient), Erin Gilmer (@GilmerHealthLaw), Anna McCollister-Slipp (@AnnaMcSlipp), Amy Gilmer (@ThePatientSide)
  8. Practicing Physicians: Wendy Sue Swanson (@SeattleMamaDoc), Dirk Stanley (@dirkstanley), Jen Dyer (@endogoddess).
  9. Famous Physicians: Farzad Mostashari (@Farzad_MD and, of course, @FarzadsBowtie), Eric Topol (@EricTopol), Atul Gawande (@Atul_Gawande)
  10. Leaders: Margaret Cary (@Boundroid), The #HCLDR Team - Lisa Fields (@PracticalWisdom)/Colin Hung @Colin_Hung), Gregg Masters (@2healthGuru), Pat Masters (@DocWeighsIn)
  11. Transformers: Leonard Kish (@leonardkish), Susannah Fox (@SusannahFox), Jane Sarashon Kahn (@healthythinker).
  12. Some Quirky Non-Health Related Follows: Guy Kawasaki (@GuyKawasaki), Boing Boing (@BoingBoing), and Crumpy Gat (@CrumpyGat).

Need a little Twitter 101? Here ya go:

  1. @ signs are put in front of user names to mention them in tweets. Follow people you think you’ll be mentioning often so twitter knows to autocomplete the username.
  2. Brevity is king. You have 140 characters, use them wisely. Resist the urge to use strange abbreviations. (Example: you want to use the word “atrocious” but it won’t fit, so use “bad” instead. Don’t try to abbreviate it “atrocs”).
  3. Make sure to use #Hashtags at conferences – search by hashtag to figure out who else is there and meet up in person. Check out symplur.com for a list of commonly used healthcare hashtags.
  4. Favorite things (clicking the star button) you want to find later. I usually favorite things when I don’t have time to read the link someone posted but want to eventually and/or someone says something nice about me that's nice to remember).
  5. While retweeting is nice, adding something to the tweet is even nicer. Unfortunately you can’t do this in the Twitter browser without a third party app like Buffer. If you use an iPhone you can click “quote tweet” and add to the conversation. Even if you retweet without modifying tweets you’re still broadcasting the information to your audience which spreads the content.
  6. A lot of people like Direct Messaging (DM). Personally I find it annoying because the Twitter messaging service is a little janky and only works half the time. Use at your own risk.
  7. It’s good practice to reply to people who mention you and thank them. A lot of people thank people for retweeting or following them. I don’t usually do this, but I probably should. Sorry Twittersphere…
  8. When you write your bio you get 160 characters, not 140. Use the extra characters to add a “Tweets are my own.” Many companies have social media policies require a statement like this. Even if yours doesn’t currently, it probably will, so get ahead of the game and disclaim!
  9. Don’t be a creeper – make sure you upload a profile picture.
  10. Join the conversation.

 

 

TeamJessBanner

 

In putting together my story to become a member of The Walking Gallery, I started thinking about all the people who have helped me out since I got sick. Maybe they helped me out physically, maybe emotionally. All I know is that all of these people were there for me. Most of them were there for me multiple times. Some stayed up with me all night. Some pushed me to get help. Some listened to me complain, cry, and laugh. And I know that without this cast, I wouldn't be who I am today.

So, everyone, thanks -- you prove that the heart of life is good.

 

 

The Home Fries

 

The people who understand where I come from. It’d been years, yet when I got sick, they called, sent flowers, and visited. They don’t pick me up off the ground, but they’re always only a phone call away.

My Girls1. The Sister, 2. The Mother

My Boys3. The Father 4. The Brother 5. Becky, 6. Bissie, 7. Jessie, 8. Ryan

 

The Cal Kids

suzie

9. Suzie

From the beginning of college through the present, no matter what the issue is, they listen to me, laugh with me, and pick me up when I fall.

viv matt

10. Stephanie, 11. Vivian, 12. Matt

Or they send their parents, or their boyfriend, or their boyfriend’s friend. Basically they’re hyphy rockstars who stood by me before I got sick, stood by me when I got sick, and stand by me to this day.

Sonja Nayeli13. Sonja (14. Tal), 15. Nayeli

Amanda

16. Amanda

havah steph

17. Havah (18. Jason), 19. Stephanie,

AGO ADX20. Stephanie, 21. Carrie, 22. Laura, 23. Arri, 24. Susan, 25. Laurelei, 26. Erin, 27. Carissa, 28. Amanda, 29, Carla, 30. Sarah, 31. Andrea, 32. Emma, 33. Peter, 34. Dave, 35. Jared, 36. Mark, 37. Bryson

At Cal, it’s hard to have real relationships with your professors, your GSIs, your classmates. You’re one in 500 students. But when you fall over, these barriers somehow disappear. My bioethics professor offered to be my medical advocate and call my parents. My social psych professor took me to the student health center in a police car. My GSIs took me home and didn’t freak out too much when I got pulled out of their classes by EMTs. My classmates told me their personal stories, walked me home, and ran the interference required to keep me out of the hospital. Then I worked at a homeless resource center, and, of course, I had my own contingent of the tribe.

gorcey

38. Max, 39. Lev, 40. Ryan, 41. Ben, 42. Joe, 43. Andi, 44. Neil, 45. Steven, 46. Eric, 47. Emilie, 48. Chad, 49. David, 50. David, 51. Diva, 52. Robb, 53. Dylan, 54. Olivia, 55. Kevin, 56. Kristen

 

The Georgetown Crew

I know I owe my masters degree to my cohort at GU - they ensured that I graduated with some cognitive surplus intact. They stole a wheelchair (we returned it... eventually...), drove me home, tucked me into bed, picked me up in weird places, took me to the hospital and waited for hours, staged an intervention, rescued me from water, were my chauffeurs, and caught me when I fell.

Dantana

57. Karen, 58. Veronica, 59. Erin, 60. Dantana, 61. Zach, 62. Veronica, 63. Ashley, 64. Matt, 65. Chris, 66. Matt, 67. Anthony, 68. Betelle, 69. Elliott, 70. Hooman, 71. Jennifer, 72. Kyle, 73. Laura, 74. Maria, 75. Sarah, 76. Stephanie, 77. Charlotte, 78. Haymi, 79. Heather, 80. James, 81. Alice, 82. Alex, 83. Dr. C, 84. Dr. H, 85. Amy, 86. Miriam, 87. Michelle

Phil

88. Phil

ekat
89. Ekat

 

The Feds

For a crew that wears suits all the time, they’re surprisingly protective. From the ONC to HRSA to the FDA, these people were amazing.

90. Wil, 91. Farzad, 92. Lanre, 93. Sachin, 94. Andrea, 95. Sameer, 96. Yael, 97. Marty, 98. Miryam, 99. Robyn, 100. Ian, 101. Mike, 102. Rose, 103. Mary Beth, 104. Georgie, 105. Lori, 106. Jim, 107. Jill, 108. James, 109. Adam, 110. Damon, 111. Aman, 112. Alina, 113. Alon, 114. Mary, 115. Doris, 116. Amy, 117. Gary, 118. Sasha

hhs

High Fives

High Fives

119. Alicia

randi120. Randi

The Law Kids

I was scared that when Amanda left and I wasn’t with the GU kids everyday I’d be alone. That I wouldn't have a person anymore. Nothing could be further from the truth. These people adopted me into their family and are there for me as if I had always been a member of the crowd. Even though I’m not an attorney.

121. Brad, 122. Marie, 123. Gabe, 124. Shaun, 125. Michelle, 126. Sam, 127. Natalie, 128. Laura, 129. Navin, 130. Kathleen

OLYMPUS DIGITAL CAMERA

 

 

The Walking Gallery (and Twitterati)

ted regina131. Regina, 132. Ted,
These people gave me a voice to speak out about being a patient. They helped me discover telling your story is one of the most empowering things you can do.

Whitney133. Whitney (and 134. Jake)

Rebecca135. Rebecca
gallery 136. Nikolai, 137. Wen, 138. Tiffany 139. Lisa, 140. Matthew, 141. Fred, 142. Alan, 143. Gregg, 144. Leonard, 145. Alan, 146. Amy, 147. Brian, 148. Diana, 149. Kait, 150. Greg, 151. Christine

 

The Entrepreneurs

And we have all the technophiles.Some are health, some are not. All want to make the world a better place.

152. Katie, 153. Dhruva, 154. Dave, 155. Marco, 156. Kyle,157. Adam, 158. Henry, 159. Jamie, 160. Michael, 161. Andre, 162. Polina, 163. Anish, 164. Adam, 165. Lygeia, 166. Raph,

Marvin167. Stephanie, 168. Marvin

 

The Alturists

And last, but certainly not least, we have all the people who took me in and really had no idea what they were getting into. I can never thank you enough for all the love and care you all have shown me.

Donna and Dennis

 

169. Donna, 170. Dennis

 Konstantin171. Konstantin

 Leonard172. Leonard
Kelli171. Kelli

This morning I had the opportunity to present on federal mHealth Policy at #HIMSS13. It was totally a great time and people had some amazing questions. Most of which I hoped I answered...

 Policy Continuum

 Download the slides here. 

“Are your eyes closed?”
“No”
“Yes they are. Jess, why do you lie? It scares me when you lie.”
…“Wait, what?”
“You’re going to fall.”

And, like clockwork, I fall, semiconscious to the sidewalk on the corner of Pennsylvania and Constitution.

Somewhere above me someone is concerned. “Is she ok?” “Yes” “No, really, is she ok?” “Yes, she has a heart problem.” “Really? Is she ok?” “Yes, I’ve got this.” “You’re sure?” “I’m sure.” Yes, lady, he has this. He always has it. No matter how embarrassed he is. No matter how inconvenienced he is. He has this.

So, what’s wrong with me? Postural Orthostatic Tachycardia Syndrome. POTS. What’s that mean? It means that sometimes when I stand, my heart rate doubles, my blood pressure drops, and I pass out.

Apparently most people grow out of this. But I’m not most people. I’m 25. I’ve had POTS since, if I’m honest, I was about 9. When I finally got it diagnosed at 21, my condition became legitimate. I’ve seen the statistics; the odds that this goes away after fifteen years are almost nonexistent. I won’t die, but sometimes I’ll want to. As my cardiologist put it, “I’m [his] problem.” I’m the one he can’t fix. But that makes sense. I have an idiopathic condition. It lies somewhere between the heart, autonomic nervous system, and mind. It’s a veritable no-mans land of drugs and specialists where there’s no cure and very little understanding.

During my last “bad” episode, my friend called to check up on me: “Jess, if they make you go to the hospital I’m not going to fight them. Plus, isn’t that what you do?” No, that isn’t what I do. Yes, I have a degree in Health Systems Administration. Yes, I’m an “expert” on Health Information Technology. But that doesn’t change the fact that I’m a horrible patient. That I carry my medical records around with me in a hot pink binder. That I hate hospitals.

And I always have. If I had my way, I’d keep everyone out of them. It’s why I “do” health IT. See, I’ve been in lots of hospitals - from community hospitals to major academic medical centers. They're filled with well intentioned, highly trained, people. Unfortunately the mechanisms these care facilities have put in place don't actually connect the people within, let alone between, instances of care.

I used to think I’d trade anything for perfect health. Now, I don’t know if I would. See, I’m happy. I have people. I have a future. And I know that my life has been influenced by my sickness. Without it, I wouldn’t understand. I wouldn’t understand powerlessness. I wouldn’t understand frustration. I wouldn’t understand that the system is broken.

How broken?  During one stay, despite my credentials, I ended up semiconscious at the bottom of a flight of stairs, in tears, begging to go home. See, in the moments I’m a patient, I can’t manage my life. And, despite their credentials (on this visit: a MD/MBA, a MPH, and three MHSAs), my friends can’t manage it for me. Can you imagine someone without this support system navigating the bureaucracy that is healthcare? I don't know how they do it.

Luckily this is only one side of my coin— I’m healthy enough to have a day job advising the people that chart the course of American health policy. The philosopher Herodotus got it right: “the greater the man, the greater the misfortune,” or, as our friend Peter Parker put it “with great power comes great responsibility.” I know that the weaker I get, the stronger I become. The weaker I get, the more I understand that my care continuum isn't the only one with flaws. The weaker I get, the more I understand that together, we can change our health system. That the whole is greater than the sum of its parts.

Back under the glow of the US Capitol, I hear my friend:

“Jess, you’re broken. But I’m broken too. We’re all broken.”
“You think that together we make a whole person?”
“Yeah, Jess, together we’re a whole person.”

And with that, he picks me up. And carries me home.

http://i2.wp.com/mw2.google.com/mw-panoramio/photos/medium/56925708.jpg?w=630

This is the story behind my Walking Gallery Jacket: "Is She Alright"

8197658371_d50573660a

EMP_Wil

Social psychology shows that if you say thanks you're happier. Recently, Georgetown asked me to write a piece on my mentor-mentee relationship during grad school. You might know that I was an Innovation Fellow at the Office of the National Coordinator in 2010. While I was there, Special Assistant Wil Yu became my "Health IT and Innovation 101" guide. I definitely owe my health IT know-how to Wil and am certain that working with him changed the trajectory of my career (for the good!!!). Here's what I submitted to GU, it's a puff piece, but I think the gratitude comes through (their slightly modified post can be found here) (more…)

As you know - Meaningful Use Stage Two posted this week! Whoo hoo! There were a few changes from stage one and but from where I sit, it looks like things are aligned rather well. I did a summary of the NPRM (copy/pasted below (download it with pretty graphics here)), and also distributed by HIMSS. It's a pretty complete summary and highlights the differences between stage one and two. The only thing I didn't consider was the incentive/penalty structure. I'm not about to get into the business of telling people where the money's at!



HIMSS

HIMSS

Summary

The 2009 American Recovery and Reinvestment Act (ARRA) authorized incentive payments for the Meaningful Use of Electronic Health Records (EHR) through Medicare/Medicaid. This document is a high-level summarization highlighting the differences between the objectives in the Notice of Proposed Rule Making for Stage Two[i] and the Stage One Final Rule.[ii] CMS is “soliciting public feedback on several mechanisms for electronic CQM reporting, including aggregate-level electronic reporting group reporting options; and through existing quality reporting systems.”
Stage Two:

  • Eligible Providers (EPs): 17 core objectives, and 3 of 5 menu objectives
  • Eligible Hospitals and Critical Access Hospitals (EH/CAH): 16 core, 2 of 4 menu objectives

 This differs from Stage One:

  • EPs had 15 Core Objectives, 5 of 10 Menu Objectives, and 6 CQM.
  • EH/CAH had 14 Core Objectives, 5 of 10 Menu Objectives, and 15 CQM.

 

Timeline & Reporting

Reporting:

  • EPs: Calendar Year; EH/CAH: Federal Fiscal Year
  • 1st Year of MU (Stage One): Reporting Period is 90 days; Submission period is any time up to 2 months following the end of reporting period’s year
  • All other years of MU (All Stages): Reporting period, 1 year; Submission period, 2 months following the end of the reporting year

 Timeline:

The table below shows which Stage of Meaningful Use providers will need to achieve to receive incentive payments based upon their starting year.

First Payment Year

Payment Year[iii]

2011

2012

2013

2014

2015

2016

2017

2018

2019

2020

2021

2011

1

1

1

2

2

3

3

TBD

TBD

TBD

TBD

2012

1

1

2

2

3

3

TBD

TBD

TBD

TBD

2013

1

1

2

2

3

3

TBD

TBD

TBD

2014

1

1

2

2

3

3

TBD

TBD

2015

1

1

2

2

3

3

TBD

2016

1

1

2

2

3

3

2017

1

1

2

2

3

 

Guidelines and Definitions:

  • If a provider submits exclusion criteria for 1 of their menu sets, they are also attesting that they meet the exclusion criteria for all of the menu objectives that they did not select.
  • A Certified EHR must be used for at least 50% of a provider’s population over the entire reporting period. If the EP practices at multiple locations, this will include only patients seen at locations with certified EHRs.
  • Denominators will be one of four things:
    • Unique patients seen by the EP (stratified by age or previous office visit) or EH/CAH (stratified by age).
    • Number of Orders (medication, labs, radiology, imaging, and procedures).
    • Visits/Bed Days:
      • EP Office Visits: any billable visit that includes 1. Concurrent care/transfer of care visits; 2. Consultant visits or 3. Prolonged physician service without direct, face to face patient contact.
      • EH/CAH Inpatient bed days: admission day and each of the following full 24-hour periods during which the patient is in the inpatient dept of the hospital.
      • EPs will have latitude to include or not include telemedicine, minimal consulting services, and double counting (counting patient for both NP/PA and EP in same office).

Objectives

Changes to Stage One Criteria: 

  • This Stage Two rule alters some Stage One criteria – these changes will be optional in 2013 and required in 2014 (except otherwise noted):
    • CPOE: more than 30% of medication orders created by the EP/authorized providers at a EH/CAH are recorded using CPOE.
    • Vital Signs: addition of alternative age limitations (blood pressure will be only applicable for those over the age of three, while height/weight is for all ages) and exclusions (if all vitals, blood pressure, height/weight do not impact practice, provider does not have to record).
    • Exchange Key Clinical Data: Eliminated. Effective 2013.
    • Report CQM: Eliminated. Effective 2013.
    • Patient Electronic Communication: Same as Stage Two.
    • Public Health: Adds “except where prohibited” to language. Effective 2013.

 Differences between Stage One and Stage Two Criteria:

  • All Stage One Menu Set criteria are now in the core set, with the exception of two which will remain in the menu set: submitting syndromic surveillance data (EPs) and recording advanced directives (EH/CAH).
  • State Flexibility: States will continue to be able to specify transmission of data and public health measures so long as it does not require EHR functionality above and beyond that which is included in the ONC EHR certification criteria.
  • Other measures were Consolidated/Eliminated, including:

Consolidated/Eliminated Measures

Consolidated/Eliminated Measure

Logic

Drug/Drug and Drug Allergy Checks Combined into CDS.
Report CQM to CMS or States Completed with QMS reporting section of MU and not necessary as an objective.
Drug-Formulary Checks Combined into eRx
Maintain an up-to-date problem list of current and active diagnoses. Combined into Transition of Care.
Maintain active medication list.
Maintain active medication allergy list.
Provide patients with an electronic copy of their health information. Combined with objectives for online viewing and downloading
Provide patients with an electronic copy of their discharge instructions.
Capability to exchange key clinical information. Removed for Stage 2. Considering options for Stage 1.  Actual use case is more beneficial.


 



 

 

Stage Two

Objectives

Measure

Stage 1

Exclusions

Exclusions/Notes

Policy Priority: Improving quality, safety, efficiency, and reducing health disparities
Use computerized provider order entry (CPOE) for medication, laboratory and radiology orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines to create the first record of the order.  Core, 60%Numerator: CPOE OrdersDenominator: All orders Core, 30% Providers with less than 100 orders. Must be used the first time the order is placed and before any action can be taken on the order.This measure has changed from “% of patients with one order in their EHRs”
EP Only: Generate, Compare to one drug formulary, and transmit permissible prescriptions electronically (eRx).  Core, 65%Numerator:  eRxDenominator: all Rx Core, 40% Less than 100 Rx’s writtenNo electronically connected pharmacy within 25 miles Does not include controlled substances for schedules II-V as many vendor offerings lack the required DEA specifications. Will revisit for MU III.In 2015 the MIPAA eRX program will be phased out for MU.MU Stage One “compare to a drug formulary” menu objective is rolled into this one.
Record the following demographics as structured data
  • Preferred language
  • Gender
  • Race
  • Ethnicity
  • Date of birth
  • Date and preliminary cause of death in the event of mortality (EH/CAH Only)
Core, 80%Numerator:  Patients with all demographic information recordedDenominator: All Patients Core, 50% If the patient refuses to give the information the provider can count that patient in the numerator.
Record and chart changes in vital signs as structured data:
  • Height
  • Weight
  • Blood pressure (age 3 and over)
  • Calculate and display BMI
  • Plot and display growth charts for patients 0-20 years, including BMI
Core, 80%Numerator: Patients with information recordedDenominator: All patients Core, 50% No patients over the age of 3 years old.The provider believes that height/weight or blood pressure have no relevance to their practice
Record smoking status for patients 13 years old or older Core, 80%Numerator: Patients with information recordedDenominator: All patients over 13 years Core, 50% No patients over 13 years old
Use clinical decision support to improve performance on high-priority health conditions Core, Implement 5 CDS rules related to 5 or more clinical quality measures at relevant point.Implement Drug/Drug and Drug/Allergy Interaction Checks. Core, 1 rule Previously Drug/Drug and Drug/Allergy checks was a Core standalone objective.
Incorporate clinical lab-test results into Certified EHR Technology as structured data (either positive/negative or numerical). Core, 55%Numerator: Lab Tests recorded as structured dataDenominator: All Lab Tests Menu, 50% EPs who do not order labs that are in a yes/no or numerical format.
Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach. Generate at least one report listing patients of the EP, eligible hospital or CAH with a specific condition. Menu, 1 list
EP Only: Use clinically relevant information to identify patients who should receive reminders for preventive/follow-up care. Core, 10%Numerator: Number of patients in the denominator who received a reminder during the EHR reporting periodDenominator: Unique patients who have an office visit with the EP in the 24 months prior to the EHR reporting period Menu, 10% No office visits in the 24 months before the reporting period Different from stage one – requires the use of EHR to identify appropriate reminders instead of just sending reminders based on patient preference.
EH/CAH Only: Automatically track medications from order to administration using assistive technologies in conjunction with an electronic medication administration record (eMAR). Core, 10%eMAR is implemented and in use for the entire EHR reporting period in at least one ward/unit of the eligible hospital or CAH. N/A, New Measure A ward or unit is defined having unique staff, patient population, geographic location or function from other IP/ER Departments.
Policy Priority: Engage patients and families in their health care
EP Only: Provide patients the ability to view and download their health information within four business days of the information [labs, imaging, etc] being available to the EP. Core, 50%Numerator: Patients who can access their informationDenominator: Number of Unique Patients Core, 50% within 4 days Providers who provide 50% of their care in areas where 50% of their patients do not have at least 4 Mbps broadband availability
Core, 10%Numerator: Patients who access/download/transmit their informationDenominator: Number of Patient Visits N/A
EH/CAH Only: Provide patients the ability to view online and download information about a hospital admission within 36 hours of discharge Core, 50%Numerator: Patients who can access their informationDenominator: Number of Unique Patients New 50% of patients do not have at least 4 Mbps broadband availability
Core, 10%Numerator: Patients who access/download/transmit their informationDenominator: Number of Patient Visits N/A
EP Only: Provide clinical summaries for patients within 24 hours for each office visit. Core, 50% Numerator: Office Visits with Clinical SummariesDenominator: Office Visits Core, 50% within 3 days No office visits in reporting period
Use Certified EHR Technology to identify patient-specific education resources and provide those resources to the patient. Core, 10% Numerator: Patients provided resourcesDenominator: Number of Unique Patients Menu, 10% No office visits in reporting period
EP Only: Use secure electronic messaging to communicate with patients on relevant health information. Core, 10% Numerator: Patients receiving messageDenominator: Number of Unique Patients New
Policy Priority: Improve care coordination
Medication Reconciliation is performed upon receiving a patient from another setting of care.Most accurate list of all medications that the patient is taking:
  • Name
  • Dosage
  • Frequency
  • Route

 

Core, 65% Numerator: Patients for which MR was performedDenominator: Patients received from another setting of care Menu, 50% It’s unlikely to be an automated process so the electronic exchange of information is not required.“another setting of care” is from outside the organization.
Any provider who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide summary care record for each transition of care or referral. Core, 65% Numerator: TOC with Summary of Care Documents GeneratedDenominator:TOC/Referrals Menu, 50% Not the recipient of any TOC during the reporting period. Includes Eliminated Objectives:
  • Active Problem/Diagnosis List (Core, 50%)
  • Active Medication List (Core, 80%)
  • Active Medication Allergy List (Core, 80%)
Core, 10% Numerator: TOC with SOC generated electronicallyDenominator: TOC/Referrals N/A
Policy Priority: Improve population and public health
Capability to submit electronic data to immunization registries or immunization information systems. Successful ongoing submission. Menu, Test Ability If there are no appropriate agencies/registries to receive the information.If the registry/agency doesn’t accept electronic submissions format/standard specified by ONC’s certification rules.  If an HIE has been delegated to receive information on the agency/registry’s behalf this exclusion is not acceptable.Where prohibited, and in accordance with applicable law and practice. Stage 3 will likely be bidirectional.
EH/CAH Only: Capability to submit electronic reportable laboratory results to public health agencies, except where prohibited, and in accordance with applicable law and practice.
EP Menu; EH/CAH Core:  Capability to submit electronic syndromic surveillance data to public health agencies, except where prohibited, and in accordance with applicable law and practice. Core, Test Ability
Policy Priority: Ensure adequate privacy and security protections for personal health information
Protect electronic health information created or maintained by the Certified EHR Technology through the implementation of appropriate technical capabilities. Core.Conduct a security risk analysis in accordance with the requirements under 45 CFR 164.308


Menu Set Objectives

 

Eligible Providers (EPs): 17 core objectives, and 3 of 5 menu objectives

Eligible Hospitals and Critical Access Hospitals (EH/CAH):  16 core, 2 of 4 menu objectives.

Objectives

Measure

Stage 1

Exclusions

Exclusions/Notes

Policy Priority: Improving quality, safety, efficiency, and reducing health disparities
EH/CAH Only: Record advance directives as structured data for patients 65 years old or older who are admitted to the hospitals inpatient department. Menu, 50%Numerator: Patients with information recordedDenominator: All patients over 65 years Menu, 50% No patients over 65 years
Incorporate imaging results and information into/accessible through Certified EHR Technology.  Menu, 40% Numerator: Incorporated Imaging ResultsDenominator: Imaging Tests/Scans New No tests or scans Does not have to be structured data.Stage three is likely to include the exchange of the data.
Record patient family health history as structured data EHR reporting period for one or more first-degree relatives or an indication that family health history has been reviewed. Menu, 20%Numerator: Patients with Information RecordedDenominator: All Unique Patients New No Office Visits.

Objectives

Measure

Stage 1

Exclusions

Exclusions/Notes

EH/CAH Only: Generate, check against one formulary, and transmit permissible discharge prescriptions electronically (eRx). Menu, 10%Numerator: Rx GeneratedDenominator: Discharge Rx Written New Measure limited to new and changed Rx. Invited comment on whether refilled Rx should be included.
Policy Priority: Improve Population and Public Health
EP Only: Capability to identify and report specific cases to a specialized registry (other than a cancer registry). Successful ongoing submission. New Except where prohibited,  as appropriate to the provider’s practice, and in accordance with applicable law and practice
EP Only: Capability to identify and report cancer cases to a State cancer registry.
EP Menu; EH/CAH Core:  Capability to submit electronic syndromic surveillance data to public health agencies. Menu

Clinical Quality Measures

  • Many measures were put out in the NPRM, only a subset will be finalized.

EP CQM Measures: 125 Potential Measures

Two Options:

  • Option 1a: Select and submit 12 measures from the list of measures; one measure from each domain is required. If a provider’s EHR doesn’t include information for 12 measure, they must submit all of the measures that they can.
  • Option 1b: Report 11 “core” CQM, plus 1 “menu” CQM.
  • Option 2: Submit and satisfactorily report CQM under the Physician Quality Reporting System’s EHR Reporting Option (42 CFR 414.90).

Measures Include:

  • Conditions/Disease Management:
    • Asthma
    • Cardiology: Coronary Artery Disease, Ischemic Vascular Disease, Myocardial Infarction, Heart Failure, COPD, Atrial Fibrillation
    • Dementia
    • Eyes: Cataracts, Glaucoma
    • Hepatitis C
    • HIV/AIDS
    • Joints/Bones: Rheumatoid Arthritis, Osteoarthritis, Osteoporosis, Lower Back Pain, Knee/Hip Replacement
    • Kidney Disease
    • Oncology: General Oncology, Breast, Cervical, Colorectal, Colon, Prostate, Melanoma Diabetes
    • Otitis Externa
    • Psychiatric: Major Depressive Disorder, ADHD, Bipolar Disorder
    • Urinary Incontinence
    • Wound Care
    • Drug Management:
      • Antibiotic Use: Pharyngitis, Bronchitis, Upper Respiratory Infection, Perioperative Care
      • Asthma
      • ADHD
      • Cardiology: Heart Failure, Atrial Fibrulation, Coronary Artery Disease (CAD), Ischemic Vascular Disease (IVD), Myocardial Infarction (MI), Chronic Obstructive Pulmonary Disease (COPD),
      • Depression
      • Diabetes
      • Hypertension
      • HIV/AIDS
      • Kidney Disease
      • Oncology: Chemotherapy/Radiation/Pain, Colon, Breast, Prostate, Prostate
      • Osteoarthritis (OTC Assessments)
      • Perioperative VTE Prophylaxis and Antibiotic Timing
      • Preventative Care:
        • Alcohol/Drug Dependence
        • Antibiotic Use: Pharyngitis, Bronchitis, Upper Respiratory Infection, Perioperative Care
        • Blood Pressure
        • Chlamydia Screening
        • Cholesterol
        • Dental Decay
        • Immunizations: Flu, childhood, pneumonia, HCV, HBV
        • Falls Risk
        • Maternal/Prenatal Care
        • Tobacco Screening
        • Weight Screening
        • Medical Practice:
          • Adverse Event Reporting
          • Complex Chronic Condition Assessment
          • Diagnostic Imaging Reports
          • Medication Reconciliation
          • Specialist Referral Loop Closure
          • Use of High Risk Medications in Elderly


EH/CAH Measures: 49 possible measures

  Two options for attesting:

  • Select and submit 24 measures from a list of 49 measures (all 15 from Stage One are included); one measure from each domain is required.
  • Submit 24 CQM in a manner similar to the 2012 Medicare EHR Incentive Program Electronic Reporting Pilot (Medicare Hospitals Only).
  • Drug Management:
    • Antibiotics: Pneumonia, Perioperative
    • Asthma
    • Cardiology: AMI, HF,
    • Ischemic Stroke
    • Pneumonia (antibiotics)
    • VTE Prophylaxis
    • Disease/Condition Care:
      • Asthma
      • Cardiology: Heart Failure, AMI,
      • Immunizations: Pneumococcal, Flu
      • Ischemic Stroke
      • Labor/Delivery: hearing, elective births, surfactant, complications
      • Surgical: VTE Prevention, Antibiotics, Catheter, Hair Removal
      • Medical Practice:
        • Home Management Plan of Care
        • Emergency Department Throughput
        • PICU Pain Assessments
        • NICU temperatures

[1] Author’s Note:  This summary was based upon publicly available knowledge and does not represent the view of the FDA, HHS, or ORISE. The author was not involved in writing this NPRM; any errors or omissions are solely the author’s. This summary was supported in part by an appointment to the Research Participation Program at the Center for Drug Evaluation and Research administered by the Oak Ridge Institute for Science and Education through an interagency agreement between the U.S. Department of Energy and the U.S. Food and Drug Administration. The author can be reached at jess.a.jacobs@gmail.com.


[i] References to Stage Two of Meaningful Use were taken from the Notice of Proposed Rule Making Released Feburary 23, 2012. http://www.ofr.gov/OFRUpload/OFRData/2012-04443_PI.pdf

[ii]References to Stage One of Meaningful Use were taken from the Final Rule Released July 28, 2010 http://edocket.access.gpo.gov/2010/pdf/2010-17207.pdf

[iii] Taken from the NPRM, Page 28: http://www.ofr.gov/OFRUpload/OFRData/2012-04443_PI.pdf#page=28

2009 Graduate Scholar (Second Runner Up)

In 2004, President George W. Bush set a goal that by 2014 every American should have an electronic health record (EHR). October 1st 2010 marked the government’s foray into the 2011 Fiscal Year -- it is now T-3 years and counting. I have no doubt that every American will have an electronic health record by 2014. And if they don’t, well, they can have one of mine.

As a young person with a medical issue, I have access to upwards of 15 EHRs and their requisite patient portal access. Despite the prevalence of EHRs, I doubt the quality of my care is significantly better. See, my data is stuck in EHRs don’t talk to each other. A few months ago I found myself trying to get care at a well-respected, technologically savvy, teaching hospital. Having not been there before, I attempted to have my medical records sent from another electronically enabled medical center. This task proved impossible and I had to have my friends bring me my hot-pink binder of medical records, which, unfortunately, did not reflect my most recent notes. See, in schlepping my medical records from hospital-to-physician-to-hospital, I had missed a visit. Indeed, it is a pain to ensure that the records are complete, even though many of them originated in EHRs. After all, a paper printout of an EHR is still just paper printout. The point of this anecdote is that if I, a Masters student in Health Systems Administration, cannot figure out the system, neither can your grandmother. This process is not safe or efficient and frustrates providers and patients alike.

2009 estimates show good progress toward President Bush’s goal: 46% of hospitals and 44% of ambulatory providers indicated that they have an EHR. Unfortunately, like my story showed, “adoption” is not indicative of meaningful adoption. When these rates are examined again, fully functional, communicating, EHR systems account for only 1.5% of adoption in hospitals and 6% of adoption in ambulatory providers. I don’t deny that full, meaningful, adoption is difficult -- startup costs are immense, workflow issues prohibitive, the Return on Investment questionable. Anyway the picture is painted, adopting a fully functional EHR is seemingly impossible for all but the largest medical centers. Fortunately, President Obama’s thrown a curve ball with the American Reinvestment and Recovery Act of 2009. Through the Title VII: Health Information Technology for Economic and Clinical Health Act, ARRA promotes the adoption of Electronic Health Records, promising upwards of 20 Billion dollars in incentive payments for the Meaningful Use of EHRs as defined by the Office of the National Coordinator (ONC). Furthermore, it allocates funds to provide assistance in vetting EHR software choices, training workforces, and creating Health IT test-beds.

But these programs are just tools. Indeed, the first step to creating a continuously learning high performing health IT system is to take advantage of these tools and incentives to lay a solid EHR foundation which exchange can be built from. Second, it is time to spend energy not only on adopting EHRs but ensuring that we utilize them in patient centric ways. If patients aren’t engaged by their health information, what is the point? Sure, the physician has a complete record of care and is held responsible by mandatory quality reporting. Sure, with clinical decision support tools and ePrescribing, drug safety increases. But how does a patient know that these functionalities exist, let alone, that they are benefitting their health? If a provider cannot access an aggregated EHR at the point of care, again, what is the point?

Great strides have been made in integrating communities of care with electronic health information. Through the Patient Protection and Affordable Care Act, the Center for Medicare and Medicaid Innovation (CMMI) has been tasked with defining and creating Accountable Care Organizations. These organizations will likely be based off of the Geisinger/Kaiser model and pay based on a capitated system. But what is more important than their payment structure and commitment to provide comprehensive care is their continual commitment to innovation.
This commitment to innovation is exhibited by CMMI’s reception to mobile health technologies. The ability of EHRs to interface with remote medical devices will be groundbreaking. Take, for instance, a diabetic. Currently, a diabetic takes a blood glucose reading and records it by hand. These logs are often illegible and physicians do not have the time to page through them to identify trends. Currently the technology exists to link glucose meter readings to patient records electronically. This link ensures that readings are recorded correctly and allows for physicians to passively monitor a patient’s blood glucose, enabling them to take immediate action when levels fall outside a predetermined range. Furthermore, the system can remind a patient to check their blood sugar and allows the patient to track their progress via an online portal. This application is a prime example of how technology enables effortless patient communication and provider accountability. Pilot studies show that this kind of application is effective; indeed, it is correlated to a reduction of 5 points in blood glucose readings and a 1% reduction in HbA1c readings over a three-month period.

But this level of innovation is not possible so long as we believe that EHRs are simply static repositories of information. Until there is an open flow of information between providers and patients, this level of innovation will remain but a dream. Indeed, patients and providers alike must demand this kind of functionality be reimbursed by payors by proving the tool’s value through consistent utilization and better outcomes. I believe that we can move beyond this dysfunctional Health IT system and into one that is truly patient centered. Have I been drinking the proverbial kool-aid? Probably. But if that’s what gets me to think outside of the “EHR as savior” box and vocalize the need for the engaged exchange of medical information across the continuum of care, pour me another glass. Cheers.

 

 

Note: With this essay I won the distinction of being the 2011 NCHE Graduate Scholar.

Before I went to the reception I sent this picture to a friend telling them that I couldn't wear the "hooker heels" UNLESS I won. If you win you get to wear whatever non-totally-business appropriate shoes you want!

Hooker Shoes

This is a covert shot I took as soon as  I won and sent to my Grandma. Grandmas like images like that. Covert Shot

 

 

Works Cited:
“About ONC.” http://healthit.hhs.gov/portal/server.pt?open=512&objID=1200&mode=2.
Medical Records Privacy Rights. http://www.privacyrights.org/fs/fs8-med.htm
Beacon Partners. Healthcare Leaders Speak up on Where THey are in the EHR Adoption Process. http://www.beaconpartners.com/ehradoption/BeaconPartners_EHR_AdoptionStudy.pdf
NAMCS Data. Accessed May 2010. http://www.cdc.gov/nchs/data/hestat/emr_ehr/emr_ehr.pdf
Jha et al., 2009, NEJM. Accessed May 2010.
NAMCS Data. Accessed May 2010. http://www.cdc.gov/nchs/data/hestat/emr_ehr/emr_ehr.pdf
Yu, Wil. Ambulatory Adoption. July 2010. Office of the National Coordinator for Health Information Technology.
Simon et. Al.” Correlates of Electronic Health Record Adoption in Office Practices: A Statewide Survey.” JAMA. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2215070/
Electronic Health Records and Meaningful Use. http://healthit.hhs.gov/portal/server.pt?open=512&objID=2996&mode=2
HIT Regional Extension Centers. http://www.regionalextensioncenters.com/
Community College Consortia to Educate Health Information Technology Professionals in Health Care Program. http://healthit.hhs.gov/portal/server.pt?open=512&objID=1804&parentname=CommunityPage&parentid=14&mode=2&in_hi_userid=11673&cached=true
Beacon Community Program. http://healthit.hhs.gov/portal/server.pt?open=512&objID=1805&parentname=CommunityPage&parentid=2&mode=2&cached=true
Fact Sheet: Medicare Meaningful Use http://www.cms.gov/apps/media/press/factsheet.asp?Counter=3792&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=6&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date
Hunt et al. JAMA. Effects of Computer-Based Clinical Decision Support Systems on Physician Performance and Patient Outcomes. http://jama.ama-assn.org/cgi/content/abstract/280/15/1339
Lee et. Al. Creating Accountable Care Organizations. NEJM. http://www.nejm.org/doi/full/10.1056/NEJMp1009040
$10B CMS Innovation Center to pilot eCare. http://mobihealthnews.com/7587/10b-cms-innovation-center-to-pilot-ecare/
Bluetooth Blood Glucose Meter Now Interoperable With Nokia Phones. http://www.medgadget.com/archives/2010/04/bluetooth_blood_glucose_meter_now_interoperable_with_nokia_phones.html
Watson et al. “Diabetes Connected Health: A Pilot Study of a Patient- and Provider-Shared Glucose Monitoring Web Application” Journal of Diabetes Science and Technology, March 2009, Volume 3, Issue 2: Page 345-352. http://www.connected-health.org/programs/diabetes/research-materials--external-resources/diabetes-connected-health-a-pilot-study-of-a-patient--and-provider-shared-glucose-monitoring-web-application.aspx