Massachusetts is creating an ecosystem which enables providers, patients, and payers to exchange health information with patient consent at low cost using Meaningful Use Stage 2 standards. It goes live October 15.
We're also encouraging innovative companies to create applications that will empower healthcare stakeholders using this newly freed data. Our upcoming Healthmart Conference and Datapalooza will showcase these efforts.
The HealthMart Conference, Trade Show, and Datapalooza will be held on October 2-3 at the DCU Center in Worcester. Day one will address the topics of EHR deployment, accountable care, mobile health, and analytics. Day two will be the Datapalooza, which is a competition among innovators to develop apps and products using federal health data, and I will be one of the judges. Attendee, Datapalooza contestant, and vendor registration are now open at the Massachusetts Health Data Consortium's website. Contestant registration is now free!
The Citizens of Unity Farm
I'm on vacation this week, introducing new livestock to our farm. We now have our full complement of animals:
2 Great Pyrenees mountain dogs
8 alpacas
1 llama
13 chickens
22 guinea fowl
2 rabbits
2 cats
Here's a brief introduction to the citizens who have recently moved in.
Our two Great Pyrenees mountain dogs are livestock guardians for the male alpacas. Bundle is a 9 month old female from Rosasharn farm in Rehoboth, MA
Shiro is a 9 week old male from a breeder in New Gloucester, Maine who also has dogs with Rosasharn bloodlines. Shiro's grandmother is also Bundle's grandmother. Bundle's father is Shiro's grandfather. Although Bundle and Shiro have know each other less than a week, they're already best friends. Bundle is teaching Shiro how to guard effectively. They have boundless energy.
Our 8 alpacas are from Bittersweet Cove Farm in Maine. At Unity, they are separated into two paddocks - 3 males and 5 females. Our males are Stanley (1 year old), Midas (3 years old) and Domino (3 years old). They're very good natured and Stanley likes to rub noses with his humans. Our females are Ella Mae (5 years old), Tinkerbell (4 years old), Persia (2 years old), Daisy Mae (1 year old), and Mocha (7 years old). They have very fine fiber and spend their days enjoying hay and fresh growing orchard grass in the warmth of summer.
Our llama is Black Orchid from Fort Lucas farm in Colrain, MA. She guards the female alpaca vigilantly. She's pregnant and today she'll have her first pre-natal visit from a traveling vet.
We have 12 hens and 1 rooster. Each is named according to their color and personality - we have i.e. Rainbow, Terra, Clover, Silver, Chipmunk, Midnight. Our rooster is named Lucky since we received him as a gift from a farm that prepares roosters for Sunday dinner. Our hens will begin laying very soon.
Our 22 guinea fowl roost in the coop at night but spend their days wandering our property, eating ticks and other high protein foods they find in the forest. They ground flock - moving together a single large group. We have 9 blacks, 11 silvers, and 2 whites. One of the guineas is not able to walk due to a birth defect, but he's a fighter and has learned how to hop along with the flock. Every night one of the large guineas flies down from the rafters of the coop to keep him company.
Our rabbits are 10 years old and share the coop with the chickens. The male is Jack and the female is Annie. They enjoy the scraps of fresh vegetables we bring to the flock - broccoli stems from the garden, corn cobs, and lettuce.
Our cats are also 10 years old. Tigger enjoys sleeping in the sun, while his sister, Lily spends her time exploring the house and looking for small creatures to chase.
Since moving to the farm at the end of April, we've had to build the infrastructure and support systems to keep our barnyard citizens healthy and happy. Picking the right hay, controlling flies, and managing manure are all skills we did not have a few months ago. In upcoming Thursday posts, I'll share all our lessons learned on topics that may be unfamiliar territory for my usual readers!
2 Great Pyrenees mountain dogs
8 alpacas
1 llama
13 chickens
22 guinea fowl
2 rabbits
2 cats
Here's a brief introduction to the citizens who have recently moved in.Our two Great Pyrenees mountain dogs are livestock guardians for the male alpacas. Bundle is a 9 month old female from Rosasharn farm in Rehoboth, MA
Shiro is a 9 week old male from a breeder in New Gloucester, Maine who also has dogs with Rosasharn bloodlines. Shiro's grandmother is also Bundle's grandmother. Bundle's father is Shiro's grandfather. Although Bundle and Shiro have know each other less than a week, they're already best friends. Bundle is teaching Shiro how to guard effectively. They have boundless energy.
Our rabbits are 10 years old and share the coop with the chickens. The male is Jack and the female is Annie. They enjoy the scraps of fresh vegetables we bring to the flock - broccoli stems from the garden, corn cobs, and lettuce.
Our cats are also 10 years old. Tigger enjoys sleeping in the sun, while his sister, Lily spends her time exploring the house and looking for small creatures to chase.
Since moving to the farm at the end of April, we've had to build the infrastructure and support systems to keep our barnyard citizens healthy and happy. Picking the right hay, controlling flies, and managing manure are all skills we did not have a few months ago. In upcoming Thursday posts, I'll share all our lessons learned on topics that may be unfamiliar territory for my usual readers!
Learning More About the New MU Rules
On Thursday, August 30, 2012, from 12p-2p, the National eHealth Collaborative, will host an important webinar led by CMS and ONC experts. I've reviewed the slides and this will be an excellent presentation. To sign up, visit the program website.
Program Description:
The final rules for Meaningful Use Stage 2 and the Standards and Certification Criteria were released on August 23. On August 30, NeHC will host experts on both of these rules to describe the intricacies and answer questions on each rule. NeHC will be joined by Travis Broome from CMS’s Office of E-Health Standards and Services to give an overview of the final rule and answer questions. Travis will also discuss the feedback that was incorporated into the final rule and what this means for those ready to attest for both Stage 1 and Stage 2. Then, NeHC will welcome Steve Posnack, Director of the Federal Policy Division at the Office of the National Coordinator for Health IT (ONC) for an in-depth look at the 2014 Edition Standards and Certification Criteria final rule. Steve will discuss the revised definition for Certified EHR Technology, identify changes from the proposed rule, and give his insight into the next steps.
Faculty:
Travis Broome – Health Insurance Specialist, Office of E-Health Standards and Services, CMS
Steve Posnack – Director, Federal Policy Division, ONC
Program Description:
The final rules for Meaningful Use Stage 2 and the Standards and Certification Criteria were released on August 23. On August 30, NeHC will host experts on both of these rules to describe the intricacies and answer questions on each rule. NeHC will be joined by Travis Broome from CMS’s Office of E-Health Standards and Services to give an overview of the final rule and answer questions. Travis will also discuss the feedback that was incorporated into the final rule and what this means for those ready to attest for both Stage 1 and Stage 2. Then, NeHC will welcome Steve Posnack, Director of the Federal Policy Division at the Office of the National Coordinator for Health IT (ONC) for an in-depth look at the 2014 Edition Standards and Certification Criteria final rule. Steve will discuss the revised definition for Certified EHR Technology, identify changes from the proposed rule, and give his insight into the next steps.
Faculty:
Travis Broome – Health Insurance Specialist, Office of E-Health Standards and Services, CMS
Steve Posnack – Director, Federal Policy Division, ONC
The Meaningful Use Stage 2 Balance
Over the past 4 days many people have written about Meaningful Use Stage 2. Some have said it too aggressive, some have said it is not aggressive enough.
To me, the perfect compromise means that every stakeholder is just a little unhappy but all can live with the outcome.
I believe MU Stage 2 achieves this level of balance.
Complaints I've heard include
*The NPRM required that 10% of transitions of care include electronic transmission of structured data across vendor boundaries. The final rule still requires 10% transmissions but eliminates the requirement for transmission across vendor boundaries, instead noting that a single transition of care must be sent across vendor boundaries or to a test EHR operated by CMS for the purpose of receiving and validating these transactions. Some have said that proprietary HIE within a single vendor product may still persist. My experience in Massachusetts suggests that the care coordination demands of accountable care organizations are creating pressures on vendors to open their platforms to third party analytics, personal health records, and community HIE infrastructures. The Meaningful Use requirement to reconcile problems, meds, and allergies plus the required demonstration of data exchange across vendor boundaries will melt away proprietary silos of data.
*The NPRM required that EHRs support "download and transmit" of DICOM images to third-parties:
"We propose to require EHR technology to be capable of enabling images formatted according to the Digital Imaging and Communications in Medicine (DICOM) standard to be downloaded and transmitted to a third party. We believe this specific capability has the potential to empower patients to play a greater role in their own care coordination and could help assist in reducing the amount of redundant and duplicative imaging-oriented tests performed. In fact, the National Institutes of Health has recently funded activities focused on personally controlled sharing of medical images and published a solicitation notice on the same topic."
The final rule drops this requirement and includes only viewing of image data within the EHR.
"Image results. Electronically indicate to a user the availability of a patient’s images and narrative interpretations (relating to the radiographic or other diagnostic test(s)) and enable electronic access to such images and narrative interpretations."
Although many people will argue with me, I believe that cross organizational internet-based DICOM exchange still needs refinement before making it a certification requirement. If the standards for ubiquitous exchange across EHRs are good enough, then why do third party cloud-based image exchange companies such as LifeImage have so many customers?
I agree that image exchange is important to reduce costs and enhance quality of care. It's a perfect requirement for Stage 3, once EHRs have enabled view capability and the Standards Committee has reviewed existing standards to assess the readiness of existing implementation guides for cross organizational internet-based exchange.
*There have been questions about the protection of patient privacy, given the increased amount of data sharing in MU Stage 2
I think of privacy as maintaining confidentiality per personal preferences.
Per wikipedia's definition of informational privacy
"Medical privacy allows a person to withhold their medical records and other information from others, perhaps because of fears that it might affect their insurance coverage or employment, or to avoid the embarrassment caused by revealing medical conditions or treatments."
Patient accessible audit trails enable the patient to monitor/enforce their preferences for information sharing
Encryption prevents breaches when mobile devices are stolen. Encryption of client devices is required by MU Stage 2
"7) End-user device encryption. Paragraph (d)(7)(i) or (ii) of this section must be met to satisfy this certification criterion.
(i) EHR technology that is designed to locally store electronic health information on end-user devices must encrypt the electronic health information stored on such devices after use of EHR technology on those devices stops."
In addition, given that audit trails record the encryption status of client devices, the Office of Civil Rights can hold individuals accountable for breaches involving non-encrypted client devices. Increased enforcement will lead to increased encryption.
*Some complained about the real world operational impact of the workflow changes implied by MU Stage 2.
The Standards Committee is compromised of world class professionals who implement systems for a living. Their advice (especially that of the Implementation Workgroup) is from the trenches.
My honest opinion is that MU Stage 2 creates stretch goals for vendors, IT departments, and providers, but all are achievable. MU Stage 2 lives up the metric first articulated by David Blumenthal - the escalator should move up fast, but not so fast that people fall off.
Next week I'll met with the BIDMC CEO to finalized my major thematic goals for FY13. I'll tell him that MU Stage 2, ICD10 and Compliance/Regulatory support are my focus for the next year. The change management of implementing so many new applications and workflows will not be easy, but the taking the uphill road often leads to the best views. I believe the MU Stage 2 appropriately balances policy goals, change management realities and clinical quality imperatives.
More Meaningful Use Stage 2 Highlights
Yesterday, I posted a few of the innovative aspects of the ONC Final Rule.
Today, here's my top 10 list of the bolder aspects of the final rule.
1. Hospital labs must provide results to community clinicians in structured electronic format - paper and fax goes away.
2. A requirement for cross-vendor transition of care health information exchange will force functional interoperability by requiring disparate applications to use common content, vocabulary and transmission standards over the wire.
3. "Incorporate" data after receipt of structured documents combined with a requirement for decision support on this data means that healthcare information exchange will become actionable. Structured medication, allergy and problem list data from outside applications will be reconciled, resulting in a patient centered electronic medical home that improves quality, safety, and efficiency.
4. Coded structured data with one set of standards per domain of medicine - problems, meds, labs, smoking status - will be foundational for innovations in decision support and patient education.
5. Backwards compatibility with CCR and CCD so that next generation approaches using consolidated CDA can evolve while still maintaining the ability to receive the older summary formats.
6. Identity reconciliation as a component of information reconciliation. The rule notes "upon receipt of a transition of care/referral summary is the appropriate point at which to verify that the transition of care/referral summary is being attributed to the correct patient." This will require vendors to implement novel patient matching techniques.
7. Patient online access to audit logs of their own view/download/transmit activities. Innovative yes, but it's doable and a great aid to help ensure patient privacy preferences are respected.
8. Quality measures which are based on EHR data elements and can be computed in real time, with standards to report patient level and aggregate data. The rule notes "we have adopted both the HL7 QRDA Category I standard to support a patient level data submission approach and HL7 QRDA Category III to support an aggregate level data submission approach."
9. Data portability via a summary export capability that enables transition from one EHR to another. This eliminates vendor lock in and empowers the market to evolve more rapidly.
10. ICD 10 was included in the final rule for encounter diagnoses. This was important given that the October 1, 2014 ICD-10 adoption deadline was finalized this morning
Each of these 10 items provides potential for innovation by start up companies that could fill functional gaps in enterprise vendor products. The new certification approach will make such gap filling easier than with stage 1.
Also today the folks at the Advisory Board published booked versions of the rules
ONC
CMS
It's not only the most exciting time to be in healthcare IT, but with the requirements above, the most exciting time to be an innovator creating new functionality that does not exist in the marketplace today.
Today, here's my top 10 list of the bolder aspects of the final rule.
1. Hospital labs must provide results to community clinicians in structured electronic format - paper and fax goes away.
2. A requirement for cross-vendor transition of care health information exchange will force functional interoperability by requiring disparate applications to use common content, vocabulary and transmission standards over the wire.
3. "Incorporate" data after receipt of structured documents combined with a requirement for decision support on this data means that healthcare information exchange will become actionable. Structured medication, allergy and problem list data from outside applications will be reconciled, resulting in a patient centered electronic medical home that improves quality, safety, and efficiency.
4. Coded structured data with one set of standards per domain of medicine - problems, meds, labs, smoking status - will be foundational for innovations in decision support and patient education.
5. Backwards compatibility with CCR and CCD so that next generation approaches using consolidated CDA can evolve while still maintaining the ability to receive the older summary formats.
6. Identity reconciliation as a component of information reconciliation. The rule notes "upon receipt of a transition of care/referral summary is the appropriate point at which to verify that the transition of care/referral summary is being attributed to the correct patient." This will require vendors to implement novel patient matching techniques.
7. Patient online access to audit logs of their own view/download/transmit activities. Innovative yes, but it's doable and a great aid to help ensure patient privacy preferences are respected.
8. Quality measures which are based on EHR data elements and can be computed in real time, with standards to report patient level and aggregate data. The rule notes "we have adopted both the HL7 QRDA Category I standard to support a patient level data submission approach and HL7 QRDA Category III to support an aggregate level data submission approach."
9. Data portability via a summary export capability that enables transition from one EHR to another. This eliminates vendor lock in and empowers the market to evolve more rapidly.
10. ICD 10 was included in the final rule for encounter diagnoses. This was important given that the October 1, 2014 ICD-10 adoption deadline was finalized this morning
Each of these 10 items provides potential for innovation by start up companies that could fill functional gaps in enterprise vendor products. The new certification approach will make such gap filling easier than with stage 1.
Also today the folks at the Advisory Board published booked versions of the rules
ONC
CMS
It's not only the most exciting time to be in healthcare IT, but with the requirements above, the most exciting time to be an innovator creating new functionality that does not exist in the marketplace today.
Meaningful Use Stage 2 Rules Released
The Office of the National Coordinator for Health IT (ONC) and The Centers for Medicare & Medicaid Services (CMS) today released final requirements for Stage 2 Electronic Health Records Incentive programs. The regulations can be found here:
CMS
ONC
A fact sheet on CMS's final rule is available here.
A fact sheet on ONC's standards and certification criteria final rule is available here.
The vocabulary, transport, and content standards in the ONC Final rule align perfectly with previous recommendations from the HIT Standards Committee. A few highlights of interest from my initial reading:
1. SMTP is the required transport standard for all certified EHRs and has been included in the Base EHR definition, meaning that all EHR technology used by EPs, EHs, and CAHs and that meets the CEHRT definition will, at a minimum, be capable of SMTP-based exchange.
There are two optional approaches for the transitions of care certification criteria SMTP/XDR and XDR/SOAP. The specific language reads
"The Secretary adopts the following transport standards:
(a) Standard. ONC Applicability Statement for Secure Health Transport (incorporated by
reference in § 170.299). .
(b) Standard. ONC XDR and XDM for Direct Messaging Specification (incorporated by
reference in § 170.299).
(c) Standard. ONC Transport and Security Specification (incorporated by reference in §
170.299).
EHR technology must be able to electronically receive transition of care/referral summaries in accordance with:
(A) The standard specified in § 170.202(a).
(B) Optional. The standards specified in § 170.202(a) and (b).
(C) Optional. The standards specified in § 170.202(b) and (c).
To permit additional flexibility and options for EHR technology developers to provide their customers with EHR technology that has been certified to support an EP, EH, or CAH’s achievement of the “transitions of care” MU objective and associated measure, we have adopted two optional certification approaches for transport standards. For each option, EHR technology would need to demonstrate its compliance with both of the identified specifications in that option in order to be certified to the option.
• The first option would permit EHR technology to be certified as being in compliance with our original proposal: certification to both the Applicability Statement for Secure Health Transport specification and the XDR and XDM for Direct Messaging specification.
• The second option would permit EHR technology to be certified to: the Simple Object Access Protocol (SOAP)-Based Secure Transport Requirements Traceability Matrix (RTM) version 1.0 standard and the XDR and XDM for Direct Messaging specification."
2. Electronic notes must be searchable
"Enable a user to electronically record, change, access, and search electronic notes."
I look forward to vendor implementations of searching free text - will they use simply keyword indexing or more innovative natural language processing techniques that enables text to be search with context as I wrote in this blog post.
3. EHRs must support display of image results, although this could be accomplished via a single sign on link to a PACS system
"Image results. Electronically indicate to a user the availability of a patient’s images and narrative interpretations (relating to the radiographic or other diagnostic test(s)) and enable electronic access to such images and narrative interpretations."
4. Encryption is required for EHR data stored locally on client devices - this refers to caches and local databases created by the application and not a user saving a file or doing a screen print.
"Record the encryption status (enabled or disabled) of electronic health information locally stored on end-user devices by EHR technology in accordance with the standard specified in § 170.210(e)(3) unless the EHR technology prevents electronic health information from being locally stored on end-user devices (see 170.314(d)(7) of this section)."
Here's a summary of the intent
5. Care Coordination data must be receivable using the Direct protocol and incorporated in structured form.
"(B) Data incorporation. Electronically incorporate the following data expressed according to the specified standard(s):
(1) Medications. At a minimum, the version of the standard specified in § 170.207(d)(2); (2) Problems. At a minimum, the version of the standard specified in § 170.207(a)(3); (3) Medication allergies. At a minimum, the version of the standard specified in § 170.207(d)(2)."
6. Health Information Exchange with Patients is required using the Direct protocol
"EHR technology must provide patients (and their authorized representatives) with an online means to view, download, and transmit to a 3rd party the data specified below.
Transmit to third party. (1) Electronically transmit the ambulatory summary or inpatient summary (as applicable to the EHR technology setting for which certification is requested) created in paragraph (e)(1)(i)(B)(1) of this section in accordance with the standard specified in § 170.202(a).
(2) Inpatient setting only. Electronically transmit transition of care/referral summaries (as a result of a transition of care/referral) selected by the patient (or their authorized representative) in accordance with the standard specified in § 170.202(a)."
I'll write more over the next few days. I look forward to industry reaction as to the difficulty of implementing some of the more novel workflows.
CMS
ONC
A fact sheet on CMS's final rule is available here.
A fact sheet on ONC's standards and certification criteria final rule is available here.
The vocabulary, transport, and content standards in the ONC Final rule align perfectly with previous recommendations from the HIT Standards Committee. A few highlights of interest from my initial reading:
1. SMTP is the required transport standard for all certified EHRs and has been included in the Base EHR definition, meaning that all EHR technology used by EPs, EHs, and CAHs and that meets the CEHRT definition will, at a minimum, be capable of SMTP-based exchange.
There are two optional approaches for the transitions of care certification criteria SMTP/XDR and XDR/SOAP. The specific language reads
"The Secretary adopts the following transport standards:
(a) Standard. ONC Applicability Statement for Secure Health Transport (incorporated by
reference in § 170.299). .
(b) Standard. ONC XDR and XDM for Direct Messaging Specification (incorporated by
reference in § 170.299).
(c) Standard. ONC Transport and Security Specification (incorporated by reference in §
170.299).
EHR technology must be able to electronically receive transition of care/referral summaries in accordance with:
(A) The standard specified in § 170.202(a).
(B) Optional. The standards specified in § 170.202(a) and (b).
(C) Optional. The standards specified in § 170.202(b) and (c).
To permit additional flexibility and options for EHR technology developers to provide their customers with EHR technology that has been certified to support an EP, EH, or CAH’s achievement of the “transitions of care” MU objective and associated measure, we have adopted two optional certification approaches for transport standards. For each option, EHR technology would need to demonstrate its compliance with both of the identified specifications in that option in order to be certified to the option.
• The first option would permit EHR technology to be certified as being in compliance with our original proposal: certification to both the Applicability Statement for Secure Health Transport specification and the XDR and XDM for Direct Messaging specification.
• The second option would permit EHR technology to be certified to: the Simple Object Access Protocol (SOAP)-Based Secure Transport Requirements Traceability Matrix (RTM) version 1.0 standard and the XDR and XDM for Direct Messaging specification."
2. Electronic notes must be searchable
"Enable a user to electronically record, change, access, and search electronic notes."
I look forward to vendor implementations of searching free text - will they use simply keyword indexing or more innovative natural language processing techniques that enables text to be search with context as I wrote in this blog post.
3. EHRs must support display of image results, although this could be accomplished via a single sign on link to a PACS system
"Image results. Electronically indicate to a user the availability of a patient’s images and narrative interpretations (relating to the radiographic or other diagnostic test(s)) and enable electronic access to such images and narrative interpretations."
4. Encryption is required for EHR data stored locally on client devices - this refers to caches and local databases created by the application and not a user saving a file or doing a screen print.
"Record the encryption status (enabled or disabled) of electronic health information locally stored on end-user devices by EHR technology in accordance with the standard specified in § 170.210(e)(3) unless the EHR technology prevents electronic health information from being locally stored on end-user devices (see 170.314(d)(7) of this section)."
Here's a summary of the intent
5. Care Coordination data must be receivable using the Direct protocol and incorporated in structured form.
"(B) Data incorporation. Electronically incorporate the following data expressed according to the specified standard(s):
(1) Medications. At a minimum, the version of the standard specified in § 170.207(d)(2); (2) Problems. At a minimum, the version of the standard specified in § 170.207(a)(3); (3) Medication allergies. At a minimum, the version of the standard specified in § 170.207(d)(2)."
6. Health Information Exchange with Patients is required using the Direct protocol
"EHR technology must provide patients (and their authorized representatives) with an online means to view, download, and transmit to a 3rd party the data specified below.
Transmit to third party. (1) Electronically transmit the ambulatory summary or inpatient summary (as applicable to the EHR technology setting for which certification is requested) created in paragraph (e)(1)(i)(B)(1) of this section in accordance with the standard specified in § 170.202(a).
(2) Inpatient setting only. Electronically transmit transition of care/referral summaries (as a result of a transition of care/referral) selected by the patient (or their authorized representative) in accordance with the standard specified in § 170.202(a)."
I'll write more over the next few days. I look forward to industry reaction as to the difficulty of implementing some of the more novel workflows.
The Golden Spike Planning Session
Today, nine organizations interested in early adoption of the Statewide HIE met to plan the final details of the October 15, 2012 go live.
We explored in the depth the details of the Direct standard and its supporting components including S/MIME clients/servers, XDR (SOAP), Webmail (Secure web-based messaging), use of gateway appliances that act as middleware between existing EHRs and Direct compliant HISPs, certificate lookup via web services/DNS, and provider directory standards.
We reviewed these slides
Here's what we decided:
All our early participants - Partners, BIDMC, Childrens, Baystate, Atrius, Network Health, Holyoke, Vanguard, and a solo practioner declared that the gateway appliance or XDR would meet their needs.
The gateway appliance supports simple EHR integration via file drop, FTP, XDR, HL7 via TCP, West Services and REST. The XDR approach enables automated routing to XDR or SMTP recipients - the Massachusetts HIE provider directory query will return the XDR address of XDR capable recipients or the state's Direct gateway address for XDR to SMTP translation and forwarding for those organizations which can only receive SMTP. This moves the complexity out of the EHRs and into the HISP for protocol conversion and routing services.
We reviewed the draft HIE participation agreement and received broad support for the document and its supporting addendum.
Next, we reviewed pricing. The principles we discussed included
*All participants should pay some subscription fee to cover the private sector share of operating costs, but prices should be tiered like a progressive income tax - wealthier organizations pay more to reduce the burden on organizations with fewer resources
*Participants will pay only for the service level they consume
*Fees will be adjusted periodically as circumstances change, recognizing that the first year costs are an estimate
Finally we discussed the effort to ensure the 14 vendors which constitute 90% of the Massachusetts marketplace will be connected to the HIE as needed.
A very exciting time for HIE - the energy of the early adopter stakeholders is palpable. I'll provide several updates over the next two months as we countdown the days until go live.
We explored in the depth the details of the Direct standard and its supporting components including S/MIME clients/servers, XDR (SOAP), Webmail (Secure web-based messaging), use of gateway appliances that act as middleware between existing EHRs and Direct compliant HISPs, certificate lookup via web services/DNS, and provider directory standards.
We reviewed these slides
Here's what we decided:
All our early participants - Partners, BIDMC, Childrens, Baystate, Atrius, Network Health, Holyoke, Vanguard, and a solo practioner declared that the gateway appliance or XDR would meet their needs.
The gateway appliance supports simple EHR integration via file drop, FTP, XDR, HL7 via TCP, West Services and REST. The XDR approach enables automated routing to XDR or SMTP recipients - the Massachusetts HIE provider directory query will return the XDR address of XDR capable recipients or the state's Direct gateway address for XDR to SMTP translation and forwarding for those organizations which can only receive SMTP. This moves the complexity out of the EHRs and into the HISP for protocol conversion and routing services.
We reviewed the draft HIE participation agreement and received broad support for the document and its supporting addendum.
Next, we reviewed pricing. The principles we discussed included
*All participants should pay some subscription fee to cover the private sector share of operating costs, but prices should be tiered like a progressive income tax - wealthier organizations pay more to reduce the burden on organizations with fewer resources
*Participants will pay only for the service level they consume
*Fees will be adjusted periodically as circumstances change, recognizing that the first year costs are an estimate
Finally we discussed the effort to ensure the 14 vendors which constitute 90% of the Massachusetts marketplace will be connected to the HIE as needed.
A very exciting time for HIE - the energy of the early adopter stakeholders is palpable. I'll provide several updates over the next two months as we countdown the days until go live.
Joyful Chaos
In past personal blogs about our cancer journey, I've explained the "why" - looking forward to a vision of a bucolic future made the six months of cancer treatment a lot more tolerable.
Ive never explained the "how". In a new series of Thursday blogs, beginning today, I'll recount what we've done and what we're doing to turn 15 acres of Sherborn, Massachusetts into a productive working farm providing a non-stressful environment numerous animals and a nurturing ecosystem for a bountiful fruit/vegetable harvest.
The property we purchased in April 2012 has all the right ingredients - former pastureland filled with 1700's rock walls, flat sunny well drained soil with generous sun exposure, forest, a meadow, and a stream/wildflower wetland.
Over the past hundred years, the pastures have filled with second growth trees - pines, oaks, and black birch. The rock walls have been lost in a sea of bittersweet, wild grape, and poison ivy.
Our first task was re-open the pastures. We cleared over 50 trees including numerous invasive/non-native plans. We used an expert tree contractor for the large trees and for the smaller trees I used a Stihl MS290 chainsaw, a Gransfors Bruks splinting maul/Swedish forest axe, and a steel farm push cart capable of hauling 800 pounds.
Our next task was to clear debris - fallen branches and deadwood. I created a pile 50 feet long and 10 feet high, which we chipped into mulch.
Then we created paths throughout the property which enabled us to manage the land. We covered the paths with the mulch we created from chipping.
Once the rough clearing was done we had to move rocks. New England is full of rocks. Although I hand carried many and used a heavy duty wheelbarrow for others, we used a small front loader (Bobcat) for the really large ones.
Once the topography of the land was more obvious, we planned our planting areas, buildings and fences.
A wetland engineer is working with the town of Sherborn to plan our future planting areas - likely an orchard of heirloom apples and a meadow filled with high bush blueberries.
We created a 10x12 chicken coop and a loafing shed to keep animals warm in winter/cool in summer. We planned 1000 feet of fences and chose to use 5 foot woven wire fence supported by posts at 20 foot intervals, topped by a hot wire (9000 volts, low amperage) to keep the predators out.
The end result was 2 quarter acre paddocks - one for males and one for females, and a half acre pasture, connected with a series of 8 gates that support manure management, hay storage, and easy movement of animals.
We then planned the barn. The property included a barn, but it was originally designed as more of a garage than a barn. We added hay loft doors, thick rubber mats for the stalls, a water hydrant with a french drain, fans to keep animals cool in Summer, and wall mounted feeders. We painted the building red with black trim and added barn lights above each door.
With this layout done, we had the infrastructure in place to complete our animal strategy. We raised 12 chickens from 3 day old chicks indoors and moved them to the coop at 6 weeks. A friend gave us a rooster. We named him "Lucky" since he'll be living with vegans/vegetarians.
We raised 22 guinea fowl from 3 day old chicks and moved them to the coop at 6 weeks.
By pure happenstance, my Telecom manager is selling her herd of 8 alpaca. After meeting them, we purchased the entire herd - 3 males and 5 females.
Realizing that alpacas need guardians because they do not defend themselves well against the coyotes, fisher cats, and other predators on our property, we researched llamas. We found an ideal guard llama who has lived with alpaca for many years. She also happens to be pregnant.
The female llama will guard the female alpaca.
For the male alpaca, we chose an experienced female Great Pyrenees mountain dog, the livestock guardian used by Basque shepherds. We also chose a male Great Pyrenees puppy who will keep the female company and learn how to guard from her.
On August 18, the alpaca arrive. On August 20, the female Great Pyrenees arrives. On August 23, the male Great Pyrenees arrives. On August 26 the llama arrives.
The journey of joyful chaos at Unity Farm has replaced the cancer journey and our property is about to blossom with new arrivals.
The August HIT Standards Committee
The August HIT Standards Committee focused on criteria to assess standards maturity, concerns about the timing of the Meaningful Use 2014 edition final rule, further work on the national curated vocabulary and code set repository, and an important discussion about future ONC S&I framework efforts.
Dixie Baker presented the final recommendations of the NwHIN Power Team regarding the objective criteria used to assess the maturity of standards. Her framework was very well received. The Standards Committee will draft a formal letter of transmital to ONC suggesting that these criteria be applied when addressing and ONC or HIT Standards/HIT Policy Committee questions about standards readiness. Jim Walker offered a friendly amendment that these criteria are so good they could be used as an effective tool for predicting the future success of a new national standard. Given the current discussions by the Policy Committee's Meaningful Use Workgroup which is finalizing Stage 3 recommendations based on the future maturity of standards, all agreed that these maturity criteria should be used by HITSC workgroups to answer HITPC questions. Over the next month, we will use the criteria to respond to the Meaningful Use workgroup's latest requests for future standards availability.
Liz Johnson presented the work of the Implementation Workgroup, expressing the best thinking of those in operational settings who need to address software acquisition, installation and training by October 1, 2013 to meet Meaningful Use Stage 2 timelines. After much discussion we agreed that the discussion of our concerns in the Standards Committee was sufficient communication to ONC. Hopefully, the final rule will be issued very soon and the contingency plans we outlined will not be required.
Jim Walker presented an update on the foundational work being done by the National Library Medicine to create a national vocabulary and code set resource in support of meaningful use data exchanges and quality measures. The Standards Committee will continue to offer their support, advice and encouragement to the NLM efforts.
Finally, Doug Fridsma answered many committee questions about the S&I framework and current initiatives. Once the FY13 ONC budget is finalized, the HIT Standards Committee will offer its advice how use those limited resources in the most efficient way possible to accelerate standards availability for future versions of Meaningful Use. Doug will update the Committee about Meaningful Use Stage 2 testing and certification criteria in September. Carol Bean noted that ONC will soon authorize the permanent certification bodies to begin their work.
We all look forward to seeing the final rule and continuing our focus on the necessary details to ensure the success of Meaningful Use stage 2 and 3 interoperability efforts.
Dixie Baker presented the final recommendations of the NwHIN Power Team regarding the objective criteria used to assess the maturity of standards. Her framework was very well received. The Standards Committee will draft a formal letter of transmital to ONC suggesting that these criteria be applied when addressing and ONC or HIT Standards/HIT Policy Committee questions about standards readiness. Jim Walker offered a friendly amendment that these criteria are so good they could be used as an effective tool for predicting the future success of a new national standard. Given the current discussions by the Policy Committee's Meaningful Use Workgroup which is finalizing Stage 3 recommendations based on the future maturity of standards, all agreed that these maturity criteria should be used by HITSC workgroups to answer HITPC questions. Over the next month, we will use the criteria to respond to the Meaningful Use workgroup's latest requests for future standards availability.
Liz Johnson presented the work of the Implementation Workgroup, expressing the best thinking of those in operational settings who need to address software acquisition, installation and training by October 1, 2013 to meet Meaningful Use Stage 2 timelines. After much discussion we agreed that the discussion of our concerns in the Standards Committee was sufficient communication to ONC. Hopefully, the final rule will be issued very soon and the contingency plans we outlined will not be required.
Jim Walker presented an update on the foundational work being done by the National Library Medicine to create a national vocabulary and code set resource in support of meaningful use data exchanges and quality measures. The Standards Committee will continue to offer their support, advice and encouragement to the NLM efforts.
Finally, Doug Fridsma answered many committee questions about the S&I framework and current initiatives. Once the FY13 ONC budget is finalized, the HIT Standards Committee will offer its advice how use those limited resources in the most efficient way possible to accelerate standards availability for future versions of Meaningful Use. Doug will update the Committee about Meaningful Use Stage 2 testing and certification criteria in September. Carol Bean noted that ONC will soon authorize the permanent certification bodies to begin their work.
We all look forward to seeing the final rule and continuing our focus on the necessary details to ensure the success of Meaningful Use stage 2 and 3 interoperability efforts.
An Alternative HIE Architecture
Massachusetts has created a three year, three phased HIE plan based on "pushing" records from place to place, creating analytic repositories, and "pulling" data from providers based on a centralized consent repository/ master patient index. Here's a brief overview from an NPR broadcast yesterday.
We all want to solve the "Unconscious in the Emergency Department problem" which requires states/regions to build significant supporting components including a registry of all the healthcare institutions which a patient has visited and opted in for disclosure of records. Massachusetts has the funding and alignment of stakeholders needed to make this happen.
However, many states will not be able to create consent repositories and record locator services. Is there another approach that does not require significant centralized infrastructure?
BIDMC has created such a "pull" data exchange with the Social Security Administration.
Here's how its works:
The transaction was designed to be as simple as possible.
Social Security identifies themselves via a secure certificate and is considered a trusted partner. Then, Social Security computers send a secure SOAP request, including a scan of the patient's signed medical record release document and patient identifiers to servers at BIDMC. We store the patient release document in our logs. We look up the patient in our system and if we can reliably match the patient using multiple identifiers, we create a CCD/C32 (Summary of Care document) and return that to the Social Security computers via the secure SOAP response.
The transaction is a query/response model without any centralized infrastructure.
Since there are no widely implemented standards for consent data, we're using something simple - a TIFF that is a scan of the patient release document and patient identifiers.
No human reviews these TIFFs during the initial record exchange - the patient release document is stored and the response is sent immediately. If a question about the release arises, we have the original signed scan and audit trails to review.
The C32 document is sent via a secure, encrypted, session back to the Social Security Administration. If the session concludes successfully, then the document was received.
Thus, it is possible to "pull" records from an outside institution without any centralized indexes or registries - just send a scan of the consent with the electronic query for records.
Admittedly a statewide master patient index that includes consent to disclose records from specific institutions will scale better and enable targeted retrieval of data from each location where a patient has data, but for those who want a query response approach for retrieval of data from a specific institution, the Social Security Administration approach works well.
We all want to solve the "Unconscious in the Emergency Department problem" which requires states/regions to build significant supporting components including a registry of all the healthcare institutions which a patient has visited and opted in for disclosure of records. Massachusetts has the funding and alignment of stakeholders needed to make this happen.
However, many states will not be able to create consent repositories and record locator services. Is there another approach that does not require significant centralized infrastructure?
BIDMC has created such a "pull" data exchange with the Social Security Administration.
Here's how its works:
The transaction was designed to be as simple as possible.
Social Security identifies themselves via a secure certificate and is considered a trusted partner. Then, Social Security computers send a secure SOAP request, including a scan of the patient's signed medical record release document and patient identifiers to servers at BIDMC. We store the patient release document in our logs. We look up the patient in our system and if we can reliably match the patient using multiple identifiers, we create a CCD/C32 (Summary of Care document) and return that to the Social Security computers via the secure SOAP response.
The transaction is a query/response model without any centralized infrastructure.
Since there are no widely implemented standards for consent data, we're using something simple - a TIFF that is a scan of the patient release document and patient identifiers.
No human reviews these TIFFs during the initial record exchange - the patient release document is stored and the response is sent immediately. If a question about the release arises, we have the original signed scan and audit trails to review.
The C32 document is sent via a secure, encrypted, session back to the Social Security Administration. If the session concludes successfully, then the document was received.
Thus, it is possible to "pull" records from an outside institution without any centralized indexes or registries - just send a scan of the consent with the electronic query for records.
Admittedly a statewide master patient index that includes consent to disclose records from specific institutions will scale better and enable targeted retrieval of data from each location where a patient has data, but for those who want a query response approach for retrieval of data from a specific institution, the Social Security Administration approach works well.
The People Behind the Massachusetts HIE
I'm back! Sorry for the 10 day gap in blog posts, but given a limit of 168 hours in a week and the need prepare my father-in-law's home for sale in early September and ready Unity Farm for the August 19 arrival of 8 alpaca, 2 llama, and a Great Pyrenees livestockgGuardian dog, my evening writing time has been compromised. On Thursdays I'll begin a new personal series describing our life on the farm now that cancer treatment is over - "Building Unity Farm" starts later this week.
Although August is usually a time of vacations and downtime before the post labor day acceleration of projects, this August has been filled with Massachusetts Health Information Exchange policy and technology work in preparation for the October 15, 2012 "golden spike" which will eliminate silos of healthcare data in Massachusetts by connecting numerous early adopter provider organizations via the state's HIE backbone.
I've long believed that HIE is more about psychology and personality than policy and technology. You need the trust of the community and passionate people to make it happen.
Here's a primer on the most important people driving HIE in Massachusetts:
Manu Tandon is a unique public servant He's the CIO of the Executive Office of Health and Human Services (EOHHS) and is more interested in making a difference than fame or fortune. He's had a distinguished career in industry but chooses to serve the state government because he believes in the mission. He works tirelessly, sending emails at all hours of day and night. He's always connected and communicating with all our stakeholders inside and outside of government. He's that rare public servant who combines political savvy, transparency, and competency. Every stakeholder in the community trusts him and his position in government enables him to move projects forward rapidly.
Several folks are helping Manu Tandon work his magic. John Kelly, formerly of Harvard Pilgrim, is serving an influential architecture role at EOHHS. Venkat Jegadeesan creates the detailed specifications and requirements. Ray Campbell, CEO of the Massachusetts Health Data Consortium has helped create agreements and legal documents.
Micky Tripathi is a national treasure. He's the CEO of the Massachusetts eHealth Collaborative and chair of the HIT Policy Committee's Health Information Exchange workgroup. His domain knowledge of EHR and HIE is unique. His ability to communicate complex policies and project details is unmatched. The presentations that led to industry, academic and government support of the Massachusetts HIE were authored by Micky.
Laurance Stuntz is both a leader and a technologist. He's the new Executive Director of the Massachusetts eHealth Institute (MeHI) and was the architect of the New England Healthcare Exchange Network (NEHEN). He's also trusted by all the stakeholders. He can assemble an understandable budget with the same competency as editing a Web Services Definition Language (WSDL) specification for an HIE interface.
Dr. Larry Garber is an informatics powerhouse, creating strategy, writing code, and implementing bold pilots.
The maturity of the standards and the incentives of meaningful use have helped accelerate HIE in Massachusetts. The 90/10 matching funding from Medicaid was a catalyst. But the real secret of Massachusetts momentum is the people. It takes a village to make HIE happen and we're blessed with a superlative team that creates miracles every day.
I'm proud to be a part of it.
The Open Source Electronic Health Records Agent Conference
In 2011, I joined the Board of OSEHRA, a nonprofit organization dedicated to innovation in electronic health record software. Founded in 2011, OSEHRA supports an open, collaborative community of users, developers, and researchers engaged in advancing electronic health record software and related health information technology. OSEHRA hosts software repositories for applications such as the VA’s and DoD’s EHR systems. For more information, visit the OSEHRA website .
On October 17 and 18, 2012, OSHERA will host its First Annual Open Source EHR Summit & Workshop. The Summit brings togethers stakeholders who support the use of open source electronic health record (EHR) technology and will be held October 17 and 18, 2012, at the Gaylord National Resort & Convention Center in Washington DC (National Harbor, MD).
The Summit will feature more than 30 panelists and speakers, including government officials, health care leaders, clinical care providers and policymakers. The event will bring together the OSEHRA community, now totaling more than 1,000 members, for the first time and provide a venue for Open Source Health IT training and educational workshops.
Conference topics will include:
Open source initiatives in Federal agencies; VA, DoD, HHS and others
Best practices in open source software development
Lessons learned from related industries
Open source software development in health care
Trends in the open source software industry
New open source initiatives
It is projected that within the next few years more than 200 hospitals and 1000 clinics within the federal sector will be managing and maintaining their EHRs using open source software. Open Source electronic health records are also being used in numerous domestic community health care facilities and more than 13 foreign countries. An increasing number of state agencies and private sector health care communities facing high costs of health IT have started calling for alternate approaches to traditional proprietary electronic health records. These open source activities create a significant market opportunity for both private and public sectors.
The Summit is now accepting abstracts for presentations addressing technical, business and policy issues associated with open source software and EHR. Abstracts are limited to 100 words or less and submission requirements are detailed at the conference registration site’s “Call for Papers” tab. The deadline for submission is August 24, 2012. To submit an abstract for consideration, please respond directly to summitabstracts2012@osehra.org.
I hope to see you there!
On October 17 and 18, 2012, OSHERA will host its First Annual Open Source EHR Summit & Workshop. The Summit brings togethers stakeholders who support the use of open source electronic health record (EHR) technology and will be held October 17 and 18, 2012, at the Gaylord National Resort & Convention Center in Washington DC (National Harbor, MD).
The Summit will feature more than 30 panelists and speakers, including government officials, health care leaders, clinical care providers and policymakers. The event will bring together the OSEHRA community, now totaling more than 1,000 members, for the first time and provide a venue for Open Source Health IT training and educational workshops.
Conference topics will include:
Open source initiatives in Federal agencies; VA, DoD, HHS and others
Best practices in open source software development
Lessons learned from related industries
Open source software development in health care
Trends in the open source software industry
New open source initiatives
It is projected that within the next few years more than 200 hospitals and 1000 clinics within the federal sector will be managing and maintaining their EHRs using open source software. Open Source electronic health records are also being used in numerous domestic community health care facilities and more than 13 foreign countries. An increasing number of state agencies and private sector health care communities facing high costs of health IT have started calling for alternate approaches to traditional proprietary electronic health records. These open source activities create a significant market opportunity for both private and public sectors.
The Summit is now accepting abstracts for presentations addressing technical, business and policy issues associated with open source software and EHR. Abstracts are limited to 100 words or less and submission requirements are detailed at the conference registration site’s “Call for Papers” tab. The deadline for submission is August 24, 2012. To submit an abstract for consideration, please respond directly to summitabstracts2012@osehra.org.
I hope to see you there!
The Massachusetts HIE Procurement
I've written several blog posts about the Massachusetts HIE strategic and operating plan to implement a statewide backbone for connecting every stakeholder in the Commonwealth.
All procurements have been done and we can now share the selection with the public. Here are the service providers we have chosen:
Direct Gateway - Orion
Access and Identity Management System (AIMS) - Cognosante (Sub Contractor to Orion)
Provider Directory - Initiate (Sub Contractor to Orion)
Clinical Gateway (HL7 interfaces to EOHHS/DPH) - Orion
Children’s Behavioral Health Initiative – HL 7 Interface - Orion
Syndromic Surveillance – HL 7 Interface - Orion
Healthcare Provider Portal (Part of Direct Gateway) - Compass (Sub Contractor to Orion)
Local Access Network Distribution (LAND) - Orion
Public Key Infrastructure (PKI) SaaS - Symantec (Sub Contractor to Orion)
Hosting services in a private MA HIE cloud - Logicworks (Sub Contractor to Orion)
Technical Support –(includes Call center) - Orion
Business Support – Operations and Maintenance - Orion
The Gateway, Provider Directory, and PKI infrastructure will go live on October 15, 2012. The additional services will go live in December 2012.
We believe that our System Integration vendor, Orion, has substantial US and international experience with Public HIE implementations. Their centralized cloud hosted gateways keep costs low and agility high. For those clinicians using non-certified or non-Direct compliant EHRs, Orion will provide and manage a low cost appliance in office settings to enable participation in bidirectional data sharing. Initiate has rich experience with directories and query interfaces to directories, both patient and provider. Symantec (which acquired Verisign) has thousands of public key infrastructure customers. The combination of Orion, Initiate and Symantec seems highly credible to us.
We have completed an analysis of every EHR deployed in Massachusetts and discovered that we can connect 80% of our stakeholders (including Long Term Care and Behavioral Health) by creating HIE interfaces for:
•Meditech
•LMR (Self developed at Partners Healthcare)
•Cerner
•Allscripts
•eClinicalWorks
•GE
•WebOMR (Self developed at Beth Israel Deaconess)
•Siemens
•Epic
•NextGen
•athenahealth
•Quest Care360
•E-MDs
•Point Click Care
•Netsmart Technologies
•UNI/CARE Systems
The Massachusetts eHealth Institute (MeHI) Last Mile Management Office will hire a System Integrator to manage interface development and the selection of implementation optimizing organizations to manage interface implementation and training.
With capital funding in place, a sustainable operating budget with public/private contributions, and strong vendors, we are confident the Massachusetts Statewide HIE will leverage Federal Standards to connect payers, providers, and patients in empowering ways. I'll write many additional posts describing the technology and policy decisions we make along the path to our October go live.
Truly the perfect storm for innovation.
All procurements have been done and we can now share the selection with the public. Here are the service providers we have chosen:
Direct Gateway - Orion
Access and Identity Management System (AIMS) - Cognosante (Sub Contractor to Orion)
Provider Directory - Initiate (Sub Contractor to Orion)
Clinical Gateway (HL7 interfaces to EOHHS/DPH) - Orion
Children’s Behavioral Health Initiative – HL 7 Interface - Orion
Syndromic Surveillance – HL 7 Interface - Orion
Healthcare Provider Portal (Part of Direct Gateway) - Compass (Sub Contractor to Orion)
Local Access Network Distribution (LAND) - Orion
Public Key Infrastructure (PKI) SaaS - Symantec (Sub Contractor to Orion)
Hosting services in a private MA HIE cloud - Logicworks (Sub Contractor to Orion)
Technical Support –(includes Call center) - Orion
Business Support – Operations and Maintenance - Orion
The Gateway, Provider Directory, and PKI infrastructure will go live on October 15, 2012. The additional services will go live in December 2012.
We believe that our System Integration vendor, Orion, has substantial US and international experience with Public HIE implementations. Their centralized cloud hosted gateways keep costs low and agility high. For those clinicians using non-certified or non-Direct compliant EHRs, Orion will provide and manage a low cost appliance in office settings to enable participation in bidirectional data sharing. Initiate has rich experience with directories and query interfaces to directories, both patient and provider. Symantec (which acquired Verisign) has thousands of public key infrastructure customers. The combination of Orion, Initiate and Symantec seems highly credible to us.
We have completed an analysis of every EHR deployed in Massachusetts and discovered that we can connect 80% of our stakeholders (including Long Term Care and Behavioral Health) by creating HIE interfaces for:
•Meditech
•LMR (Self developed at Partners Healthcare)
•Cerner
•Allscripts
•eClinicalWorks
•GE
•WebOMR (Self developed at Beth Israel Deaconess)
•Siemens
•Epic
•NextGen
•athenahealth
•Quest Care360
•E-MDs
•Point Click Care
•Netsmart Technologies
•UNI/CARE Systems
The Massachusetts eHealth Institute (MeHI) Last Mile Management Office will hire a System Integrator to manage interface development and the selection of implementation optimizing organizations to manage interface implementation and training.
With capital funding in place, a sustainable operating budget with public/private contributions, and strong vendors, we are confident the Massachusetts Statewide HIE will leverage Federal Standards to connect payers, providers, and patients in empowering ways. I'll write many additional posts describing the technology and policy decisions we make along the path to our October go live.
Truly the perfect storm for innovation.
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