Cool Technology of the Week

 Although I did not attend HIMSS this year because of my wife's chemotherapy timing, I did send several of my staff.    I asked them to summarize the cool technologies, most frequently heard buzzwords, and the overall conference trends.

Just as "Plastics" was the catchword from The Graduate, this year's HIMSS Conference theme was a combination "Cloud-based EHRs" and "HIE".

Cloud-based EHRs which follow the model pioneered by AthenaHeath for minimal hardware and minimal configuration in the office now include a number of new entrants including CareCloud and iPatientCare.   It will be interesting to see how these companies address the issue of integration with hardware in the office, the desire for customization, and the need for unique interfacing/integration with third party products.

HIE companies are appearing on the landscape faster than ever before.   Companies such as Orion, Intersystems, RelayHealth, United/OptumInsight, Aenta/Medicity, DBmotion, Axway, and Certify are increasingly visible in the industry.

With the Stage 2 NPRMs and increased HIMSS emphasis on interoperability, the industry is fast moving toward the Learning Healthcare System we've all envisioned.   That's cool!

Our Cancer Journey - Week 11

Tomorrow, Kathy starts her next round of chemotherapy - 12 weeks of Taxol administered every Friday at noon.

As with Adriamycin/Cytoxan (AC), we fear the unknown - what symptoms will it bring, how will it affect day to day and long term physical well being (since Taxol causes numbness that can be permanent).      Kathy reacted very well to AC so we're hopeful that she'll tolerate Taxol.

The process of treating breast cancer - 20 weeks of chemotherapy followed by surgery and radiation, can be wearing.   Of course, we are focused on optimizing the therapy, but at the same time we've needed a long term goal that brings joy and passion for the future, minimizing the day to day challenges of treatment.

Together we've been looking for a farm property, discussing the plans/projects ahead, and preparing for our next stage of life.   We moved to Massachusetts 16 years ago and raised our daughter in a family neighborhood, nearby to great public schools and a local library.   We believe that we have at least 2 more phases in our lives.  Phase 1 - 15 years as empty nesters at the peak of our mental and physical capabilities, ensuring the health of our parents, and supporting our daughter's early career.   Phase 2 - 15 years as retirees (and possible grandparents), continuing to write, lecture, and consult but without a "9 to 5" office schedule.

In Phase 1,  we're eager to take on the physical labor and mental creativity needed to expand our production of organic vegetables and raise a few chickens/alpaca/llama/goats/sheep.

The quest for a farm property has provided us with enough positive activity to energize our nights and weekends.

Plans and projects for the future are important to sustain optimism, but they're also essential to grow and develop our 30+ year relationship.

As noted in the recent New York Times article Love and Death, having plans and projects for the future is what sustains love beyond the physical attraction, infatuation, and novelty of the initial relationship.

Our farm vision has provided that.   To keep patients and families psychologically healthy during cancer treatment it's really important to focus on life after cancer and not let the cancer rule your life.    As you'll hear in the new few weeks, we found our farm and now we're planning our move there by May, ensuring that the end of chemotherapy marks the beginning of our new life chapter together.

The February HIT Standards Committee Meeting

The February meeting of the HIT Standards Committee included an in depth discussion of the Stage 2 Standards and Certification NPRM, updates from the projects in our 2012 HITSC work plan, and an overview of HITPC plans for 2012.   It was one of the highest energy, most optimistic meetings we've had.

We began the meeting with a review of the Standards and Certification NPRM by Steve Posnack and Doug Fridsma.  As I noted in my recent post about the NPRM, most of the HITSC "Summer Camp" recommendations were accepted.   Highlights from their presentation:

*In Stage 2, Certified Electronic Health Record Technology (CEHRT) will be "just enough" to support the functions documented during attestation.     In Stage 1, certified technology  was required for menu set items that were not part of an organization's attestation i.e. even if you did not plan to submit syndromic surveillance data, you needed to buy that technology anyway.  
*Every eligible professional/eligible hospital/critical access hospital (EP/EH/CAH)  must have a "base EHR"  that includes the ability to capture demographic data/patient history/problem lists, provide decision support, support provider order entry, record data needed to report quality, exchange electronic information, and protect confidentiality
*In addition to this base EHR, every EP/EH/CAH should have the EHR technology with capabilities for the MU core and menu set objectives they seek to achieve.  These can be a collection of modules or a complete EHR.
*Clinical Quality certification includes the ability to capture, calculate, and report clinical quality measures.   It's completely fine to use certified EHR technology to capture the data, then export it to another certified technology for calculation and reporting.   This is what BIDMC does today and to achieve it we had to do self-certification.   Now, anyone can use this approach, assembling certified components from vendors.
*The Standards specified in the 2014 Criteria include
  Content - Consolidated CDA for summaries, NCPDP for eRx, HL7 2.5.1 for public health
  Vocabulary - CVX for immunizations, SNOMED-CT for problem lists, ICD10-CM for diagnoses, LOINC for labs, RxNorm for meds, OMB, ISO639-1 for spoken language, CDA for cancer submissions 
  Transport - Direct Specifications and NwHIN Exchange
  Security - FIPS for encryption, NTP for time
*The MU Stage 2 Menu set includes  several functions with evolving standards such as Imaging display in EHRs, transmission to clinical registries, cancer case information, and family health history.  That's why they are menu set

Initial reactions from the HIT Standards Committee included

   TLS should be listed as an acceptable transmission standard for data exchange with patients
   Organizations with internal pharmacies should be allowed to use HL7 for eRx of discharge meds
   Quality reporting XML needs additional work on content, vocabularies, data model
   Imaging in MU should be clarified (view/access/transmit in an EHR or via an EHR)
   Allergy terminology should be included in the Standards Final Rule - RxNorm for meds, NDF-RT for drug classes, SNOMED-CT for non-meds
   Our focus should be the adoption of SNOMED-CT as the clinician facing vocabulary, not ICD-10
   XDR as a transport standard should be optional, as was defined in the Direct Project
   Patient Portals - Direct should be used with patients i.e. EHRs should be able to "cc the patient"
 
Next, Betsy Humphreys presented the Vocabulary and Code Sets update  focusing on SNOMED0CT, LOINC and RxNorm tools.  A new API to access cloud hosted SNOMED-CT resources from NLM will be available in March 2012.

Next, Dixie Baker presented the NwHIN Power Team review of NwHIN Exchange implementers comments.   Major themes included
*Complexity seems to be related to the specifications themselves which include optionality and layers of references to other specifications (indirection).  There was no specific complaint about SOAP or the need for REST
*No current Exchange implementation is being used for large scale production except the SSA's disability determination project
*The Exchange Patient Discovery architecdture lacks scalability

Next, Paul Tang presented the 2012 HITPC work plan.  He reviewed the 5 year vision with 2011being capture of structured data, 2013 being HIE/Care Coordination, and  2015 being outcomes measurement and improvement.   The 2012 work plan includes
*Q1 discussion of MU Stage 3 principles, review of the MU Stage 2 NPRM, governance, next generation quality measures
*Q2  Quality measure lifecycle, patent generated data, information exchange, EHR safety
*Q3  Stage 3 draft recommendations, long term and post-acute care, governance NPRM
*Q4   Reconcile MU3 Recs with Stage 2 Final rule,  HITSC feedback on stage 3 , Consumer eHealth, Strategic plan revisions

Next, Jim Walker presented the work plan for the Clinical Quality Workgroup.

Finally, Doug Fridsma presented the S&I Framework update identifying the levels of support currently available - Self Service, Limited Service, Strategic Support and Full support.  S&I portfolio of new work includes longitudinal coordination of care, electronic submission of medical documentation signatures and content, query health, and data segmentation for privacy.

Thus, the HIT Standards Committee is on track for our 2012 work plan, the first quarter of which includes 4 projects

a.   NPRM review
b.  Quality measurement
c.  NwHIN Exchange refinement
d.  Value sets/vocabulary mapping

At the next meeting, we'll review our collective comments on the NPRM (gathered from each of our workgroups) and ensure we're on the right trajectory for our next quarter's work on standards governance, Query Health, Radiology Standards and NwHIN supporting components (Provider Directories, PKI).

S&I Framework Implementation Guides

Now that the Stage 2 Standards and Certification NPRM has been released, many people are asking me for the detailed implementation guides that will support it.

The S&I Framework website is being enhanced to make their work products easier to find.

In the meantime, here are some of the major S&I Framework resources

Final DNS/LDAP Hybrid Specification for Direct Project Certificate Discovery

Final Data Model for Query/Response to the Provider Directory for electronic service information (implementation guidance forthcoming):

Latest Laboratory Reporting Implementation Guide (will be balloted a second time at HL7 this spring)

Final Consolidated CDA Implementation Guide

We're getting closer to our goal of one stop shopping - a single website with all the content, vocabulary, and transport standards needed for certification.

The Stage 2 Standards and Certification NPRM

On Friday, ONC released the Standards and Certification NPRM, the companion to the the CMS Meaningful Use Stage 2 NPRM.

Here's a bookmarked PDF  - thanks to Tony Panjamapirom of the Advisory Board.

In my view, the NPRM is a work of art, reflecting the work of the HIT Standards Committee, the S&I Framework, and  the multi-stakeholder consensus that fewer, more complete standards with less optionality will lead to greater interoperability.

I've always thought of healthcare standards as having three components -  content, vocabulary, and transport.

For content, the NPRM specifies HL7 2.51 for lab results, syndromic surveillance, reportable lab, and immunizations (HL7 2.31 is not longer an option).   For summary transactions, the Consolidated CDA is the only recommended standard.   (CCR and CCD/C32 are no longer specified).    NCPDP is specified as standard for the exchange of prescription information between entities, including for discharge medications.

For vocabularies, the NPRM specifies a single vocabulary per domain, just as HITSC recommended
Lab - LOINC
Medications - RXnorm
Problem Lists - SNOMED-CT
Discharge Diagnosis - ICD10-CM
Immunizations - CVX
Demographics preferred language - ISO 639-1
Demographics preliminary cause of death ICD10-CM

For transport, two standards are available, consistent with the Direct Project - SMTP/SMIME and SOAP.   A RESTful option is not specified, but ONC recognizes that a RESTful implementation guide may be available in the future.

The 2014 edition of the Standards and Certification NPRM eliminates the "OR", since this standard OR that standard implies that vendors need to support both, creating an "AND" for implementers.  

The ONC NPRM is clear, unambiguous, forward looking and reasonable.   Congrats to the team who wrote it.

A First Look at Meaningful Use Stage 2

The Meaningful Use Stage 2 Notice of Proposed Rulemaking was released today at 4:15pm.  It represents the work of hundreds of people from every healthcare stakeholder group.   I'll summarize all 455 pages this weekend and give two webinars next week (Greater New York Hospital Association and a special session for the Harvard School of Public Health).  

For now, I recommend you read this summary on pages 156-163 to understand that EPs must meet or qualify for an exclusion to 17 core objectives and 3 of 5 menu objectives.   Also that eligible hospitals and Critical Access Hospitals must meet or qualify for an exclusion to 16 core objectives and 2 of 4 menu objectives.

Other key points from the executive summary:

*For EPs, we propose a set of clinical quality measures beginning in 2014 that align with existing quality programs such as measures used for the Physician Quality Reporting System (PQRS), CMS Shared Savings Program, and National Council for Quality Assurance (NCQA) for medical home accreditation, as well as those proposed under Children's Health Insurance Program Reauthorization Act CMS-0044-P 18 (CHIPRA) and under ACA Section 2701.

*For eligible hospitals and CAHs, the set of CQMs we propose beginning in 2014 would align with the Hospital Inpatient Quality Reporting (HIQR) and the Joint Commission's hospital quality measures.

*This proposed rule also outlines a process by which EPs, eligible hospitals, and CAHs would submit CQM data electronically, reducing the associated burden of reporting on quality measures for providers. We are soliciting public feedback on several mechanisms for electronic CQM reporting, including aggregate-level electronic reporting group reporting options; and through existing quality reporting systems. Within these mechanisms of reporting, we outline different approaches to CQM reporting that would require EPs to report 12 CQMs and eligible hospitals and CAHs to report 24 CQMs in total.

*Stage 2 meaningful use requirements include rigorous expectations for health information exchange including: more demanding requirements for e-prescribing; incorporating structured laboratory results; and the expectation that providers will electronically transmit patient care summaries to support transitions in care across unaffiliated providers, settings and EHR systems.

To understand the themes underlying Meaningful Use Stage 2, here's a great blog post from Health Affairs.

Finally, here's a powerpoint summary you can reuse for your own presentations - no attribution needed.  I've compared each criteria to its Stage 1 equivalent.

Our Cancer Journey (Week 10)

Kathy is now finished with the hardest part of her chemotherapy regimen, Adriamycin/Cytoxan.   Next week, she begins Taxol every week for the next 12 weeks.    Taxol is typically far less fatiguing than AC.    It does have a problem that it is suspended in an solvent that can cause allergic reactions.   Her regimen will include supportive doses of diphenhydramine (benadryl) and dexamethasone (a steroid).

At last week's checkup, Kathy's oncologist could no longer locate the tumor.

Her breast surgeon will order an MRI at the completion of the Taxol cycles and if the tumor is undetectable, Kathy may be able to have to breast conserving surgery rather than a complete mastectomy.

On Taxol, her hair will begin to grow back and her energy is likely to rebound.   However, she is quite concerned about one side effect - a neuropathy causing numbness in her hands.    As an artist, she depends on a keen sense of touch to create her work.

She will no longer need Neulasta (a bone marrow stimulant).   She welcome the fact that Neulasta protected her from neutropenic nadirs/infections but really did not like the bone pain/total body aches that it caused.

So the journey continues and we feel that we've turned the corner.   It's too early to see the light at the end of the tunnel, but at least the tunnel will be easier to traverse for he next 12 weeks.