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March 27, 2008

Electronic Health Record and Health Information Exchange Update

While providers and patients embrace the value of electronic health records, personal health records, and health information exchange; there has been a noticeable slow down in advancement due to lack of or slow progress on developing standards for the industry; lack of consensus on addressing patient privacy and confidentiality concerns at national level; and economic issues at local and national levels.

Patient Privacy and Confidentiality Grants Through AHRQ – Illinois Initiative
At a federal level, the Agency for Healthcare Research and Quality (AHRQ) has released several rounds of grants focused on coordinating efforts among states to reach consensus on common issues on patient privacy, confidentiality, and public health and research initiatives utilizing health information. A major thrust of one of the grants was to have all the states identify gaps and obstacles that exist in state rules or regulations that do not allow for ready exchanges among other states; such as laws on guardianship, behavioral health conditions, etc. AHRQ is assembling all of the variations and will provide analysis of the issues that need to be addressed to achieve national consensus on health information exchanges. All of the initiatives under AHRQ are identified as the Health Information Security and Privacy Collaborative (HISPC).

The Illinois Department of Public Health has been the recipient of the HISPC grants and IHA has served on their steering committee and task forces since its inception. The committee and task forces include health information exchange stakeholders throughout Illinois. The Illinois HISPC has developed and released many useful documents as well as information on each of the grant phases. The HISPC information can be found at http://www.idph.state.il.us/hispc2/index.htm. Information on forms and documents developed for use by providers include Notices of Privacy Practices; Consent for Use and Disclosure of Certain Types/Categories of Protected Health Information; Authorization for Use and Disclosure of Protected Health Information for Research -- these can be found on IHA’s web site at www.ihatoday.org under Issues on Information Technology.

As the AHRQ developments progress, there is a growing tension between the demand for reductions in obstacles to health information exchange and demand by patients and consumers to control and protect their health information. Already there are several bills introduced at a federal level on privacy and confidentiality concerns --- some viewed and reported as HIPAA II.

AHIC Movement to Public-Private Organization
The American Health Information Community (AHIC) was first developed as a federal advisory body, chartered in 2005 to make recommendations to the Secretary of the U.S. Department of Health and Human Services on how to accelerate the development and adoption of health information technology and EHR implementation by 2014. Late last year, the federal government opted to move this initiative to be a public-private organization to address and develop an "effective, interoperable nationwide health information system."

The movement to a public-private organization is to be complete some time in fall 2008. During this transition period, standards for health information exchange have slowed down and are expected to continue at a slow pace. The AHIC organizational structure is under development and the ability to engage the provider community and consumers at this time is unknown. As with several national IT initiatives, many are dominated by vendors that may or may not have the same common interests of providers or consumers and may at times have conflicting goals. IHA will keep you updated as AHIC progresses in its development.

Electronic Health Records and CCHIT
Hospitals and physicians considering electronic health record (EHR) systems should check the Certification Commission for Healthcare Information Technology web site at http://www.cchit.org/ before finalizing selection of an EHR. Many government and non-governmental organizations are requiring CCHIT certification in order to participate in particular programs or awards programs. In addition to the current ambulatory and inpatient care EHR CCHIT certifications, several more are planned for other health care settings such as nursing homes, home care, behavioral health, etc.

Late last week, CCHIT and the Mitre Corporation unveiled a new product, Laika, for vendors to test their EHRs prior to applying for certification. The open source software is available at no charge and allows vendors to test their softwares before submitting their application to CCHIT thereby avoiding delays in bringing the products to market for providers. It is anticipated that Laika will also provide part of the interoperability certification later in 2008. More information can be found at http://laika.sourceforge.net/.

Additionally, the Centers for Medicare and Medicaid Services (CMS) recently rolled out a pilot testing of the Physician Quality Reporting Initiative (PQRI) measurements from CCHIT Ambulatory EHRs. The companies involved in the pilot testing are: Cerner Corporation, eClinicalWorks, NextGen Healthcare Information Systems, Inc., DocSite, Allscripts, and Anceta. Five measurements have been fully specified and focus on diabetes, coronary artery disease, and heart failure. In terms of inpatient care and reporting of the Hospital Quality Alliance information, it is still a struggle in getting the detailed measurement elements automatically to download from an inpatient EHR as the EHRs are designed to prompt and remind providers about interventions and report out results. There may be some lessons to be learned from the PQRI and EHR pilot that could be applicable to the inpatient setting.

For additional information on CCHIT and to view listings of CCHIT approved inpatient and ambulatory EHRs, go to http://www.cchit.org/.

CMS Formalizing Complaint Process for HIPAA Transactions and Other Standard Violations Not Related to HIPAA Privacy
Several years ago, healthcare covered entities were required to implement various HIPAA transactions following standards established by the federal government through a process involving input from various standard setting organizations and the public. After many years of confusion as to how to best addresses different perspectives or incorrect application of standards, the Office of E-Health Standards and Services (OESS) of the Department of Health and Human Services (DHHS) has unveiled a web site for covered entities to have their issues addressed.

Additionally, as IHA is on the National Uniform Billing Committee, the draft forms for identifying HIPAA transaction or other non-privacy standard violations or disagreements among covered entities are being discussed at the April 1 and 2 NUBC Board meeting. To provide hospitals with a sense of the tools that soon will be available to report violations, click here.

Illinois Health Information Exchange Advisory Group
The Illinois Health Information Exchange Advisory Group is spearheaded by the Illinois Department of Healthcare and Family Services. The mission is to advance the adoption of electronic health records in Illinois and facilitate the secure exchange of health information through a broad-based, collaborative initiative. The members are all healthcare stakeholders from throughout Illinois.

At the first meeting, the mission, goals, and objectives were outlined along with a strong statement that the initiative is focused on a federated health information exchange model in which providers are responsible for hosting and securing their patient information. The HIE Advisory Group is now progressing with the ongoing efforts of four sub-committees including: Pilot, Grant-Writing, Public Awareness, and Privacy and Security. The Privacy and Security sub-committee is led by the Illinois Department of Public Health with efforts focused on the HISPC grant and national privacy standards. IHA participates and is a member of the Advisory Group and serves on all of the sub-committees. We will keep you updated on developments as they occur.

Illinois and Federal CMS Initiatives on Physician EHRs
On March 5, Kerry Weems, Acting Federal CMS Director, held a meeting for stakeholders at Delnor-Community Hospital focused on the value of electronic health records (EHR) for physician practices and an announcement about a new CMS demonstration project for physician practices. As less than 10% of physicians have implemented EHRs, the Department of Health and Human Services is traveling around the country promoting the adoption and usage of EHRs.

Much of the meeting was focused on the roll out of the new CMS demonstration program to spur on EHR implementation among physicians.  There will be 12 sites selected around the nation through a competitive bidding process -- 4 will start up in fall 2008 and the remaining 8 will start up on 2009 --- each of the 12 sites will be under a five year contract.  The bids are due May 13, 2008 with the awards being announced around Memorial Day.

The sites can be large communities or sections of a state as they need to have 200 physician practices involved (from 1 to 5 physicians per practice).  The catch - 100 will be chosen by CMS as control sites and 100 will be active participants.  Each physician practice that is an active participant will have the opportunity of receiving $58,000 per physician up to a maximum of $290,000 per practice (for 5 or more physicians) over a five year period.  Each physician practice that is an active participant will need to have a CCHIT (certified) EHR up and running after a year that does e-prescribing, interventions and clinical reminders, and can generate output for some required performance measurements.  There are some criteria but it still is too general as it is "a work in progress" according to CMS.

• Physicians can qualify for this if they have already have an EHR in place
• Physicians can also qualify if they have an EHR through a hospital
• Physicians without EHRs can enroll as long as they commit to have an EHR up and running within one year after the commitment to participate is signed by the practice. Physicians do not need to have the system fully operational in Years 1 and 2 of the demonstration.
• Strategically CMS wants a mix of urban and rural physician practices. They also have established some criteria for thresholds for number of patients being seen and percent of Medicare mix.

• There are no funds for start up for any of the physicians just bringing up EHRs
• A provider could end up in the control group and not receive any funds (hard to solicit to participate knowing they may need to implement or end up being in the control group and not get any funding).
• This is a five year demonstration program in which physician practices will need to sign 5 year commitments to participate
• Physician practices could participate but may not receive full payment based upon not meeting all of the CMS requirements that CMS will specify at later date
• Physicians would also need to report on 26 Physician Quality Reporting Initiative (PQRI) measurements in year 3
• Worth physician participation?  Clearly this will be a challenging decision for physicians knowing they could end up in either control or experimental group and many will need to conduct a cost-benefit analysis

Next Steps
As the response to the CMS demonstration project does not require commitment of physician practices to sign up or commit to participate until the grant is awarded, IHA has joined with other organizations in preparing and participating in a state-wide initiative to respond to the demonstration proposal. Partners in this initiative include the Illinois Department of Healthcare and Family Services, Illinois Hospital Association, Northern Illinois Physicians for Connectivity (NIPC), NIU Health Network Initiative, Midwest Business Group on Health, Illinois Foundation for Quality Health Care, Illinois Academy of Family Physicians, Chicago Medical Society, and other medical groups and hospitals. NIPC is taking the lead in coordinating the demonstration response.

Health E Gateway
IHA’s Health E Gateway is up and running with several hospitals utilizing for exchanges of confidential information at no charge in a secure, private network. Hospitals can exchange information and images among their physicians as well as among other hospitals, clinics, and physicians. For more information on Health E Gateway, please contact Matt Angela, at mangela@ihastaff.org.

IHA will continue to keep you updated as these developments progress . If you have additional questions on the topics above, please send them to Pat Merryweather at pmerryweather@ihastaff.org.