HIT Trends

November 2009

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ContentsNovember 2009

Focus on E-prescribing

– Reports on 200+ plan sponsors that launched voluntary initiatives to increase prescriber adoption of e-prescribing →

– OIG assessment of Medicare Part D plan sponsors’ ability to meet e-prescribing standards shows partial compliance →

– NCPDP, a pharmacy standards group, outlines how pharmacy is supporting industry transformation through HIT →

– Harry Totonis, Surescripts CEO, comments about e- prescribing and Surescripts future industry role →

Focus on EHR

– Study shows EMR clinical decision support applications can lower use of antibiotics →

– Two new studies on EMRs in hospitals point to only marginal gains →

– AAFP 2009 EHR User Satisfaction Survey →

– American Medical Group Association EMR survey →

– Commonwealth Fund reports on how the US healthcare lags other nations including HIT →

– EMR implementation guide released by the Texas Medical Association →

– WSJ Health Blog: Senator Grassley letter to EMR vendors →

Tracking HITECH

– Dr. David Blumenthal outlines how ARRA is designed to attack the barriers to patient-centered care →

– HIT Policy Committee recommends a simple Meaningful Use framework to get started →

– National Quality Forum publishes its Quality Data Set to help rationalize HIT interoperability →

Focus on Health Information Exchange

– Information Week on different models of HIEs →

Focus on Health Information Exchange (continued)

– GE positions new division in the Health Information Exchange platform

market →

Focus on Care Communications

– New body area network is an advance in personal health communications →

– Text messaging reminders improved medication adherence in adolescents →

– AHRQ reports on the impact of Consumer Health Informatics (CHI)

applications on health outcomes →

– AHRQ study confirms a lack of standards for calculating medication adherence

and a variety of data sources used →

– Study suggests that medication adherence may be handled by physicians

without adding time to the visit →

– InformationWeek focuses on Smartphone applications for healthcare →

Focus on Social Media

– Physicians focus on social media →

– Sharecare.com launches a new healthcare search and social media site

backed by big media →

– NPR reports on health social media →

Focus on Comparative Effectiveness Research

– New company launch to bring “big data” technologies to healthcare research →

– IBM announces new Health Analytics Center →

Company Spotlight

– Dell: A comprehensive solution for health systems to help automate affiliated

providers →

Commentary

– End note: HIT to support industry process integration →

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HHS report on Medicare Part D plan sponsor electronic prescribing initiativesFocus on E-prescribing

Reports on 200+ plan sponsors that launched voluntary initiatives to increase

prescriber adoption of e-prescribing

20% of sponsors had a program; 18% more in planning

50% of these had average or high participation

75% didn’t report quantifiable benefits because they didn’t measure

Many because they couldn’t get the data from multiple participating software vendors

25% who measured most commonly reported increases in generics prescribed and formulary compliance

More Info: HHS

Elements of Plan-Sponsored Initiatives

Editorial: While it’s disappointing that more measurement wasn’t done, there is encouraging news about participation. Strategies discussed in the report include: physician mandates, quality bonuses, incentive to pharmacies, and partnering with others.

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OIG assessment of Medicare Part D plan sponsors’ ability to meet e-prescribing standards shows partial complianceFocus on E-prescribing

69% report partial plan-to-prescriber

connectivity and only 8% report complete

Problems implementing the formulary and benefits standard limited connectivity

Plans had problems with a batch process instead of real time for each beneficiary upon request

Only 5% of plan sponsors reported no plan-to-dispenser connectivity

More Info: OIG

Editorial: There are supporting anecdotal reports from health plans indicating that many EMR solutions, in particular, struggle with providing good functional medication management connectivity. This an area where improvements can create significant value.

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NCPDP, a pharmacy standards group, outlines how pharmacy is supporting industry transformation through HITFocus on E-prescribing

More Info: NCPDP

Healthcare Need Pharmacy Experience

Health information network infrastructure to support real-time claims adjudication and coordination of benefits

Telecommunication standards and standardized routing identifiers

Standardized health benefit identification cards

NCPDP healthcare ID cardimplementation guides

Computerized order entry and results reporting

NCPDP SCRIPT standard used for e-prescribing fill status

Integration of medical history from other providers

Use of medication history via the SCRIPT standard

Real-time clinical evaluation of medical history

Use of drug utilization review elements in NCPDP telecommunication standard

Coverage validation before treatmentUse of NCPDP formulary and benefits standard and telecommunication standard

Editorial: Here’s a reminder that pharmacy has the most advanced national network and a discussion of its elements

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Harry Totonis, Surescripts CEO, comments about e-prescribing and Surescripts future industry roleFocus on E-prescribing

Progress in adoption140,000 prescribers or 23% of the market

Good progress but we need to do more in smaller practices

BarriersDEA regulations where there’s been progress

Physician resources where the regional extension centers are helpful

Consumer pressureOn physicians, yes. Less so on pharmacies who have adopted faster.

Physician incentivesPrimarily safety through more legible scripts and access to medication history

Reducing costs for all stakeholders is what will continue its viability

What’s next for SurescriptsNeutral platform has led to industry collaboration

Leverage these into new services for health information exchange

More Info: Healthcare IT News

Editorial: Surescripts has enormous assets which are likely to make it a larger player in the national health information exchange landscape as it unfolds.

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Study shows EMR clinical decision support applications can lower use of antibioticsFocus on EHR

Hospital-acquired Clostridium difficile infections are almost always associated with inappropriate use of anti-microbial agents

Studied impact of EHR and computerized physician order-enter (CPOE) at Pitt County Memorial, NC (739 beds)

Measured 46 commonly prescribed antibiotics as well as the cases of Clostridium difficile infections before and after EHR

There was an 18% decrease in the use of all anti-

microbials and a 26.2% decrease in the rate of infection after the EHR was implemented

More Info: Public Communications, Inc.

Editorial: Additional proof that if physicians are alerted appropriately by EHRs they generally do the right thing.

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Two new studies on EMRs in hospitals point to only marginal gainsFocus on EHR

Hospital Computing and the Costs and Quality of Care: A National Study (American Journal of Medicine, Himmelstein)

4,000 US hospitals

More computerized hospitals had higher total costs

Degree of computerization is not related to costs

Speed of implementation is associated with higher costs

Hospital quality of care and HIT (reported in the NYTimes, Jha and DesRoches)

3,000 US hospitals

Follow up to New England J. Med. study in April 2009

Categorized as advanced, basic or no-EHR

Results: insignificant marginal gains to an EHR

Prior evidence of benefits come from elite environments studied, e.g., Kaiser, Cleveland Clinic and Mayo Clinic

More Info: Am. J. Medicine; NYTimes

Editorial: The learning is that benefits come from EHRs that are well-implemented and well-utilized.

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AAFP 2009 EHR User Satisfaction SurveyFocus on EHR

2000+ family practice providers rate their EMRs on

a variety of measures

Ease of use, cost and value

Documenting care

Finding and reviewing info

Ordering tests

E-prescribing

Health maintenance

Disease management

Messaging and tasking

High quality medicine

Worth the expense

Training and support

Satisfaction

More Info: AAFP

Editorial: This is the appendix to an earlier study that was only available to members. It highlights the value that some low cost EMRs create for their customers.

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American Medical Group Association EMR surveyFocus on EHR

Major Themes from the Survey

Expected benefits: clinical quality, patient service, efficiency, financial performance, market position

Need to budget for and plan training, system planning and customization

Capturing benefits takes a long time and only after workflow redesign and expanding utilization

Experience breeds optimism as expectations of benefits rise over time

Ongoing education and training is critical to realizing benefits

Patience and persistence are among the most critical factors

More Info: AMGA

Editorial: It’s not the systems per se that create value, but their utilization over time. Commitment to see it through is key.

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Commonwealth Fund reports on how the US healthcare lags other nations including HITFocus on EHR

10,000 primary care physicians surveyed in 11 countries

About US physicians

58% say patients often can’t pay for drugs

29% say they can get patients after hours care

46% use EMRs compared with 90% elsewhere

28% report patients have long waits to see specialists (among the best)

59% deploy care teams (among the lowest)

Practice routine use of IT

Practice Routinely Sends Patients Reminders for Preventive or Follow-Up Care

More Info: Commonwealth Fund

Editorial: International comparisons fuel the health reform debate. These reports also remind us that there is a strong market for EHRs outside the US.

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EMR implementation guide released by the Texas Medical AssociationFocus on EHR

More Info: TX Medical Assoc.

Editorial: Comprehensive (100+ pages) and practical guide covering all relevant aspects of EMR implementation

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Table of Contents of the Guide

Introducing HIT ……………………………………….…………….9

Why now? ..............................................................12

ARRA ………………………………………………………..….…….18

Is your practice ready for HIT? ………….…….…….……27

Case Study: Change is Good

Which product is right for your practice? …..…....…37

Open source solutions …………………………..……..…...44

Making the selection ………………………………………….54

Request for proposal ………………………..……….……….59

Case study: The Networking Element

Budgeting and financing for HIT …….………..…………66

Creating the Contract …………………….…………..………72

Moving forward: Implementation …….………..………81

The law and HIT ……………………………….…………..……91

Case study: Using technology from Day One

Glossary and resources ………………………………………98

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WSJ Health Blog: Senator Grassley letter to EMR vendorsFocus on EHR

“Over the past year, I have received complaints from patients, medical practitioners and technologies engineers… for example, faulty software that miscalculated intracranial pressures and interchanged kilograms and pounds…

In addition, it has been reported that HIT/CPOE manufacturers rely on a legal doctrine known as “learned intermediaries,” to shift responsibility for errors in the HIT systems to physicians, nurses, pharmacists, and other health care providers…”

3M

Allscripts

Cerner

Cognizant

Computer Sciences

More Info: WSJ Blog; Letter

Letter was sent to these HIT companies

Eclipsys

Epic Systems

McKesson

Perot Systems

Philips Healthcare

Hold harmless

Learned intermediaries

Adequate training

Complaint tracking

Financial incentives

Settlement agreements

Key contract issues of interest

Editorial: This month Charlie McCall, an ex-HBOC executive, was convicted of accounting fraud related to revenue recognition in 1999.

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Dr. David Blumenthal outlines how ARRA is designed to attack the barriers to patient-centered careTracking HITECH

We cannot restrict private and secure messaging across providers or networks

More Info: HHS

Key premise: Information should follow the patient and be private and secure

The HITECH Act calls for the “development of a nationwide health information technology infrastructure that allows for the electronic use and exchange of information and that…promotes a more effective marketplace, greater competition...[and] increased consumer choice” among other goals. (Section 3001(b))

Commercial barriers

Economic barriers

Technical barriers

Info Exchange

HITECH incentives encourage information exchange

EHRs sharing information that follows patients and HHS investments in infrastructure including HIE connections

$564M targets info exchange across boundaries as part of a national framework

Editorial: Here’s a clear statement by ONC about the top level strategy talking points.

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HIT Policy Committee recommends a simple Meaningful Use framework to get startedTracking HITECH

Early Emphasis on Primary Care

Key role of primary care

Fewer specialty measures available

Number and complexity of specialties

Begin with a Simple FrameworkCore measures – all providers

Use CPOE for all orders (process)

Avoid use of high-risk medications in the elderly (quality)

Percent of patient encounters with insurance eligibility confirmed (efficiency)

Adult primary care measuresReport percent of diabetics with A1c under control

Pediatric primary care measuresReport up-to-date status for childhood immunizations

Specialty measuresCross all specialties: closing the loop on referrals

Specialty-specific measures

More Info: HHS

Editorial: In general this is a good idea. A slightly broader focus to include a measure for BP control would be welcome. This lowering the bar might encourage more companies to enter the meaningful use market.

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National Quality Forum publishes its Quality Data Set to help rationalize HIT interoperabilityTracking HITECH

QDS framework provides a standardized set of data that should be captured in patients’ electronic health records and is applicable to all care settings a patient is likely to use in his or her lifetime.

QDS acts as a dictionary for quality measurement, providing a standardized core set of data.

QDS enables quality measurement from a variety of electronic sources, including electronic health records (EHRs), personal health records (PHRs), registries and health information exchanges (HIEs).

More Info: NQF

What is the Quality Data Set?

Editorial: The HITEP panel is chaired by Paul Tang, MD from PAMF. It is building on prior work in 2008 which identified 11 data categories and 39 data types.

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Information Week on different models of Health Information ExchangesFocus on HIE

Maine statewide: 700 clinicians serving 560K patients; expected to shortly double

Oracle central repository of continuity of care records on about 1/2 the population

Browser access by clinicians

More Info: Information Week

NYC Primary Care Information Project

OR / Canada border: 3 hospitals connected to Harborview in Seattle, WA

150,000 patients in centralized databank

Initial focus on remote pharmacy services

NYC underserved: 1600 physicians growing to 2500 and 1.3M patients

Free eClinicalWorks EMR with record exchange via messaging

MA/RI: six hospitals connecting through Microsoft Amalga patient repository

Patients connect through Microsoft HealthVault PHR with device connectivity

Editorial: HIEs are growing in importance as the national infrastructure gets created. One difference to track is the centralized repository versus the federated model of request-response. Another is whether there is a specific application focus like an EMR or PHR.

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GE positions new division in the Health Information Exchange platform marketFocus on HIE

Investing $90M to create new eHealth business

Focused on regional and statewide health information exchange networks

Part of $250M Healthyimagination Fund of a $6B project

Service areas

Patient health records through LifeSensor, developed by InterComponentWare (ICW)

Health information sharing through its Centricity HIE infrastructure

Structured clinician views through a new eHealth clinician portal

Patient ID and matching through its own Master Patient Index (MPI) technology

More Info: GE

Editorial: GE could excel in this area. They bring significant assets including their financing arm. The ICW relationship makes sense also. They will jointly approach the international market.

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New body area network is an advance in personal health communicationsFocus on Care Communications

Toumaz in collaboration with Imperial College, London, is

designing health applications using ultra-low power microchip and

wireless technology

Providers can monitor the human body continuously, wirelessly, at low-cost

Multiple vital signs in real-time via PCs, PDAs and cell phones

Information, not raw data

End-to-end, from body to provider

More Info: Toumaz

Editorial: This might be breakthrough technology. It allows for very thin batteries and very light-weight, but robust devices. The focus on end-to-end is intelligent positioning.

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Text messaging reminders improved medication adherence in adolescents Focus on Care Communications

Mount Sinai Hospital in New York recruited 41 adolescent liver transplant patients

Text message reminders sent at pre-determined times requesting confirmation

Alerts sent to caregivers after 30-minutes without intake confirmation

Results suggest significant improvement in medication adherence and reduction in rejection episodes

More Info: Pediatrics

Editorial: This is an interesting architecture and workflow that has broader application. The confirmations and notifications can add value in gaps-in-care messaging.

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AHRQ reports on the impact of Consumer Health Informatics (CHI) applications on health outcomesFocus on Care Communications

146 studies reviewed including 121 randomized controlled trials

Studies were very heterogeneous and of variable quality

Positive impact was cited in most categories

Intermediate health outcomes

Doctor-patient relationship

Clinical outcomes

Insufficient evidence to assess economic impacts

Conclusions for select CHI applications

May effectively engage consumers

Enhance traditional clinical interventions

Improve both intermediate and clinical health outcomes

1. What is the evidence of impact of CHI applications on health outcomes?

2. What are the barriers that clinicians, developers, consumers, and their families or caregivers encounter that limit utilization or implementation of CHI applications?

3. What knowledge or evidence deficits exist regarding needed information to support estimates of cost, benefit, and net value with regard to consumer health informatics applications?

4. What critical information regarding the impact of consumer health informatics applications is needed in order to give consumers, their families, clinicians, and developers a clear understanding of the value proposition particular to them?

More Info: AHRQ

Report is a 500+ page encyclopedic review of consumer health informatics studies

Editorial: The 176 references alone are worth the download.

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AHRQ study confirms a lack of standards for calculating medication adherence and a variety of data sources usedFocus on Care Communications

15 AHRQ grantees report on issues related to studying medication adherence

Days covered and fill adherence

Medication possession ratio within an e-prescribing system

Adherence by class

Patient self-reported adherence

Determining reasons for non-adherence

More Info: AHRQ

Editorial: This is a well-organized report on the current developments in medication adherence research and HIT.

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Study suggests that medication adherence may be handled by physicians without adding time to the visitFocus on Care Communications

Adult primary care visit frequency, quality, and duration increased between 1997 and 2005

Modest relationships were noted between visit duration and quality of care

The average visit lasted 18 minutes in 1997, while visit time had increased to nearly 21 minutes by 2005

Providing counseling or screening required additional physician time

Providing appropriate counseling or screening generally took 2.6 to 4.2 minutes

Ensuring that patients were taking appropriate medications seemed to be independent of visit duration

There were improvements in beta blockers for coronary artery disease or appropriate medications for heart failure

Adult primary care visit duration (1997-2005).

More Info: Arch. Internal Med.

Editorial: This is encouraging, particularly to the projects that are beginning to engage physicians in adherence issues through their EMR.

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InformationWeek focuses on Smartphone applications for healthcareFocus on Care Communications

A junior at Princeton received a grant to work on an iPhone app for diabetics to record what and how much they eat, insulin injections, blood sugar readings, and activity levels

Glide Health encourages its 1M patients to store medical history data as audio or text on smartphones and securely share with medical professionals

The Louisville School of Medicine deploys mobile medical apps to its 600 med students, including ePocrates

Blue Cross of Northeast Pennsylvania is deploying smartphone apps to 5,000 to 10,000 patients to carry medical histories

Charlie Kimball, a race car driver, uses the Documents To Go iPhone app from DataViz to record his food, exercise, and blood sugar log in an Excel spreadsheet for his diabetes control

More Info: InformationWeek

Editorial: General technology press continues to highlight healthcare opportunities for new, emerging architectures.

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Physicians focus on social mediaFocus on Social Media

Surgeon uses Twitter to keep families in touch during long surgeries

Internist uses Facebook to encourage patients to communicate with her over secure e-mail

A surgeon tweets during surgeries as an educational device for students

Dermatologist tweets medical facts to her followers

Orthopedist created iPhone app (Dr. Rounds) to collect patient information and email it to his office manager or other physicians

More Info: Miami Herald

Editorial: Security and privacy issues are addressed in each story. In most cases patient names aren’t used or only one initial. And Facebook isn’t used for patient messaging.

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Sharecare.com launches a new healthcare search and social media site backed by big mediaFocus on Social Media

Health Q&A format and social network as foundation of new eco-system

Created by Jeff Arnold and Dr. Mehmet Oz, in partnership with Harpo Productions, HSW International, Sony Pictures Television, and Discovery Communications

Hospitals and Academic Medical Centers: Cleveland

Clinic, Johns Hopkins Medicine, and New York-Presbyterian Hospital

Leading health and wellness authors: Drs. Oz, Roizen,

Ornish and Deepak Chopra (new publishing business model licensing chapters in books)

Associations/Societies: Society of Thoracic Surgeons

Healthcare professionals: Drs. Kaufmann, Hoy, Lisa

Online healthcare resources: Discovery Health,

HowStuffWorks.com, and Oprah.com

Consumers: Daily Strength web site

Not for profits: Challenge America

More Info: Sharecare

Editorial. Jeff Arnold is a visionary who has pulled together an impressive array of health and media assets to compete in consumer health search. This feels similar in style to his creation of WebMD.

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NPR reports on health social mediaFocus on Social Media

About 20 percent of e-patients go to Internet and social-networking sites where they can talk to medical experts and other patients

The Pew study found that 39 percent of e-patients already use a social-networking site like Facebook

But the source patients say they trust the most is their own doctor

PatientsLikeMe has 50,000 members living with conditions like multiple sclerosis, fibromyalgia or bipolar disorder

Patients find out whether their concerns are justified, they make sense, and whether they’re doing the right thing

Press to Play

More Info: NPR; Audio← To ToC

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New company launch to bring “big data” technologies to healthcare researchFocus on Comparative Effectiveness Research

Explorys enables instantaneous search, tagging, and collaboration across very large healthcare datasets

Equity partnership with Cleveland Clinic to leverage its clinical data and network of researchers and clinicians

Solutions provide a secure web interface for clinicians to mine patient population data without IT expertise

Encourages exploration by clinicians

Led by serial entrepreneurs with a successful track record in technology innovation

More Info: Explorys

Editorial: As CER gets more attention in the market, we are likely to see innovations. This one is worth noting because of its access to an important data source, and the experience of its founders.

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IBM announces new Health Analytics CenterFocus on Comparative Effectiveness Research

First center of its kind to address the need for advanced analytics across the

healthcare industry

Collect and analyze data from sensors, patient monitoring

systems, medical instruments, handheld devices and hospital monitors

Apply to health quality in disease management, hospital quality

improvement, patient population studies and performance reporting

Highlight best facilities in improving patient outcomes and

identifying the best drug combinations, modifications and care approaches

Explore patterns of unnecessary care and opportunities for

improving patient safety or quality of care

Developed with leading hospitals such as Duke University

Medical Center, Geisinger Health System, Mayo Clinic, New York's Memorial Sloan Kettering Cancer Center and the University of North Carolina to advance health analytics technology

More Info: IBM

Editorial: This effort is part of a broader initiative around business analytics. It is opening six other analytics solution centers in Berlin, Beijing, Tokyo, New York City, London and Washington, D.C.

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DellCompany Spotlight

A comprehensive solution for health systems to help automate affiliated providers

EMR software from eClinicalWorks or Allscripts delivered as a hosted service

Creative financing coordinated with meaningful use incentives to limit physician need for cash

Assessment, deployment, training and support services utilizing Perot and other resources

Includes practice readiness and workflow reengineering

Includes specially trained Dell technical support staff

Health system architecture design services and support to create an HIE

Community promotion and market development

More Info: Dell; Seminar

Dell Affiliated Physician EMR Solution

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CommentaryEndnote

Kaiser Permanente, Mayo Clinic, Cleveland Clinic have best-leveraged HIT because of their integrated organizational structures, among other things

Our challenge as an industry is to use HIT to help create a solid foundation across our disparate US system

We are reporting this time about how entrepreneurs, like Jeff Arnold, or established companies, like Dell, are putting creative partnerships together to help develop more integrated frameworks

We hope Health Information Exchanges can get on a similar path that is sustainable and can support layers of future growth

Stack, Tony Cragg, 1975

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HIT Trends © 2009 Circle Square Inc.

Michael LakeSan Francisco, CA

www.michaellake.com

Note: If you would like to receive this report monthly via direct e-mail, please send a note to michael@michaellake.com.