The Healthcare Information Technology Expert Panel II

Last week, I joined an amazing group of colleagues at the National Quality Forum's Healthcare Information Technology Expert Panel to work on a next generation quality data set. They key breakthrough was the development of a universal terminology for the design of quality measures which captures process and outcome data from electronic systems.

Elements which are captured include:

Datatype (e.g., medication order)

Data (e.g., aspirin)

Attributes (e.g., date/time)

Data Source (e.g., physician, patient, lab)

Data Recorder (e.g., physician, lab, monitor)

Data Setting (e.g., home, hospital, rehab facility)

Health Record Field (e.g., problem list, med list, allergy)

In the original HITEP work last year, 35 datatypes were defined such as encounter, diagnosis, diagnostic study, laboratory, device, intervention, medication, symptom etc. Each datatype can have subtypes describing specific events. Here's an example of the subtypes of the medication datatype

medication administered
medication adverse event
medication allergy
medication discontinued
medication dispensed
medication intolerance
medication order
medication prescribed
medication offered
medication refused

A traditional measure of quality might be

"Was Aspirin administered within 5 minutes of ED arrival in diagnosis of acute MI?"

If an EHR transmits datatypes for encounter, diagnosis, and medication to a quality data warehouse, we could capture the following data:

Datatype - encounter
Data - ED arrival
Attribute - date/time of arrival
Source - registration system
Recorder - ED ward clerk
Setting - ED
Health record field - ED arrival date/time

Datatype - diagnosis
Data - MI
Codelist - SNOMED code 12345
Attribute - date/time of diagnosis
Source - physician
Recorder - physician
Setting - ED
Health record field - encounter diagnosis

Datatype - medication administered
Data - ASA
Codelist - RxNorm code 123456
Attribute - date/time of administration
Source - nurse
Recorder - nurse
Setting - ED
Health record field - medication administered

then the quality measure could be defined as

Diagnosis="SNOMED 12345" AND (medication administered="RxNorm 123456" date/time - ED arrival encounter date/time) < 5 minutes

Such an approach makes quality measures more clearly defined, more directly related to data elements in EHRs, and more easily maintained.

The next steps for NQF include review of their existing 500 quality measures to determine which could be placed into such a framework. If there are gaps or revisions needed, the NQF will work with quality measure development organizations.

Meaningful use of EHRs will likely include quality measurement. Having a framework for recording quality data and computing measures is foundational.

Followup on Dispute Resolution

In my earlier blog about Dispute Resolution, I described the planned gathering of computer scientists, electronic health record experts, and dispute resolution professionals called "Online Dispute Resolution in a Technology-oriented Healthcare World"

I attended the event and enjoyed the multidisciplinary discussion, learning a great deal about possible disputes among the data stakeholders in healthcare - patients, providers, payers, employers, compliance organizations, public health, government, national security, research etc.

Here are a few lessons learned

1. There's a need to web enable dispute workflow in healthcare. As e-patient Dave pointed out, I did not hear about any data concerns regarding personal health records likely because there was no easy way to raise the issue. Hospitals have policies regarding medical record disputes. Generally the workflow involves writing letters, making phone calls, and resolving disputes via committee. As the country implements more electronic records and shares more data (with patient consent), among more stakeholders, we need to embrace automated dispute resolution workflows such as are used by eBay. In healthcare, the issues are complex because the medical record is a legal record and there are many compliance issues involved in annotating it. However, I can imagine adding a comment field to the problem list which could be electronically annotated by the patient, so a clinician examining the record could understand the patient's point of view if data is disputed. In our medication reconciliation application, we give clinicians the ability to make notations about patient compliance with medications i.e. discontinued, taken infrequently, changed to a different medication etc. I can imagine gathering this input directly from patients.

Thus, the work of the dispute resolution community working with the healthcare data community will be to think through the workflow that can be supported via web-based dispute resolution tools, while still ensuring the non-repudiability of the medical record and complying with federal, state, and local medical record policies.

2. For issues that cannot be resolved via automated tools, an electronic escalation to an Ombudsman is a reasonable workflow. Complex issues are generally more easily resolved when two people speak directly rather than virtually. However, a web application could be used to identify the issues, exchange background information, and schedule the discussion.

3. If there is assertion of malpractice or harm caused to the patient, then workflows involving risk management and insurance organizations are appropriate.

The full report of the meeting will be available soon, but in the meantime, I will be more sensitive to the need to consider the modes of failure in electronic health records, especially those which are shared with patients, and the desirability of automated dispute resolution workflow.

Your Karma Account Balance

It's a tough time for everyone right now.

The economy is troubled, there's an H1N1 flu outbreak, and there's increased competition for scarce resources.

This causes people to be edgy, angry, and impatient.

I encounter a sense of frenzy when I board airplanes, when I search for parking, and when I commute on busy highways.

It's time to dust ourselves off, make the most of each day, and strive for more good Karma.

What do I mean?

Conflict happens every day. I have always believed that the nice guy can finish first in any conflict by doing the right thing.

1. By trying to win every competition you may win the battle of office politics but lose the Karma war. I've found that those who are Machiavellian live by the sword and eventually die by the sword. Thus, do not grandstand, take credit inappropriately, or demean others to enhance your own stature.

2. Rather than worrying about fame, fortune, or glory, just try to make a difference. Treat everyone with respect, listen to their concerns, and make decisions based on the greatest good for the greatest number.

3. Use email as a communication tool, not a weapon. If you feel emotion, save as draft and send it later. Never use blind cc's or use email to make others look bad to their superiors.

4. At the end of every day, look back on each open issue and ask if you've moved the issue forward. Many conflicts are not easily resolvable, but can be moved forward over time via gradual change and aligning the interests of stakeholders.

5. Stick to your principles. Integrity, honesty, and consistency should guide your actions.

If everyone looked at the balance in their Karma account at the end of every week, the world would be a much more positive place.

Yesterday in a meeting, someone asked how I was doing. My answer what that my 401k may be bad, but my Karma account is looking good. I have my health, a happy marriage , a loving daughter, and a set of really interesting challenges that enable me to make a difference.

I do not know where the future will lead, but when I look back in 30 years, I'll feel good about the journey. Along the way I'll be optimistic, kind, and fair.

Speaking of journeys, I'm at NASDAQ today doing a live webcast at 2:00pm Eastern. You can watch it at http://bit.ly/5Zm1P

Next Steps on the HIT Policy and Standards Committees

Last week, ONC formally established the HIT Policy and Standards Committees via publication in the Federal Register. Here are the announcements:

ACTION: Notification of the Establishment of the HIT Policy Committee.

SUMMARY: This notice announces the establishment of the HIT Policy Committee. The American Recovery and Reinvestment Act of 2009 (Pub. L. 111-5), section 13101, directs the establishment of the HIT Policy Committee. The HIT Policy Committee (also referred to as the
"Committee'') is charged with recommending to the National Coordinator a policy framework for the development and adoption of a nationwide health information technology infrastructure that permits the electronic exchange and use of health information as is consistent with the Federal Health IT Strategic Plan and that includes recommendations on the areas in which standards, implementation specifications, and certification criteria are needed. The HIT Policy Committee is also charged with recommending to the National Coordinator an order of priority for the development, harmonization, and recognition of such standards, specifications, and certification criteria.

FOR FURTHER INFORMATION CONTACT: Judith Sparrow, Office of the National Coordinator for Health Information Technology, e-mail judy.sparrow@hhs.gov

SUPPLEMENTARY INFORMATION:
I. Background
The Committee and its staff are governed by the provisions of the Federal Advisory Committee Act (FACA) (Pub. L. 92-463), as amended (5 U.S.C. App.), which sets forth standards for the formation and use of federal advisory committees.

The Committee shall determine a schedule of meetings following an election of a Chairperson and a Vice Chairperson from among its members.

II. Criteria for Members
The Committee shall be comprised of the following, including a Chair and Vice Chair, and represent a balance among various sectors of the health care system so that no single sector unduly influences the recommendations of the Committee. Committee members shall be appointed in the following manner:
3 members shall be appointed by the Secretary of Health and Human Services, 1 of whom shall be appointed to represent the Department of Health and Human Services and 1 of whom shall be a public health official;
1 member shall be appointed by the majority leader of the Senate;
1 member shall be appointed by the minority leader of the Senate;
1 member shall be appointed by the Speaker of the House of Representatives;
1 member shall be appointed by the minority leader of the House of Representatives;
Such other members as shall be appointed by the President as representatives of other relevant Federal agencies;
13 members shall be appointed by the Comptroller General of the United States of whom-
3 members shall be advocates for patients or consumers;
2 members shall represent health care providers, one of which shall be a physician;
1 member shall be from a labor organization representing health care workers;
1 member shall have expertise in health information privacy and security;
1 member shall have expertise in improving the health of vulnerable populations;
1 member shall be from the research community;
1 member shall represent health plans or other third-party payers;
1 member shall represent information technology vendors;
1 member shall represent purchasers or employers; and
1 member shall have expertise in health care quality measurement and reporting.
Non-federal members of the Committee shall be Special Government
Employees, unless classified as representatives.

III. Copies of the Charter
To obtain a copy of the Committee's charter, submit a written request to the above contact.
Dated: April 23, 2009.
David Blumenthal,
National Coordinator for Health Information Technology, Office of the
National Coordinator for Health Information Technology.
[FR Doc. E9-9839 Filed 4-24-09; 4:15 pm]
------------

ACTION: Notification of the Establishment of the HIT Standards Committee.

SUMMARY: This notice announces the establishment of the HIT Standards Committee. The American Recovery and Reinvestment Act of 2009 (ARRA) (Pub. L. 111-5), section 13101, directs the establishment of the HIT Standards Committee. The HIT Standards Committee (also referred to as the "Committee'') is charged with making recommendations to the National Coordinator on standards, implementation specifications, and certification criteria for the electronic exchange and use of health information for purposes of adoption, consistent with the implementation of the Federal Health IT Strategic Plan, and in accordance with policies developed by the HIT Policy Committee.

FOR FURTHER INFORMATION CONTACT: Judith Sparrow, Office of the National Coordinator for Health Information Technology, e-mail judy.sparrow@hhs.gov

SUPPLEMENTARY INFORMATION:
I. Background
The Committee and its staff are governed by the provisions of the Federal Advisory Committee Act (FACA) (Pub. L. 92-463), as amended, (5 U.S.C. App.), which sets forth standards for the formation and use of federal advisory committees. The Committee shall determine a schedule of meetings following an election of a Chairperson and a Vice Chairperson from among its members. An initial meeting of the Committee shall take place not later than 90 days from passage of the ARRA.

II. Criteria for Members
The HIT Standards Committee shall not exceed thirty (30) voting members, including a Chair and Vice Chair, and members are appointed by the Secretary with input from the National Coordinator. Membership of the Committee shall at least reflect providers, ancillary healthcare workers, consumers, purchasers, health plans, technology vendors, researchers, relevant Federal agencies, and individuals with technical expertise on health care quality, privacy and security, and on the electronic exchange and use of health information and shall represent a balance among various sectors of the health care system so that no single sector unduly influences the recommendations of the Committee. Non-Federal members of the Committee shall be Special Government Employees, unless classified as representatives.

III. Copies of the Charter
To obtain a copy of the Committee's charter, submit a written request to the above contact.
Dated: April 23, 2009.
David Blumenthal,
National Coordinator for Health Information Technology, Office of the
National Coordinator for Health Information Technology.
[FR Doc. E9-9838 Filed 4-24-09; 4:15 pm]
------------

We'll hear more about these committees soon, since their meetings are mandated by ARRA to occur in the month of May. Watch the ONC Website for announcements of the meetings and the members to be named.

More Meaningful Use

My colleague Micky Tripathi testified to NCVHS about meaningful use on April 29. His major points included:

1) We need substantial implementation support and significant resources for health information exchange if we are going to achieve meaningful use. The Regional Health Information Technology Extension Centers (RHITECs) are ideal organizations to assist with these issues.

2) ARRA currently delivers incentive payments directly to clinicians. These payments should be shared with RHITECs, which will assist clinicians with implementation of EHRs. Otherwise, RHITECs will bear the burden/expense of implementation but the physicians alone will be paid for meaningful use.

3) We should use Health Information Exchange activity measurement as a “sufficient statistic” for meaningful use. We should require basic clinical summary exchange through authorized health information exchanges, and require quality measures/public health reporting to be sent to authorized data aggregation entities. If a physician is accomplishing these, then we do not need to measure at the EHR-level because they could not accomplish these things without meaningfully using the EHR.


Also, for completeness, here is the meaningful use statement from the College of Healthcare Information Management Executives (CHIME), also submitted to NCVHS. Sharon Canner from CHIME added a clarification to this testimony:

There is an error in our statement, discovered late in the process. The statement should have read “HL7 Continuity of Care Document (CCD).” CHIME Prefers the CCD; however, it may be a stretch for some hospitals initially.

Information Technology and the H1N1 Virus

At BIDMC, our Infection Control staff have sent out daily updates about the H1N1 Virus, our process changes to protect patients/staff, and our planning for future activities if the infection escalates.

There are many things that IT can do to support the hospital and the country during this outbreak. Here are five projects we've implemented.

1. Support CDC's Biosense

Every day, BIDMC electronically sends 4000 data elements to the Centers for Disease Control using the HITSP Biosurveillance standards. Patients are not identified - no names, MRN’s or addresses are sent. Birthdays are month and year only. Here are the data elements we send:

Inpatients
ADT information – a message that there was an admission, discharge or transfer with date and time
Diagnosis
Procedures
Pharmacy orders
Daily census

Emergency Department Visits
Visit information
Acuity
Diagnosis
Procedures
Pharmacy orders
Patient instructions

Outpatient Visits
Visit information
Diagnosis

All patients
Microbiology orders and results (including viral studies)
Radiology orders and results

The CDC uses this to track outbreaks and prioritize resource allocation.

2. Build an intranet site to educate faculty and staff

We've supported our Infection Control staff with template-based content management tools and launched "H1N1 Central". In this single intranet site we link together our institutional polices, CDC reports, local news, and best practices.

Also, all our login screens display the message

"H1N1 Influenza Employee Screen:
In order to prevent spread of infection to patients and staff,
the following guideline should be followed by all staff:
If you have two or more of the following:
- fever over 100 in past 7 days
- flu symptoms (chills, cough, sore throat, stuffy nose, body aches, headache)
in past 7 days
- contact within 6 ft of someone who has a flu-like illness
Please put on a mask if you are in the hospital, contact your manager/supervisor
immediately to arrange coverage for your absence and to advise regarding
need for swab testing. Contact your PCP if appropriate, and recover at home."


3. Employees have been told to stay home if they have flu symptoms. In the case of H1N1 or any infectious outbreak, it's important to support remote access to applications, data, and communications. BIDMC applications are all web-based and accessible anywhere in the world. All our files are web accessible as well as mountable via VPN. We have an SSLVPN from Juniper Networks available at https://secure.bidmc.harvard.edu. We have a web-based large file transfer systems available at https://transfer.bidmc.harvard.edu. We are testing the ability to route incoming phone calls to cell phones and home numbers. The combination of all these features makes working from home simple and seamless.

4. Provider Order Entry order sets for isolation of infected patients

We're enhancing our internally developed provider order entry system with order sets specific to H1N1 so that clinicians can easily order standardized protocols for H1N1 isolation and treatment.

5. Public Health data reporting

We've built an automated interface to the Boston Public Health Commission.

Every day we send the following data to them from the Emergency Department

Daily volume
Chief complaint
ICD9 codes
Date of service
Zip
Age
Gender
Race

The Public Health folks create control charts and identify unexpected variations in symptoms and diagnoses.

We also participate in the Aegis project, a regional real time mapping of symptoms from 20 hospitals. Aegis includes alerting and cluster detection tools for use by public health officials.

The Aegis team at Children's hospital has also created Healthmap which parses news stories and displays outbreak information.

We remain nimble and will support our local, regional and national stakeholders as needed during this outbreak.

Cool Technology of the Week

As folks who read my blog know, I'm a great fan of cloud computing, software as a service, and working remotely.

There's a perfect client to complement these technologies - netbooks.

Netbooks are simple computers with an operating system, a processor that's good enough, and just enough memory and storage to ensure a positive web browsing experience. Most cost under $500.

I recently evaluated the Dell Mini 10 and it's my Cool Technology of the Week.

The Mini 10 is a netbook with a 1024x567 ten inch display, web cam, an Intel Atom Processor Z520 (1.33GHz/533MHz FSB/512K Cache), 1 Gig of memory, and a 160 Gig hard drive in a 2.5 pound package for under $400.

I found the keyboard, multi-touch track pad, and 10" screen to be the right proportions for rapid typing and easy viewing with my 47 year old presbyopic eyes. I accessed all my storage and applications in the BIDMC and HMS clouds via 802.11g on my home FIOS network and found the Atom processor fast enough to meet my needs.

Here are the full specs.

The device I tested ran Windows XP, but I plan to test Ubuntu, which is offered on other Mini models, as soon as it is available.

A full featured netbook with a screen like a 720p television that's lightweight and low cost. Cool!