Hail to the New ONC Chief

On Friday, HHS Secretary Kathleen Sebelius announced that Dr. Farzad Mostashari will be the next National Coordinator:

"I’m very pleased to announce that Farzad Mostashari, MD, ScM will become the new National Coordinator for Health Information Technology within the Office of the National Coordinator (ONC) effective today. Dr. Mostashari joined ONC in July 2009 and serves as Deputy National Coordinator for Programs and Policy. Previously, he served at the New York City Department of Health and Mental Hygiene as Assistant Commissioner for the Primary Care Information Project, where he facilitated the adoption of prevention-oriented health information technology by over 1,500 providers in underserved communities. Dr. Mostashari also led the Centers for Disease Control and Prevention-funded NYC Center of Excellence in Public Health Informatics, and an Agency for Healthcare Research and Quality-funded project focused on quality measurement at the point of care. He is a graduate of Harvard College, the Harvard School of Public Health, and the Yale School of Medicine, and conducted his training in internal medicine at Massachusetts General Hospital.

Farzad has been a critical member of the leadership team at ONC, and I look forward to continuing to work with him in this new capacity as he builds on the incredible progress made in the adoption and meaningful use of health information technology during David Blumenthal’s tenure."

I agree that Farzad is the logical choice to follow David Blumenthal.

What can we expect from Farzad?

David Blumenthal's role was akin to a startup CEO.  He had a small staff, $2 billion dollars to spend quickly/wisely, and a bold vision to improve healthcare quality/safety/efficiency using IT.

Now that the ONC staff is hired, the initial regulations are written, and the money is allocated, Farzad must evolve vision and startup into implementation and operations.

ONC has a very broad portfolio at the moment including

*Achieving EHR adoption goals by leveraging Regional Extension Centers
*Accelerating health information exchange (HIE) by providing oversight of state HIE plans
*Ensuring the success of the Beacon Communities
*Completing the standards and certification regulations needed for Stage 2 and Stage 3
*Supporting the policy goals of HIPAA, ARRA/HITECH, and Healthcare Reform through continued work by the Federal Advisory Committees working for ONC

Farzad must make midcourse corrections as needed to manage these projects to completion.

Can he do it?   Absolutely.

When the EHR marketplace did not offer the features that New York City needed to measure quality and improve population health, he motivated the industry to change the EHRs.    For example, Farzad greatly influenced the evolution of eClinicalWorks version 7 into version 8.

When the marketplace did not offer standards-based quality registries, he organized the PopHealth  initiative to transform CCRs and CCDs into quality metrics.  Given Farzad's background and public health orientation, we'll likely see an enhanced ONC focus on population health.

During his tenure as National Coordinator I predict he'll oversee the completion of blueprints for a true Nationwide Health Information Network including certificate management, provider directories, patient matching algorithms, PCAST-inspired metadata envelopes, and transport for query/response transactions (resolving the REST v. SOAP debate).

Yes, the work ahead will be hard.   However, the path forward for Meaningful Use is clear.   With resources and sound project management, we can do anything.

As a next step for the HIT Standards Committee, ONC staff will work with Jon Perlin and I to create a Gantt chart of everything we must do so we'll have monthly milestones and deadlines to guide us.

Good luck Farzad, we're here to support you.

Cool Technology of the Week

Structured electronic clinical documentation is the next frontier in EHR implementation.  It's particularly challenging in Emergency Medicine which is a fast paced, sometimes chaotic environment.   Documentation can be time consuming and is the most frequently interrupted task.  How can we balance the need for structured data capture with ED workflow?

There is no single right answer - we've used iPads with web applications, voice recognition, and disease specific templates.

We now have a new tool in our quiver, the Digital Pen from Anoto as implemented by Forerun Systems for ED charting.    Forerun is a technology spin out of BIDMC and I have no financial relationship to it.

The digital pen is NOT a handheld scanner, capturing graphics or PDFs.   It's a means to capture discrete patient data to support clinical documentation, quality reporting, and regulatory requirements.  It captures data at the bedside with a granularity that dictation cannot.

Here's how it works.

Forms are printed with a special background matrix that identifies the unique form, patient, clinician, and data elements.  Think of it as a page of  2D barcodes.   Forms can be printed as needed at various points in the ED workflow either manually or automatically.

The pen "knows" exactly which patient form is being used and what fields are being entered.   You can write on multiple forms in parallel without confusing it.    Checking a box generates structured data indicating that a sign or symptom is present.   Writing through a word generates structured data indicating that a sign or symptom is absent.   When free text is entered, both the original text and an optical character recognition interpretation are available.

As the pen is inserted in a USB dock, the structured data is uploaded into the EHR.

Here's an example

The form as entered by the user

The discrete data displayed in a web application (including handwriting recognition in red for editing).

The final output with all discrete data converted to structured documentation for clinical use.

Although we hope to use iPads for clinical documentation throughout the institution, there are workflows in which digital pens are faster, easier, and less intrusive to the caregiver/patient interaction.

A pen for patient specific structured electronic clinical documentation.   That's cool!

Preparing for Scotland

On Friday of Memorial Day weekend, I'll be lecturing about the US National Healthcare IT program in Edinburgh, Scotland

Since I'll have Saturday and Sunday free, my hosts graciously arranged a trip to the Scottish Highlands to climb:

Aonach Eagach 
Bidean nam Bian
Ben Nevis via Carn Mor Dearg (the highest point in the UK).

I asked my hosts what kind of weather to expect in May.  Their answer -
Ben Nevis has an average year 261 gales per year and 171 inches of rain.

I'm used to the mountains in the lower 48 US states - the Sierra, the Tetons, and the Whites.   All are dry climbs with an occasional brief afternoon shower.

For Scotland, I must choose boots that are completely waterproof, grip wet rocks, and are light/compact/easy to pack.     Did I mention that Ben Nevis in May may have snow at the top?

After considering many brands and possibilities, I decided on a new boot technology - the TrekSta Men's Evolution Mid GTX.

Treksta designed these Gortex lined books by scanning 20,000 feet to create a three dimensional shape that is quite different from other shoes.    The sole is made from sticky rubber plus a series of fiberglass embedded inserts that add traction on rock, ice and mud.

The shoes weigh 15 ounces each, are ankle height, are completely waterproof, fit like a glove, and are stiff enough for technical climbing.

It was tough to find a boot that would work in the constant rain of the Scottish Highlands, but the Treksta's seem like an amazing departure from the road usually travelled by boot manufacturers.

Armed with my usual total body Gortex and the same clothing approach I've used in New England, I'll let you know how I fare with the Scottish Highlands next month.

The Cost of Storing Patient Records

Yesterday, I participated in a National Library of Medicine Conference called "Long term Preservation and Management of the EHR."    Given that the EHR is a legal record, a source of data for clinical care, and a repository of knowledge for clinical research, how do we preserve it for a sufficiently long period of time to maximize value to patient, caretaker, and scientist?

Here are the program details.

I presented an overview of our tiered storage approach to information lifecycle management at BIDMC.

One controversial item was my conclusion that the storage costs per patient to retain data are insignificant.

Here's the calculation.    At BIDMC we generate approximately 1 terabyte of clinical text data (structured and unstructured) per year.    We generate approximately 19 terabytes of image data per year (radiology, cardiology, pathology, Gastrointestinal, Pulmonology, Ob/Gyn etc).    We have approximately 250,000 active patients.    20 terabytes/250,000 = 80 megabytes per patient per year.

There are many kinds of storage and many ways to calculate cost.   Rather than specify a vendor or an infrastructure, I'll use storage numbers from a non-BIDMC site for purposes of computation.

The other site offers 2 kinds of storage:

Standard storage which has a marginal cost of .34 cents per gigabyte added (or .68 per gigabyte with replication).

High performance storage which has a marginal cost of .55 cents per gigabyte added (or .89 per gigabyte if it is replicated onto standard storage)

Let's choose high performance replicated storage at .89 per gigabyte.    In Massachusetts we retain medical records for 15 years and images for 7 years.     Let's compute the cost of storing the 80 megabytes per patient per year (4 megabytes of text and 76 megabytes of images) for these regulatory lifetimes.

Text storage = 4 megabytes added per person per year.    We'll need to compute the cost of storing old data plus adding new data every year i.e.

Year 1 = 4 megabytes
Year 2 = 4 megabytes old + 4 megabytes new
Year 3 = 8 megabytes old + 4 megabytes new
Year 4 = 12 megabytes old + 4 megabytes new

and sum all these costs over 15 years.     Let's use the formula for summing numbers:  n*(n+1)/2  for 15 years and .89/gigabyte

4 megabytes*15*16/2*.89/1000 = 42 cents per patient for the first 15 years

After year 15, we can begin deleting the oldest data, so we'll always have just 15 years of data - 4 megabytes*15*.89/1000= 5 cents per year thereafter

Image storage = 76 megabytes added per person per year, retained for 7 years

76 megabytes*7*8/2*.89/1000= $1.89 per patient for the first 7 years

After year 7, we can begin deleting the oldest data, so we'll always have just 7 years of data - 76 megabytes*7*.89/1000= 47 cents per year thereafter

So when we debate the question of storing data for later reuse, keep in mind that the cost per patient is 42 cents for the first 15 years of text and $1.89 for the first 7 years of images.

The equivalent of Moore's law applies to storage - continuously decreasing costs and higher density.   We'll also have cloud storage options (although only a few public cloud providers offer HIPAA compliant storage with indemnification for privacy breaches).

In my analysis above, some may question the cost per gigabyte I used.  Feel free to multiply it by 10 such that text records could be stored for $4.20 per patient for 15 years.   It's still very economical.

In the interest of completeness, let's examine fully loaded cost.  At BIDMC, we have multiple storage platforms.  About 40% of the cost is depreciation on capital budgets.   The rest is staff, software/hardware maintenance, and other operating cost.   The average cost among these collective platforms runs $1.27 per GB or $1,270 per TB per year, fully loaded.

Of course, there are other considerations:

1.   The  definition of the "official medical record" is in flux.  The usual process for most diagnostic and treatment modalities is to cull the media so that only the important content is saved.   For example, in a sleep study, you would not save uneventful sleep time.    If medical/legal issues push us toward saving raw content, especially video, the amount of data per patient is going to rapidly expand.

2.  At BIDMC, technologies and vendors have been stable for many years.    This makes backward compatibility issues much more manageable.   By staying with the same vendors and technologies, we've not been challenged with migrating our clinical data to a new database or vendor.

3.   The increased use of multimedia in clinical care may also expand the amount of storage per patient.    Voice files (call center, voice mail, raw transcription, and the like) might someday be required to be saved for medical/legal reasons.

4.  As data expands, so does the burden of dealing with release of information requests, backup/recovery, disaster replication, testing new versions, and other application life cycle requirements.  We seldom operate with just two copies of the data.  There are usually two copies locally, sometimes more for high availability, and another copy at our disaster recovery site.    We may store additional copies for testing new versions of software, snap backups, and the like.

5.  Emerging factors contribute to costs.   e-Discovery can expand our overall costs because because backups must be retained indefinitely.   The  "digital footprint"  of patient data is changing.  Text only is manageable, but the imaging/diagnostic components are ever growing, both in number and in size.

Yes, costs add up over time for large patient populations, but the cost of storing text data is so minimal that we have not deleted a single datum from the electronic health record since I became CIO in 1997 and we have no plans to do so!

Meaningful Use Attestation

Last week CMS announced that attestation for the Medicare EHR Incentive Program (Stage 1 of Meaningful Use) will open on April 18, 2011.

Their announcement includes screenshots of the attestation website that will be used by eligible professionals, eligible hospitals, and critical access hospitals to document meaningful use of certified EHR technology.

Prior to attestation, all providers must register through CMS' web-based Medicare and Medicaid EHR Incentive Program Registration and Attestation System.

The screen shots (such as the sample above) suggest that attestation will require detailed data entry including numerator, denominator, and exclusion results for meaningful use core measures, meaningful use menu measures, core clinical quality measures, alternate core clinical quality measures (required only if a core quality measure has a denominator of zero), and additional clinical quality measures (applies only to eligible professionals).

In preparation for all of these metrics, BIDMC created reports last Summer (sample for August-October 2010) to help us track our progress.   For the measurement period from January 1 to April 1, 2011,  BIDMC has achieved all meaningful use thresholds using our CCHIT EACH Certified EHR, so we plan to attest on April 18.

Once eligible professionals, eligible hospitals, and critical access hospitals complete a successful online submission through the Attestation System, they qualify for a Medicare EHR incentive payment.

For the Medicaid EHR Incentive Program, providers will follow a similar process using their state's Attestation System.  Information on state Medicaid timelines and programs is available here.

It will be fascinating to see how many hospitals and eligible providers attest in the early months of the program.     CMS plans to take a careful look at the progress on Stage 1 before finalizing its plans for Stage 2.

The Accountable Care Organization NPRM

Since the Affordable Care Act passed, many senior healthcare executives have told me - "I do not know what an Accountable Care Organization is, but I know we need to be one!"

On March 31, HHS released the Accountable Care Organization Notice of Proposed Rulemaking, so now we know what an Accountable Care Organization must be.  From the Introduction:

"This proposed rule would implement section 3022 of the Affordable Care Act which contains provisions relating to Medicare payments to providers of services and suppliers participating in Accountable Care Organizations (ACOs). Under these provisions, providers of services and suppliers can continue to receive traditional Medicare fee-for-service payments under Parts A and B, and be eligible for additional payments based on meeting specified quality and savings requirements."

Here's a bookmarked copy of the 429 page Notice of Proposed Rulemaking signed by Don Berwick and Kathleen Sebelius.

There are numerous summaries online from various stakeholders

Don Berwick's NEJM Perspective

Kaiser's excellent list of resources

The Healthcare.gov overview

I've read the regulation and there are few items to highlight from an IT perspective:

Electronic Health Records appear on 39 pages

Health Information Exchange appears on 12 pages

To be an ACO, you must first achieve meaningful use, embrace interoperability, and gather the data to pool clinical data for quality measurement.

From Page 404:

"Electronic health records technology. 

(1) At least 50 percent of an ACO's primary care physicians must be meaningful EHR users, using certified EHR technology as defined in §495.4, in the HITECH Act and subsequent Medicare regulations by the start of the second performance year in order to continue participating in the Shared Savings Program.

(2) CMS may terminate an ACO agreement under § 425.14 of this part if fewer than 50 percent of an ACO's primary care physicians are not meaningfully EHR users, using certified EHR technology as defined in §495.4, the HITECH Act and subsequent Medicare regulations by the start of the ACO's second performance year."

Pages 174-194 outline 65 quality metrics than can only be accomplished with a cross organizational quality registry.  Claims analyses are not enough.  From page 170 and 173:

"We propose that ACOs will submit data on these measures using the process described later in this proposed rule and meet defined quality performance thresholds.

Better Care for Individuals:
* Patient/Caregiver Experience
* Care Coordination
* Patient Safety

Better Health for Populations:
*Preventive Health
*At-Risk Population/Frail Elderly Health"

The NPRM is well aligned with Meaningful Use (which appears on 27 pages).  The rule notes that all the CMS programs - Meaningful Use,  Medicare Improvements for Patients and Providers Act (e-prescribing incentives), and Accountable care organizations require separate but aligned IT efforts

"Page 220
 We note that including metrics based on EHR Incentive Program and eRx Incentive Program data does not in any way duplicate or replace specific program measures within each of the two respective programs or allow eligible professionals to satisfy the requirements of either of the two programs through the Shared Savings Program. To receive incentive payments under the EHR incentive or eRx programs (or to avoid payment adjustments), eligible professionals will be required to meet all the requirements of the respective EHR and eRx programs."

So what it an ACO?

It's a group of healthcare providers who have implemented electronic health records, health information exchange, and quality data warehouses to coordinate care and measure population health.  

Our marching orders are clear.   We must implement Meaningful Use Stage 1/2/3, Medicare e-Prescribing incentives, and Healthcare Reform in parallel.

The words ICD-10 and 5010 do not appear in the NPRM.  I continue to hope that ICD-10 is deferred until 2016 to free up the resources we need to create the EHRs, HIEs, and Registries in support  of Accountable Care Organizations.

Cool Technology of the Week

Evolving accountable care organizations will need to coordinate care, measure quality, and implement the tools needed to manage wellness. All these goals require novel IT infrastructure and applications.

I've prepared a roadmap which illustrates how every EHR and Hospital Information System among all our affiliated partners exchanges (or will soon exchange data).   Yesterday, an important part of that strategy, bidirectional data exchange between BIDMC's systems and Atrius Epic System went live.

Since January 2010, all Atrius Epic clinical users have been able to view BIDMC data about the patients we share in common.

Since March 31, 2011, all BIDMC clinical users have been able to view Epic data about the patients we share in common.

A link called Atrius Epic Web appears on the BIDMC Patient Profile screen when a patient is shared between Atrius and BIDMC.  The link displays automatically if the patient has a primary care provider who is affiliated with Atrius.

When a BIDMC clinical user wants to access Epic Records, they click on the link. and a comprehensive web-based summary of the patient's Epic records  (the graphic above)  appears, without requiring a new login or re-specifying the patient.   The patient lookup is captured in the audit logs of both BIDMC and Atrius.

The entire exchange is done using simple secure RESTful calls between web servers at BIDMC and Atrius.

Comprehensive bidirectional data sharing in support of patient care among independent organizations.    That's cool.