CEO Summit at the Governor's HIT Conference

On most Thursdays, I write about something personal. However, this week is filled with special HIT events convened by Massachusetts Governor Deval Patrick.

Today, the Governor's Healthcare IT Conference began with a panel of CEOs from Humedica, Patientkeeper, Vecna, eCW, Microsoft, Intersystems, Concordant, Biscom, Bessemer Ventures, Life Image, EMC, NaviNet, Navigator Ventures, Meditech, and T2Bio.

Here's a summary of their comments

*The uncertainty in meaningful use and standards caused a delay in sales for 6 months, followed by record sales once hospitals and eligible professionals felt confident about their purchases

*Qualified staff is getting harder to find. Over the next few years, there is likely to be a competition for trained healthcare IT professional, similar to the Dot Com era. The states can really help by adding additional resources to community colleges for staff development as we prepare for 50,000 new HIT jobs.

*Medicaid programs and private insurers can accelerate adoption of HIT by aligning incentives. For example, if states and private insurers adopted meaningful use criteria, we could reduce healthcare costs by eliminating redundant testing.

*Massachusetts CEOs emphasized the need for affordable housing and transportation investments so that staff living in lower cost areas can commute to corporate locations.

*Standards, especially a consistent way to transmit clinical data from place to place are enablers.

*Loan programs for clinicians will aid investment today to achieve meaningful use stimulus payments in the future

*Health Information Exchange is a Greatest Good for the Greatest Number activity. State Governments need to provide leadership to ensure the stakeholders in each region are aligned with a single project plan, a single set of transaction priorities, and all the enablers such as regional infrastructure to accelerate adoption of data exchange.

*Regulatory barriers such as variation in privacy laws need state and federal government action to enable data liquidity. For example, revisions in the clinical laboratory improvement act (CLIA) and e-prescribing for controlled substances are already in process.

The afternoon of the conference included a great keynote by David Blumenthal outlining everything ONC has done thus far.

All that remains in the current grant program is the announcement of Beacon Communities, which he said will occur very soon.

My Thanks to HITSP

Today I wrote this email to all HITSP members thanking them for all their service from October 2005 to the present.

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Folks:

Today is a milestone day. The HITSP Contract extension expires but our work will live on as a foundation to meaningful use, standards and certification.

It is my hope that all of us will continue to be part of the ONC processes, providing input to the Federal Advisory Committees, staffing workgroups, and implementing interoperability solutions in our communities.

The HITSP website, containing all the HITSP documents, will continue to be available. ANSI has graciously offered to maintain the website for the next few months until contracts are awarded and other arrangements are made.

The new RFPs have not yet been awarded and we'll continue to watch for those announcements.

What's new in the heatlhcare standards world this month?

The April HIT Standards Committee focused on vocabulary standards, consumer engagement and healthcare reform transactions.

NHIN Direct continued its work to define simple transport implementation guides and addressing specifications.

We'll see the revised Interim Final Rule on Standards and the Notice of Proposed Rulemaking on Meaningful Use before Summer.

A busy time for all as we implement all the standards and interoperability we've all worked so hard to define.

Thank you for all you do and I look forward to seeing you in Washington as we continue our work in a new ONC framework that leverages everything HITSP has accomplished.

John

The April HIT Standards Committee Meeting

The April HIT Standards Committee today had a rich agenda and very active discussion.

We began with an update from the Implementation Workgroup and their desire to make toolkits, accelerators, and best practices available via the web. They'll align their efforts with the Tools and Standards Repository RFP described in my earlier blog.

We next discussed healthcare reform and its requirements for comprehensive insurance plan enrollment standards support as written in SEC. 3021. HEALTH INFORMATION TECHNOLOGY ENROLLMENT STANDARDS AND PROTOCOLS.

"Not later than 180 days after the date of enactment of this title, the Secretary, in consultation with the HIT Policy Committee and the HIT Standards Committee, shall develop interoperable and secure standards and protocols that facilitate enrollment of individuals in Federal and State health and human services programs, as determined by the Secretary."

As David Blumenthal described it, the intent of this provision is to make signing up for insurance as easy as using an ATM card. All the supportive transactions including identity documentation, eligibility checking, and matching identity among diverse databases needs to be specified over the next 6 months. To do this, it is clear that the Policy and Standards Committees will need to work together. Doug Fridsma and ONC was charged with recommending a process, a structure, and a framework for us to do this work.

Dixie Baker and Steve Findlay updated us on consent standards and the suite of consumer focused domain standards. The industry is asking for more specificity in the patient engagement portions of meaningful use - when producing an electronic copy of a health record, what should be included? What fields are required for an outpatient summary? The HIT Standards Committee working with ONC has more work to do in this area.

Janet Corrigan and Floyd Eisenberg described the ongoing efforts by the Quality workgroup to retool existing metrics to be EHR friendly and their project to catalog existing electronic quality measures already in use.

After lunch, Jamie Ferguson outlined two recommendations of the Vocabulary Task Force. The need for a single government office or agency to coordinate vocabulary subsets/codesets and the need to make them available via "one stop shopping" in a single repository. The committee endorsed these recommendations and they were forwarded to ONC.

Arien Malec and Doug Fridsma presented an update on the NHIN Direct effort and its short timeline to produce reference implementation. NEHEN will work to connect Massachusetts with other states as a demonstration of the NHIN Direct protocols. The HIT Standards Committee agreed that we need to coordinate all the privacy/security efforts of the HIT Policy Committee, HIT Standards Committee, NHIN Connect, and NHIN Direct efforts to ensure consistency.

Finally, Jodi Daniel from ONC and Michelle Ferritto from the Drug Enforcement Administration/Office of Diversion Control presented all the requirements for e-Prescribing controlled substances. Identity proofing is key to reducing fraud, so two factor authentication is required. Audit trails are required. Certification of software is required. e-Prescribing of controlled substances is not required as part of meaningful use at this point, but it is likely clinicians will want to do it so that they have the same workflows for prescribing Lipitor (a non-controlled substance) as Valium (a controlled substance).

The work ahead for the next few months will include

Content standards - administrative transactions such as enrollment and claims attachments in support of healthcare reform

Vocabulary standards - all the subsets/codesets required for meaningful use

Transmission standards - supporting the NHIN Direct effort

Privacy/Security - continuing our work on consent standards and the specificity needed for patient engagement

All of this will be done in the context of evolving harmonization frameworks which are supported by new RFPs.

I look forward to the work ahead!

The Genomes, Environments and Traits Conference

This morning, I'll be on stage with all the humans who have had their genomes sequenced - James Watson (pictured above), Henry Louis Gates, Misha Angrist, John West, Jay Flatley, Greg Lucier, Seong-Jim Kim, Rosalynn Gill, George Church, and James Lupski.

The GET Conference 2010 marks the last chance in history to collect everyone with a personal genome sequence on the same stage to share their experiences and discuss the important ways in which personal genomes will affect all of our lives in the coming years.

From 9a-12p, we'll discuss our personal experiences with sequencing and its impact on our lives, families, medical care, and policy thinking.

At noon we'll gather for a photograph of all the sequenced humans. By 2011 the number of individuals with personal genome sequences will rise dramatically, from a dozen today to hundreds, and possibly thousands. This makes tomorrow's photograph the last opportunity to have us all together.

I'll publish the photo on my blog as soon as it is available.

A few interesting items from the conference

In April 1953, Watson and Crick published their article characterizing DNA

In April 2003 the first Human Genome sequence was completed

In April 2008 the genetic non-discrimination act (GINA) was published

The cost of a complete human sequence in 2000 was $3 billion

The cost of a sequence 2004-2007 was $70 million

The cost of sequence in 2008 was $50,000

The cost of a sequence in 2010 is $1500

This is Moore's law on steroids. No one in the industry can believe the amazing drop in sequencing costs over the past decade.

My sequence is in the public domain and my stem cells are available online for $85.00.

I'm Coriell subject 21070.

The next addition to my online public data is a functional MRI map of my brain. I completed the scans over the weekend and I'll post an overview soon.

The Governor's Healthcare IT Conference

Although healthcare reform has its supporters and detractors, healthcare IT reform - the use of technology to improve the quality, safety and efficiency of healthcare throughout the country - has broad support from all stakeholders.

The passage of last year’s $787 billion economic stimulus bill brought with it a healthcare IT modernization program that could inject about $30 billion into the economy. Since Massachusetts is a leader both in the use and the manufacturing of healthcare IT systems, this could translate into over a $1 billion for the Commonwealth of Massachusetts.

This isn’t a “cash for computers” program though – it’s much more than that. The stimulus bill was crafted very wisely. It’s not a field day either for the doctors and hospitals who would receive these funds, or for the vendors selling this hardware and software. That’s because in order to get these dollars, physicians and hospitals have to not only buy the new systems, they have to prove that they’re using them to improve care before they’ll qualify to get any money back from the government. What does it mean to improve care? The requirements are actually quite specific and include: improving care coordination, reducing healthcare disparities, engaging patients and their families, improving population and public health, and ensuring adequate privacy and security protections.

The health IT modernization program promotes the use of advanced tools which could significantly improve the quality and efficiency of healthcare in the country today. Massachusetts is well positioned to lead this charge.

The genius of the program is that it is carefully tailored to fit our uniquely American economy and culture. We are a society that prizes individual initiative and rejects “top-down” solutions, and no other part of the economy is more reflective of that than health care delivery. We also believe in the power of markets to allocate resources where they’ll create the most value and to drive innovation that improves peoples’ lives. So unlike other countries where the government is creating its own infrastructure and dictating which systems the medical community must use, the Obama Administration’s health IT program uses federal dollars to give an adrenaline boost to the market.

It does this in three ways: incentives to providers who use IT to achieve higher quality, lower cost care; non-proprietary strict standards to create a level playing field for users and sellers of software and hardware systems; unbiased certification of software to provider assurance that it meets basic quality, safety, and efficiency standards.

Incentives. Medicare and Medicaid have defined 25 basic projects that each hospital and clinician office must complete to demonstrate that they have embraced technology to improve care. For example, medications must be electronically ordered, checked for safety, and routed to pharmacies - going from the clinician's brain to the patient's vein without paper or error-prone handwriting. Massachusetts is already the #1 electronic prescriber in the country and has been for the past 3 years. Even so, less than one-third of all prescriptions in the Commonwealth are transmitted electronically today. Fortunately, all of our regional health plans have been champions of e-prescribing, as have all of our major provider groups. Multi-stakeholder partnerships such as the New England Healthcare Institute, Massachusetts Health Data Consortium, and Massachusetts eHealth Collaborative have focused on medication safety. So even though we’re ahead of the pack, we still have a long way to go. The federal health IT program will provide a valuable boost to all of these efforts.

Standards. Well-defined precise electronic formats are needed to share data in our communities with patient consent. For more than a decade, Massachusetts has been a leading state in the secure exchange of patient data via the New England Healthcare Exchange Network (NEHEN), SafeHealth, Community Hospitals and Physician Practice Systems (CHAPS) and the Northern Berkshire eHealth Collaborative sponsored by the Massachusetts eHealth Collaborative. Massachusetts is also a national leader in providing patient access to their medical records through such programs as PatientSite, PatientGateway, myHealth Online, and Indivo Health and providers and health plans making their data available to GoogleHealth and Microsoft HealthVault.

Certification. Medical software, like any other technology that directly impacts public safety, must conform to basic testing and certification to ensure it has the capabilities needed to improve quality, safety and efficiency in hospitals and offices.

Incentives to physicians and hospitals adds fuel to the health care delivery sector, which is one of the engines of the Massachusetts economy. Furthermore, incentives to purchase software and hardware will draw dollars from other parts of the country because Massachusetts is home to several leading vendors of electronic record products such as eClinicalWorks in Westborough, AthenaHealth in Watertown, and Meditech in Westwood.

In addition to direct stimulus payments to hospitals and providers, our state has already garnered millions of dollars in grants to establish core infrastructure to spur the market. The Massachusetts eHealth Institute, a subsidiary of the quasi-governmental Massachusetts Technology Collaborative, has received almost $25 million to accelerate healthcare information exchange and facilitate electronic health record rollout. Harvard Medical School received $15 million for advanced research in electronic health records. Our academic, government, and industry experts will continue to compete successfully for additional grants as they become available.

On April 29 and 30, Governor Deval Patrick will host the Health Information Technology: Creating Jobs, Reducing Costs and Improving Quality Conference. HHS Secretary Sebelius, National Healthcare IT Coordinator David Blumenthal, and many governors will attend. It will offer us a remarkable opportunity to showcase the strength of our healthcare technology accomplishments in Massachusetts, and to learn from leaders from other parts of the country.

For all we've accomplished, there is much to do.

We still have silos of information locked away in hospitals, offices, pharmacies, and labs. We still have redundant and unnecessary testing because our care is uncoordinated. We're still using a huge amount of paper in our healthcare facilities. Paper kills.

How?

My grandmother's life was cut short by medical error. She was prescribed a combination of medications that should never be given to an older person. She developed stomach bleeding, a sudden drop in blood pressure, a stroke, and ultimately died as a result of it.

With electronic health records, data sharing, and decision support rules that inform clinicians about best practices for personalized medical care, she would have avoided harm.

Massachusetts has been an intellectual, economic, and political leader for healthcare IT for decades. We're now at the tipping point with the funding, momentum, and opportunity to ensure every patient has an electronic health record. The work ahead to complete the transformation of our manual workflows and data silos into a coordinated electronic healthcare system will be hard. Politicians, payers, providers, and patients must work together to make it happen over the next 5 years.

The lives of our grandmothers depend on it.

Cool Technology of the Week

While touring colleges this week, I was impressed by the focus on green technologies at many institutions. Many have LEED certified buildings, extensive recycling programs and innovative alternative energy sources.

I was most intrigued by Middlebury's commitment to be carbon neutral by 2016. A major component of that effort is their Biomass gasification facility pictured above, my cool technology of the week.

The idea is simple. Biomass is fuel derived from plants, such as trees, grass, soybeans and corn. Middlebury's plant uses a highly efficient gasification process in which wood chips are super-heated in an oxygen deprived environment, where they smolder creating gasses that are ignited to heat the boiler, which produces steam. The filters in the biomass facility are rated to remove 99.7 % of the particulates from the exhaust. Overall the emissions produced by the biomass plant are not greater than those that result from Number 6 fuel oil. Burning wood produce ssignificantly less emission of sulfur compounds, which contribute to acid rain.

Benefits include

*40% reduction in net emissions of carbon (12,500 metric tons)

*eliminates 1 million gallons of Number 6 fuel oil

*utilizes a local, renewable resource

*education of students and the public about energy use

*research into new fuel sources, such as willows that local farmers can grow on marginal lands

*support for locally manufactured green technology

*stimulation of the local and state economy

*less dependence on foreign oil

Additionally, the biomass plant uses the excess pressure from the steam to co-generate approximately 3-5 million kilowatt-hours of electricity per year. Also, the heat from the exhaust is used to preheat water going into the boiler.

A renewal, carbon neutral, co-generation plant - that's cool!

The NHIN Direct Addressing Specification

Every Tuesday, the NHIN Direct Implementation Group holds a teleconference to update the entire team on the progress of the technical workgroups. This week, we discussed the completed addressing specification.

As I've said many times in my blog, the most important standards implementation problem to solve right now is transport, not only the basics of transmitting data securely but also transaction orchestration and the constellation of supporting functions such as addressing the messages.

In previous blogs, I've described one way to solve the addressing problem - give every patient a voluntary opt in "Health URL" that they could use to receive all healthcare data from hospitals, offices, labs, and pharmacies.

For use cases such as sending data from provider to provider, hospital to provider or provider to public health we need some similar approach to ensure data is delivered to the right place.

The NHIN Direct Addressing specification proposes five ways to do this - secure email addressing (SMTP plus TLS), REST, SOAP, and the HL7 routing schemes XCN and XON.

First, two definitions. A "Healthcare Internet Address" is made up of a Health Domain name and a Health Endpoint Name

Health Domain Name

A Health Domain Name is a string conforming to the requirements of RFC 1034.

A Health Domain Name identifies the organizations that assign the Health Endpoint Names and assures that they correspond to the real-world person, organization, machine or other endpoint that they purport to be. For example, my organizations (BIDMC and Harvard Medical School) could control nhin.bidmc.org or nhin.hms.harvard.edu

A Health Domain Name MUST be a fully qualified domain name, and SHOULD be dedicated solely to the purposes of health information exchange.

Organizations that manage Health Domain Names MUST maintain NHIN Direct Health Information Service Provider (HISP) Address Directory entries for the Health Domain Name, as specified by the Abstract Model, and corresponding to rules established for concrete implementations of the Abstract Model. Organizations that manage Health Domain Names MUST ensure that transactions are available for Health Endpoint Names, either through proprietary means or following the Destination role transactions of the Abstract Model. Organizations may take on the HISP role or assign this function to another organization playing the HISP role (such as GoDaddy does for hosting regular email on behalf of other organizations).

Health Endpoint Name

A Health Endpoint Name is a string conforming to the local-part requirements of RFC 5322

Health Endpoint Names express real-world origination points and endpoints of health information exchange, as vouched for by the organization managing the Health Domain Name. For me, that could be a person such as Dr. John Halamka, an organization such as BIDMC Emergency Department or an aggregation point such as BIDPO Quality Data Center. Here are examples of each address type

Email

Jhalamka@nhin.bidmc.org for health information exchange (not regular email) directed to me at BIDMC

REST (example of a possible format)

https://nhin.bidmc.org/nhin/1_0/nhin.bidmc.org/jhalamka/

1_0 refers to the REST API version.

SOAP (example of a possible format)

https://nhin.bidmc.org/nhin/1_0/wsdls/messages

the person or organizational endpoint would be specified in the SOAP message itself.

1_0 refers to the SOAP API version.

HL7 XCN (extended composite ID number and name for persons)

urn:nhin:nhin.bidmc.org:jhalamka^Halamka^John^D^DR^MD^^&NHIN OID&OID

The XCN representation could be used in multiple contexts, including the intendedRecipient in an XDS/XDR web service call or in an HL7 2.x message to refer to the sender or receiver of a message (e.g., in a PV1 segment)

HL7 XON (extended composite name and identification number for organizations)

Beth Israel Deaconess Medical Center^^^^^&NHIN OID&OID^^^^urn:nhin:nhin.bidmc.org:emergency_department

Note that XCN and XON are included for compatibility with the IHE XDR spec, NHIN Document Submission, and HITSP T31.

Imagine if every EHR could send data to every other EHR using a simple addressing mechanism like Email, a consistent REST implementation or a well described SOAP WSDL. Interoperability would follow rapidly because novel packages of data will be sent to support real business needs without any barriers of how to get the data from endpoint to endpoint.

The NHIN Direct process is working well and builds upon the work of the past. It does not compete with, diminish, or in any way represent a replacement of the hard work done by so many people over the past years in HITSP, IHE, and the SDOs.

I'll continue to provide NHIN Direct updates as reference implementations with running code are deployed. Massachusetts, through NEHEN and the Massachusetts eHealth Collaborative has volunteered to test these techniques with other surrounding states. Let the testing begin this Summer!