Saturday, October 17, 2015

Weekly Overseas Health IT Links -17th October, 2015.

Note: Each link is followed by a title and few paragraphs. For the full article click on the link above title of the article. Note also that full access to some links may require site registration or subscription payment.
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How to Protect Your Patients from Identity Theft, in Four Steps

10.08.15 by Jasroop Bambrah, Michael Davis

Patients' Social Security numbers are a target for hackers. Four steps can help you to reduce the amount of sensitive data your organization stores.

With large data breaches in health care and other industries making headlines, patients increasingly are reluctant to provide their Social Security numbers. Furthermore, data thieves are specifically targeting health care organizations due to the value of information collected from patients. These factors — an increased risk of attack and an increased reluctance to provide information — mean that it is time for health care organizations to review and evaluate the types of sensitive data they collect and store.
Many health care organizations believe they must store patient SSNs for insurance, billing and collection. However, in most cases, this is not true. For example, Medicare requires insurers to send only Medicare ID numbers of Medicare beneficiaries. Also, other individual insurance policies cannot require a patient to submit an SSN, but can refuse to issue a policy if the patient doesn't provide an SSN.
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FHIR Interoperability Advancing, Cerner Expects First Apps Soon

OCT 9, 2015 7:21am ET
EHR vendor Cerner has unveiled a production version of Health Level Seven’s Fast Healthcare Interoperability Resources (FHIR) framework for information sharing based on the latest web standards.
The company’s customers will beta test Substitutable Medical Applications and Reusable Technologies (SMART)—an application programming interface on FHIR applications—in Cerner’s Millennium EHR system, with an initial catalog of SMART on FHIR apps generally available by the end of the year.
Cerner’s initiative is part of a larger effort by the five major EHR vendors to build the SMART application programming interface (API) into releases of their respective products, and to standardize the SMART API in HL7 specifications. Developed with funding from the Office of the National Coordinator for Health IT under the Strategic Healthcare IT Advanced Research Projects (SHARP) program, SMART leverages HL7’s emerging FHIR standards to make it as easy as possible for app developers to get to data and for EHR vendors to implement a common API.
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3 data privacy features in Microsoft Office 2016

Posted on Oct 09, 2015
By Tom Sullivan, Editor-in-Chief, Healthcare IT News
When Microsoft released Office 2016 at September's end, the software giant somewhat quietly revealed a host of new features geared toward healthcare providers.
Those were mostly lost amid most of the trade press and mainstream media coverage, which largely focused on the new collaboration functionalities. That makes sense given the new Office's overarching themes as collaboration, productivity, and security.
While there are collaboration and productivity enhancements for health entities, healthcare CIOs and CISOs might be most interested in the privacy features. 
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Telemedicine Is Vital to Reforming Health Care Delivery

October 07, 2015
Health care remains one of the few services that require people to have a face-to-face interaction to obtain access. But more and more consumers are questioning that reality, and change is on the way. In January 2015, the Centers for Medicare and Medicaid Services (CMS) issued a new provider reimbursement code for non–face-to-face health care services for patients who have chronic medical conditions. A new CMS code may seem like a tiny matter, but this one emblemizes a larger shift toward delivering health services independently of time and place, enabled by technologies such as smartphones, sensors, and wireless health-monitoring devices — what we in the field call telemedicine.
The concept of telemedicine is not new (its roots go back to the late 1950s). In the 21st century, the widely held goal of improving health care outcomes while lowering costs is accelerating the shift from a one-to-one to a one-to-many model of care delivery, which telemedicine makes possible. Understanding telemedicine has now become crucial for decision makers in the health care industry, and I aim to help in that effort. Let me start by exploring some industry fundamentals.
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ONC: Consumer online access to health records on the rise

October 6, 2015 | By Marla Durben Hirsch
Patients' engagement with their electronic health records is increasing, according to two recently published data briefs from the Office of the National Coordinator for Health IT.
One of the briefs, on consumer trends, found that the percentage of individuals who reported being offered access to their online medical record by a provider or insurers was 38 percent, up from 28 percent in 2013. In 2014, 55 percent of individuals who were offered such online access viewed their record at least once, up from 46 percent the year before. Of those who accessed the record, 92 percent had access to lab results, 79 percent could see the list of health and medical problems and 74 percent could view their current medications. The top reason for not accessing the record was lack of need.
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6 glaring and disruptive ICD-10 glitches

Posted on Oct 07, 2015
By Linda Girgis, MD, Family Physician, South River, N.J.
How was the first week of ICD-10 at your organization?
Despite all the years to gird for the code set conversion I have found thus far that many in the healthcare industry were ill-prepared, after all. 
What's worse, widespread fears about glitches are now coming to life. And more are bound to emerge as we watch exactly how ICD-10 will impact the revenue cycle.
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National Health IT Week: Where will we be in 5 years?

Posted on Oct 08, 2015
By Bernie Monegain, Editor-at-Large
Imagine the state of healthcare and healthcare information technology in five years. What will it look like? Will healthcare provide more – or less – value? Will care be better coordinated? Will patients be more engaged? What about interoperability? 
Imagine the state of healthcare and healthcare information technology in five years. What will it look like? Will healthcare provide more – or less – value? Will care be better coordinated? Will patients be more engaged? What about interoperability?
Those were just a few of the complicated issues a panel at the HIMSS Public Policy Summit tackled Wednesday in the nation's Capitol as part of National Health IT Week, observed each year across the country.
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SNOMED to replace Read Codes by 2020

Thomas Meek
5 October 2015
All healthcare services in England will need to switch from Read Codes to the SNOMED system for clinical terminology by April 2020.
The Health and Social Care Information Centre (HSCIC) says on its website that primary care systems need to make the move to SNOMED by the end of December 2016 while the rest of the healthcare system should follow suit just over three years later. 
Both systems are sets of numerical, machine readable codes and human readable descriptions, which can be used to uniquely identify clinical concepts.
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Kelsey: EMRs must be 'fit for purpose'

Thomas Meek
5 October 2015
Electronic patient record suppliers need to improve their engagement with clinicians to create effective systems for the NHS, NHS England’s national director for patients and information has said.
Speaking at the Healthcare Efficiency Through Technology event in London, Tim Kelsey faced a question from the audience on the impact of the recent Care Quality Commission report on Cambridge University Hospitals NHS Foundation Trust, which identified several problems with its eHospital programme and rated the trust as inadequate. 
“I think that some of the vendors of EMR systems have not done nearly enough to work with colleagues in clinical practice in the UK to ensure we have systems that are fit for purpose,” said Kelsey, who was speaking at one of his last public engagements, having recently announced he is to leave NHS England for a new role in Australia.
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Final Stage 3 Rule Pits APIs against Patient Portals

OCT 8, 2015 7:48am ET
The Centers for Medicare and Medicaid Services in the final Stage 3 meaningful use rule is fully embracing application programming interfaces (APIs) for electronic health records to enable patients to view, download and transmit their health information, potentially replacing patient portals.
While the “current trend to use a patient portal to meet the view, download and transmit functions” is “prevalent and acceptable,” the final Stage 3 rule incorporates API functionality into an objective for patient electronic access, CMS notes in the rule. “The Stage 3 objective for Patient Electronic Access is not a ‘patient portal’ versus ‘API’ requirement or a requirement to support two patient portals,” according to the rule. “Instead, this proposed objective is supporting four basic actions that a patient should be able to take: view their health information; download their health information; transmit their health information to a third party; and access their health information through an API.”
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Intermountain saves $2.5 million with blood-tracking initiative

October 8, 2015 | By Susan D. Hall
An initiative at Salt Lake City-based Intermountain Healthcare to reduce blood transfusions helped the 22-hospital system cut costs by $2.5 million over two years while significantly reducing hospital-acquired infections and mortality, according to research being presented this week at the 2015 Clinical Congress of the American College of Surgeons.
Intermountain implemented the blood ordering and tracking system in 2012, which also involved providing thousands of physicians with monthly email records of their personal transfusion-ordering practices and educating them about best practices.
Before the system was implemented, Intermountain found that various surgeons and physicians each used different thresholds to order blood. With the new system, there now is a consistent threshold across all disciplines for doing so, though physicians still can order blood for patients at varying levels when they need to, according to an announcement.
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Health IT Legislation Would Establish Consumer Rating System for EHRs

October 7, 2015
by Rajiv Leventhal
Legislation introduced on Oct. 6 from U.S. Senators Bill Cassidy, M.D. (R-LA) and Sheldon Whitehouse (D-RI) focuses on making health IT systems accountable for their performance in three key areas: security, usability, and interoperability. 
Specifically, the bill, the Transparent Ratings on Usability and Security to Transform Information Technology (TRUST IT) Act of 2015, would help ensure that certified health IT systems are performing as promised in the field, and establish a rating system that will enable consumers to compare different products based on that performance.
The TRUST IT Act is focused on making health IT systems accountable for their performance in three key areas: security, usability, and interoperability. Specifically, the bill will establish a Health IT Rating System—to be published on the Office of the National Coordinator for Health Information Technology’s (ONC’s) website—to enable consumers to compare certified health IT products on those three criteria. The Rating System would be developed through an open and transparent stakeholder input process.
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Healthcare reacts to new MU, interoperability rules

Posted on Oct 07, 2015
By Mike Miliard, Editor
"Steve Posnack from ONC declared today IT Bonanza Day," wrote Beth Israel Deaconess CIO John Halamka, MD, on his blog Tuesday evening.
Indeed, with CMS and ONC dropping much-awaited final meaningful use rules, EHR certification criteria and a final interoperability roadmap, all with National Health IT Week in full swing, there was perhaps more federal activity in single day than since the heady post-HITECH days of of the early 2010s.
As they settled in to read hundreds of pages of regulations, Halamka and industry leaders offered early reactions.
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Speaking up for voice recognition

The NHS has been slow to adopt voice recognition outside radiology and pathology; and it has not always seen the promised financial benefits when it has done so. New ways of introducing the technology, the new discharge letter target, the pressing need to save money, and integration with electronic patient record systems could yet change that. Kim Thomas reports.
One thing almost everybody agrees about voice recognition is that accuracy rates have shot up in the past three or four years.
This makes it an efficient way to create a document – faster than typing it yourself, and cheaper than paying a secretary to type it. Yet although radiologists and pathologists now use voice recognition as a matter of course, adoption in other areas is patchy at best. Why?
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NIST seeks input on email security projects

October 7, 2015 | By Susan D. Hall
The National Institute of Standards and Technology (NIST) seeks collaborators on two projects to address email security concerns in healthcare and other industries.
It's working on a special publication, now in draft form, called Trustworthy Email, that provides an overview of existing technologies, best practices and advice on addressing the most common security threats.
Email was created to enable effective communication, with less attention paid to security, NIST says in an announcement. Phishing and leaking information have emerged as the two greatest security threats. In fact, Michigan-based Oakland Family Services recently reported a phishing scam may have exposed 16,000 patients' data.
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Hospital execs: Lack of standards the biggest barrier to keeping health data secure

October 7, 2015 | By Katie Dvorak
A lack of standards when it comes to cybersecurity in healthcare is a barrier to stopping threats, improving interoperability and retaining patient trust, according to a group of hospital executives speaking Tuesday at a National Health IT Week event in the District of Columbia.
During the panel discussion, sponsored by the College of Healthcare Information Management Executives, the executives said that healthcare organizations need to work with both private and public sector partners to create a security framework.
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Penn Medicine Taps Big Data To Save Lives

10/6/2015 12:05 PM
Penn Medicine's modern big data initiative's applications alert doctors of at-risk patients. Penn plans to take the platform open source for other healthcare providers next year.
The potential to deliver better healthcare has been one of the driving factors behind the push for big data analytics in medicine in recent years. The fact that the potential is there doesn't mean every project succeeds.
Penn Medicine's big data projects, however, have already hit several milestones, and they are being successfully used within the organization, which is composed of the University of Pennsylvania's medical school and its health system of five hospitals. Initial applications have centered on predictive analytics on individual patients at risk for two conditions: sepsis and heart failure. Now Penn Medicine is getting set to release its open source real-time application platform, Penn Signals, to other organizations, too.
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ONC Unveils Final Interoperability Roadmap

Lena J. Weiner, for HealthLeaders Media , October 7, 2015

The ten-year roadmap is similar to the draft released in January for public comment, but clarifies how technical standards are to be improved so that health data can be stored in a manner conducive for sharing among providers and patients.

The Department of Health and Human Services' Office of the National Coordinator for Health Information Technology released on Tuesday the final roadmap for electronic health information interoperability.
ONC officials in Washington, DC, presented the 10-year plan stressing "sameness," standards, and compatibility" via teleconference. "The roadmap is about action. It's not just about talking, it's not just about planning. It's about doing," said Erica Galvez, interoperability portfolio manager for ONC, describing how the federal agency intends the country's goals for health data sharing and interoperability to be achieved.
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Meaningful Use Stage 3 Final Rules Elicit Mixed Reactions

Scott Mace, for HealthLeaders Media , October 7, 2015

The American Medical Association applauds CMS for allowing a hardship exemption for physicians who are unable to attest in 2015, but calls the final rule, as a whole, "deeply disappointing." The American College of Cardiology says that the program requirements "[remain] difficult to implement."

Despite pleas within the past week from more than 100 members of Congress and various healthcare stakeholders for stage 3 rules to be postponed, the Department of Health and Human Services, with the release Tuesday of twin rules totaling 1302 pages, signaled what it intends to publish in the Federal Register on October 16.
Many healthcare providers have yet to successfully achieve stage 2.
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Patient Access to Health Information Remains a Challenge

OCT 6, 2015 7:21am ET
Consumer access and use of electronic health information is growing. However, additional progress is needed in this area, particularly in increasing patient engagement, according to the Office of the National Coordinator for Health IT.
New data from ONC show a six-fold increase in the percentage of hospitals giving consumers the ability to view, download, and transmit their health information online, going from 10 percent in 2013 to 64 percent in 2014. Further, separate data reveal the percentage of Americans offered online access to their medical records rose from 28 percent in 2013 to 38 percent in 2014.
“It demonstrates progress, but we still have a lot of work to do,” said National Coordinator for HIT Karen DeSalvo, M.D., at last week’s Consumer Health IT Summit. “This has got to continue to rise.”
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Most Americans don't trust their health data is secure against hackers

Posted on Oct 06, 2015
By Erin McCann, Managing Editor
To all the healthcare info security folks out there: You may have a big trust issue on your hands. As, according to a new survey, the lion's share of adults are seriously worried about the security of their health records.
In fact, data from the survey, which was conducted by University of Phoenix College health professions school, shows that an overwhelming 76 percent of U.S. adults expressed concern over the vulnerability of their health data when it comes to cyberattackers.
After hearing back from over 2,000 adults in the U.S., the team found that those 40 and older were the most likely to express these concerns (up to 83 percent of them, in fact), contrasted with 72 percent of individuals in their 20s who expressed concern.
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5 tips for fighting cybercrime

Posted on Oct 06, 2015
By Eric Wicklund, Editor, mHealthNews
If you want to know how well a health system is protecting against cybercrime, you would have better luck talking to the criminals than asking the C-suite.
That's according to noted security expert Brian Krebs.
Speaking to a roomful of IT executives at the Gartner Symposium, Krebs said CIOs – including those in the healthcare industry – aren't doing a good job keeping the enterprise up to date on cyber threats, and that those looking to steal and make a profit from health information are much more informed, PCMagazine reported.
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David Blumenthal, M.D. Shares His Perspectives on MU, HIE, and the Future of Data-Driven Healthcare

October 5, 2015
by Mark Hagland
The complex meaningful use process will soon give way to inevitable progress towards a more data-connected, data-facilitated healthcare future, Dr. Blumenthal said last week in New York
The meaningful use program has had and continues to have its challenges, but much has been accomplished, and much will be accomplished over the next two years as well; and a bold future of data-driven healthcare is ahead of us. That was the core of the keynote presentation delivered by David Blumenthal, M.D., at the Health IT Summit in New York, held at the Convene conference center in New York City’s Financial District Sep. 28-30, and sponsored by the Institute for Health Technology Transformation (iHT2—a sister organization to Healthcare Informatics, under the corporate umbrella of parent company Vendome Group, LLC).
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ONC reveals final interoperability roadmap

Posted on Oct 06, 2015
By Tom Sullivan, Editor-in-Chief, Healthcare IT News
ONC on Tuesday finalized its eagerly awaited interoperability roadmap.
"Data needs to be free," said national coordinator Karen DeSalvo, MD. "If we're going to change the care model we need an information model to support it."
That thinking is at the heart of the report, Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap, which DeSalvo labeled a critical part of the broader delivery system reform effort.
The three overarching themes of the roadmap are: giving consumers the ability to access and share their health data, ceasing all intentional or inadvertent information blocking, and adopting federally-recognized national interoperability standards.
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Early ICD-10 Reports: Fortune Favors the Prepared

Scott Mace, for HealthLeaders Media , October 6, 2015

It's too early for a victory lap yet, but health systems and physician groups that prepared for ICD-10 are faring well. Revenue cycle implications are yet to be seen, however.

Having stared at tables full of ICD-10 reference books last week at AHIMA's annual convention and flipping through a few code books myself, I can sympathize with those clinicians and coders who are looking up all the new billing codes on paper.
But why would anyone put themselves through that?
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The Biggest Misperception about Information Security

OCT 3, 2015 11:31pm ET
Over the years, the role of information security teams has evolved from primarily a user access management and security operations function, to a holistic information risk management function.
This has led to significant changes in the portfolio of activities that fall under the Chief Information Security Officer’s umbrella.  However, it’s still common for healthcare executives to be uninformed of all the information risks affecting their enterprise and how these risks may impede business objectives.
The increasing tide of threats, data breaches and regulatory requirements is rightfully closing this communication gap, which has led to changes in executive expectations for information security teams.  Unfortunately, these expectations have resulted in a misperception about a security team’s core role and responsibility.  The misperception is that information security is primarily about technology.  
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Switching EHRs? How to Avoid Taking a Hit

OCT 5, 2015 7:56am ET
As the rate of EHR adoption by hospitals increases, so does an unpleasant side effect: lost revenue because of disruptions related to system conversions. Avoiding these shortfalls and expediting a smooth transition during an electronic health record system deployment is a major challenge for hospital CFOs and financial officers.
"Setting expectations is very important," said Patrick McDermott, senior vice president for revenue cycle at Sutter Health. "You don't want surprises."
Before joining Sutter in northern California, McDermott served as vice president of revenue services at Illinois-based Presence Health, where he helped oversee a large-scale system conversion at the first six of the health system's 12 hospitals.
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A tour of the Dark Web: home of the cyber-criminal

Posted on Oct 05, 2015
By Rick Kam, ID Experts
This is part 2 of a 3-part series on cyber-risks. Read Part 1 here.
In its 2015 U.S. State of Cybercrime Survey, Pricewaterhouse Coopers calls 2015 "a watershed year for cybercrime." This conclusion is echoed in many studies, which have found that cybercrime has now outpaced insider theft, mishandling of records, and other sources of data breach in healthcare. The PwC study showed that hackers, hacktivists, organized crime, and foreign nation-states accounted for 61 percent of data security threats in 2014.
Every information security, risk, privacy, and compliance professional who touches healthcare data needs to become intimately familiar with emerging threats and threat actors. In the first part of this three-part series on cyber-crime, I wrote about how cyber-criminals are monetizing stolen healthcare data. In this article, I'll look at the Dark Web, the information superhighway of illicit commerce.
What is the Dark Web?
Most people navigate the World Wide Web via well-known search engines such as Google or Bing. Underneath the publicly accessible web, however, is the "Deep Web," the part of the web that is not indexed by common search engines. The Deep Web hosts the "Dark Web," a series of networks called "darknets" that overlay the public Internet but require specific software or authorization to access.
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ICD-10 update from Beth Israel Deaconess Medical Center

Posted on Oct 05, 2015
By John Halamka, Beth Israel Deaconess Medical Center
The ICD-10 go live date came and went on Oct. 1, with many organizations reporting small, if any, hiccups. One of those organizations was Beth Israel Deaconess Medical Center in Boston, with CIO John Halamka, MD, reporting on his team's first few days. 
Many in the press have asked me about the first few days of ICD-10. The answer for my institution, like many, is that other than a few small refinements, the impact has been unnoticeable.
We trained 850 ambulatory clinicians in comprehensive ICD-10 code entry, and all are entering electronic billing tickets using the new vocabulary.
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3 growth areas for patient engagement in healthcare

October 5, 2015 | By Katie Dvorak
Patient engagement has been one of the key trends in healthcare and health IT in 2015 and a new Deloitte survey examines where engagement is growing the most and what it means for the industry.
One trick to patient engagement, the report's authors say, is "coming up with a set of strategies that will work across the consumer segments that are present in the market--one strategy will not fit all."
The Deloitte survey has been conducted every year since 2008; this year's survey polled roughly 3,500 consumers 18 years and older between Jan. 16 and Feb. 8.
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Disposable Wireless Monitoring Device Measures Patient Vital Signs

October 2, 2015
by Heather Landi
Health IT company Sensium Healthcare developed a disposable, single-use wearable patch that monitors patient vital signs every two minutes and wirelessly communicates the vital signs to clinicians.
According to London-based Sensium Healthcare, the SensiumVitals system is a lightweight, wireless wearable single patient use patch designed to monitor patients’ pulse rate, respiration rate and body temperature on general wards and then wirelessly communicates that data to clinicians on the hospital general floor or in emergency room via the hospital’s IT infrastructure.
The company says the SensiumVitals system was designed to serve as an early warning system to alert nursing staff when pre-set thresholds are exceeded to enable early intervention and, ultimately, improve patient outcomes and shorten hospital stays.
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IRS Should Recognize Community HIE Participation as a Community Benefit

by Joshua Vest, John Kansky and Nir Menachemi Monday, October 5, 2015
Per IRS guidelines, not-for-profit hospitals, which make up 73% of non-governmental U.S. acute care hospitals, receive tax exemptions from sales, property and income taxes in exchange for the diverse set of community benefiting activities (CBAs) they provide. The conditions for not-for-profit status, which include being able to demonstrate a reduction in governmental burden and a promotion of general welfare, have not materially changed since 1969. However, IRS changes that went into effect in 2009 were designed to reduce ambiguity and more clearly define how CBAs must be reported and quantified.
We believe that hospital participation in community health information exchanges (cHIEs) should be considered a CBA under IRS guidelines. While it does not appear that IRS guidelines prohibit such participation, IRS has not specifically commented that this practice is allowed. As a result, some hospitals may already be counting their involvement in a cHIE as a CBA, some may be considering doing so and more may be unaware of the possibility.
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Health IT Not Living Up to Its Promise

Tinker Ready, for HealthLeaders Media , October 1, 2015

When health information technology tools support medical diagnostic teams, they can improve diagnoses, says the Institute of Medicine. Yet there have been "few demonstrations that health IT actually improves diagnosis in clinical practice."

Diagnostic errors can be reduced or averted by the use of health information technology, the federal government's HIT headquarters, the Office of the National Coordinator, contends.
"With EHRs, providers can have reliable access to a patient's complete health information. This comprehensive picture can help providers diagnose patients' problems sooner," the agency's website says, confidently.
But last week, members of the Coalition to End Diagnostic Errors met in Washington to huddle over a sweeping Institute of Medicine report that challenges that conclusion.
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Niam Yaraghi | October 1, 2015 12:00pm

Going Digital: Why more physicians will adopt electronic health records

This post originally appeared on U.S. News and World Report’s Policy Dose blog.
When President George W. Bush issued an executive order in April 2004 to establish the Office of the National Coordinator for Health IT, he had a clear vision in mind: to create a secure, nationwide interoperable network that allows authorized users to access medical records of anyone at anytime and anywhere in the U.S. President Barack Obama knew very well that his plan for providing health insurance to all Americans would not be successful unless it was paired with a plan for controlling the quality and cost of health care services.
Ironically, Bush’s health IT network was (and remains to be) the instrumental element that guarantees the financial sustainability of Obamacare. It was no surprise that the economic stimulus package of 2009 allocated $25.9 billion for promoting the adoption and use of electronic health records systems among American physicians and hospitals. But a decade and $30 billion later, only half of the U.S. office-based physicians have adopted a basic electronic health records system and a mere 20 percent of them use such software, according to the latest statistics by Robert Wood Johnson Foundation.
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The Dirty Dozen

12 people who ruined the NHS

It’s free, it’s cheap to run, it’s in a right mess.
Updated 10/5/15, 9:00 AM CET
Ask a Briton which national institution they are most proud of and chances are they’ll say the National Health Service. Remember the weird spectacle of patients in pyjamas bouncing up and down on beds during the London 2012 Olympic Games opening ceremony? That’s how important the NHS is to the Brits.
The fact that the NHS is free and universal takes one big worry away from British people’s lives. And it’s remarkably cheap: Britain spends only a slightly higher proportion of its GDP looking after the health of all its citizens than the United States does on Medicare and Medicaid alone.
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Enjoy!
David.

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