The US Makes Progress in Health IT Privacy – But More to Do!

The US Government Accountability Office issues the following release and associated report a few days ago. At the same time I received an announcement of a Health IT privacy conference that is planned for Brisbane late in the year.

Health Information Technology: HHS Has Taken Important Steps to Address Privacy Principles and Challenges, Although More Work Remains

GAO-08-1138 September 17, 2008

Highlights Page (PDF) Full Report (PDF, 23 pages) Accessible Text Recommendations (HTML)

Summary

Although advances in information technology (IT) can improve the quality and other aspects of health care, the electronic storage and exchange of personal health information introduces risks to the privacy of that information. In January 2007, GAO reported on the status of efforts by the Department of Health and Human Services (HHS) to ensure the privacy of personal health information exchanged within a nationwide health information network. GAO recommended that HHS define and implement an overall privacy approach for protecting that information. For this report, GAO was asked to provide an update on HHS's efforts to address the January 2007 recommendation. To do so, GAO analyzed relevant HHS documents that described the department's privacy-related health IT activities.

Since GAO's January 2007 report on protecting the privacy of electronic personal health information, the department has taken steps to address the recommendation that it develop an overall privacy approach that included (1) identifying milestones and assigning responsibility for integrating the outcomes of its privacy-related initiatives, (2) ensuring that key privacy principles are fully addressed, and (3) addressing key challenges associated with the nationwide exchange of health information. In this regard, the department has fulfilled the first part of GAO's recommendation, and it has taken important steps in addressing the two other parts. The HHS Office of the National Coordinator for Health IT has continued to develop and implement health IT initiatives related to nationwide health information exchange. These initiatives include activities that are intended to address key privacy principles and challenges. For example: (1) The Healthcare Information Technology Standards Panel defined standards for implementing security features in systems that process personal health information. (2) The Certification Commission for Healthcare Information Technology defined certification criteria that include privacy protections for both outpatient and inpatient electronic health records. (3) Initiatives aimed at the state level have convened stakeholders to identify and propose solutions for addressing challenges faced by health information exchange organizations in protecting the privacy of electronic health information. In addition, the office has identified milestones and the entity responsible for integrating the outcomes of its privacy-related initiatives, as recommended. Further, the Secretary released a federal health IT strategic plan in June 2008 that includes privacy and security objectives along with strategies and target dates for achieving them. Nevertheless, while these steps contribute to an overall privacy approach, they have fallen short of fully implementing GAO's recommendation. In particular, HHS's privacy approach does not include a defined process for assessing and prioritizing the many privacy-related initiatives to ensure that key privacy principles and challenges will be fully and adequately addressed. As a result, stakeholders may lack the overall policies and guidance needed to assist them in their efforts to ensure that privacy protection measures are consistently built into health IT programs and applications. Moreover, the department may miss an opportunity to establish the high degree of public confidence and trust needed to help ensure the success of a nationwide health information network.

Recommendations

Our recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Implemented" or "Not implemented" based on our follow up work.

Director:

Team:

Phone:

Valerie C. Melvin

Government Accountability Office: Information Technology

(202) 512-6304

Recommendations for Executive Action

Recommendation: To ensure that key privacy principles and challenges are fully and adequately addressed, the Secretary of Health and Human Services should direct the National Coordinator for Health IT to include in the department's overall privacy approach a process for assessing and prioritizing its many privacy-related initiatives and the needs of stakeholders.

Agency Affected: Department of Health and Human Services

Status: In process

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

----- End Release.

Link is found here:

http://www.gao.gov/products/GAO-08-1138

The last paragraph of the summary is the most important. Here the GAO makes it quite clear the US Federal Health Department has not developed a co-ordinating process for ensuring privacy is properly protected and the Health Information Network program moves forward and that there is only one chance to get this right. Once the public loose trust in the way health information is shared it will be very hard to win it back.

I agree 100% with theses points (the need for a defined process and the risk of failure) and we need to build this understanding into all our plans as well! NEHTA has been a good deal less than forthcoming about its processes to date. I do hope the planned HISA conference helps flush out what the plans really are and make a contribution to improvement if required!

Here is the background I received on it.

Begin Announcement. ----

Australia is on the verge of substantial changes to the laws governing health privacy. The Australian Law Reform Commission’s report is now with parliament and new laws and regulations will soon be developed as a consequence of this submission. These changes will have a significant impact on the way healthcare professionals work with health information of all kinds and could significantly impact the way healthcare is delivered in some situations.

It is now time to understand how to prepare for these changes and also to provide leadership and feedback to the government as they draft the laws and subsequent privacy regulations that will be derived from this report.

These are the deliverables of the Health Privacy Futures conference. The program has an outstanding lineup of health privacy leaders, with a deep and practical understanding of the Australian healthcare environment. I have attached a conference brochure which outlines the provisional conference program and featured speakers.

You can find out more about the conference, or you can register for this event, by going to the Health Privacy Futures website at www.healthprivacy.org.au. There are substantial discounts for Early Bird Registration which will end on October 8.

End Announcement.----

Those interested should consider attending.

David.

Cloud Computing and Health Information Privacy.

With the ABC program on Cloud Computing last week I have been alerted to the potential uses and abuses of this approach in the broad. Others seem to have also noticed as the following appeared a few days ago.

Cloud computing puts your health data at risk

By Stuart J. Johnston

The advent of "in the cloud" medical records services, such as Microsoft HealthVault and Google Health, promises an explosion in the storage of personal health-care information online.

But these services pose sticky privacy questions — unless you know how to protect your personal medical records.

A promise of safer personal health data

Your private health information is migrating wholesale onto the public network with the advent of online health-care records stored in massive data centers around the world.

While the services aim to make it easier for consumers to access and manage their personal health information, the ready availability of this data also makes it much easier and less expensive for insurers to put your medical history under the microscope.

Surprised? You shouldn't be. You voluntarily grant access to that sensitive information every time you sign a waiver so that your health insurer can decide whether to pay for a doctor's visit, a prescription, or an expensive medical test.

What's more, most of the gathering and collating of this information is legal. In fact, the number of companies that have access to this information runs into the millions, say privacy advocates.

As recently as last year, only 1% to 3% of U.S. consumers had electronic versions of their health records, according to market research firm Health Industry Insights, an IDC company.

That is about to change.

The fact that two of the biggest players in the emerging world of cloud computing services — Microsoft and Google — are jumping into that arena with both feet will likely accelerate the shift to online medical records.

Microsoft kicked off the beta test of its HealthVault service almost a year ago, while Google announced its Google Health service last February and launched a beta in May. While both services are still in beta, each company has partnered with large health-care providers for pilot tests: Microsoft with Kaiser Permanente and Google with the Cleveland Clinic.

Much more (including suggestions as to what to do about the threat) here:

http://windowssecrets.com/2008/09/18/03-Cloud-computing-puts-your-health-data-at-risk

This is a useful discussion of the issues – albeit from a slightly American perspective – and needs to be browsed by all those contemplating the future of PHRs and how they may be best delivered. From the ‘cloud’ may not be the ideal way.

The ABC talk and transcript on the topic is still available here:

http://www.abc.net.au/rn/backgroundbriefing/stories/2008/2359128.htm

The .mp3 file will only be available for a couple more weeks so grab it now if you want to listen.

David.

Patient Consent in Health Information Exchange – A Discussion Paper

The New York eHealth Collaborative has produced an interesting discussion document on patient consent in health information exchange.

Comments Sought on How Patient Consent Will Work in Electronic Exchange

Draft recommendations released this week by the New York eHealth Collaborative (NYeC) describe how patient consent should be obtained before a patient’s health information is exchanged electronically between entities participating in a regional health information organization (RHIO). The recommendations are part of a draft white paper released for public comment, developed by NYeC’s privacy and security workgroup.

NYeC is a public-private health information technology (HIT) stakeholder group aimed at developing consensus on key HIT policies and collaborating on state on regional HIT implementation efforts. The NYeC workgroups develop policies, technical standards, and operational guidance for health IT projects in New York and the Statewide Health Information Network for New York (SHIN-NY).

The NYeC privacy and security workgroup paper asserts that given state law regarding disclosure of certain health information, “affirmative consent from the patient to exchange health information via SHIN-NY governed by a RHIO is required under existing state law for non-emergency treatment.”

The full release is found here:

http://www.hanys.org/news/index.cfm?storyid=537

The report is found here:

http://www.nyehealth.org/files/File_Repository16/pdf/Consent_White_Paper_Public_Comment.pdf

Given that after addressing privacy issues this topic is of critical importance it is timely that this paper appear.

What I found particularly insightful was the following from page 3 of the 59 page report.

“In pursuing its health IT investment program, New York is cognizant that its success will not only be measured by technical, financial and clinical achievements, but also by the policies governing the exchange, measurement and reporting of personal health information as well as accountability mechanisms ensuring adherence to such policies. In fact, establishing public trust with respect to the privacy and security of health information is the single most important goal of New York’s health IT investment program.

In pursuing this goal, New York benefits from policy thinking developed by several important projects that have addressed privacy and security, including: the Markle Foundation’s Connecting for Health initiative; the California Healthcare Foundation’s policy briefs on privacy and consumer attitudes and policy forums; studies performed by such organizations as the American Health Information Management Association (AHIMA), eHealth Initiative, Healthcare Information Management Systems Society (HIMSS), National Alliance for Health Information Technology (NAHIT), the Health Information Security and Privacy Collaborative (HISPC); and the Certification Commission on Healthcare Information Technology’s (CCHIT). New York’s investment program builds on the collective foundation of these policy efforts while seeking to go one step further. Because New York is setting policy in the context of live implementations and is doing so through a statewide public-private collaborative model, there is a unique opportunity to stress-test new concepts that to date have largely been considered in either much smaller settings, on a theoretical basis, or in connection with proprietary or narrow technological approaches. Hopefully, New York’s experience will provide all stakeholders a richer understanding of what works and what does not, and will help to inform and shape emerging state and national policy.

As I have often noted, again we find privacy and consent issues being recognised as a ‘rate limiting step’ in the development of Health Information Networks.

This document is really more that a discussion of consent – covering as it does what almost amounts to a NY Health IT Network Strategy. (It is funded at $200M so it is pretty serious stuff!). It has clearly been carefully considered and researched.

Recommended reading.

David.

The Future of the PHR Reviewed and Explored.

News of another valuable contribution from the RWJ Foundation arrived a few days ago.

New Frontiers in Personal Health Records A Report Out from Project HealthDesign and Forum on Next-Generation PHRs

19-09-08

On September 17th, Project HealthDesign hosted more than 200 guests for a day long event that showcased personal health record (PHR) applications created by program’s nine multidisciplinary grantee teams from across the United States. In addition to highlighting what Project HealthDesign teams have learned in the process of developing these PHR tools, the forum featured panels and discussions with leading health IT pioneers, policymakers and industry experts.

A technical team headed by Walter Sujansky of Sujansky & Associates LLC, also introduced a set of functional requirements and technical specifications that allow different PHR applications to securely share medical and other information, with the consumer controlling who has access to what information.

Project HealthDesign is a $5 million national program of the Robert Wood Johnson Foundation (RWJF) with additional funding from the California Healthcare Foundation that is revolutionizing the purpose and potential of electronic PHRs. Each team created applications that help move the perception of PHRs from static repositories of health information to dynamic, tailored applications that allow people to easily and actively manage their health as they go about their daily lives. The project also ensured that these PHR tools can readily share common technical functions and operate on a common technology platform.

To read the event press release visit (link to release posted in the news archives section located under resources. The release is attached for posting)

To view Project HealthDesign grantee project information and visual stories visit http://www.projecthealthdesign.org/projects

View a webcast of New Frontiers in Personal Health Records: A Report Out from Project HealthDesign and Forum on Next-Generation PHRs at http://www.rwjf.org/goto/healthdesign2008 (live September 21) or here:

http://www.rwjf.org/pioneer/product.jsp?id=34528

To read event blog posts from the Project HealthDesign blog visit http://projecthealthdesign.typepad.com/

Link to site.

http://www.projecthealthdesign.org/news/217129

The work being done is also given coverage in Health Data Management.

PHR Researchers Unveil Prototypes

September 17, 2008

Nine research teams have developed prototypes of technologies to support personal health records following 18 months of research. The prototypes range from a medication management system to help children with cystic fibrosis manage their disease to a “conversational assistant” that helps people with congestive heart failure manage their health from home.

The effort is supported by Project HealthDesign, a $5 million program of the Robert Wood Johnson Foundation. Over the next several months, the Project HealthDesign teams will publish details about their findings and attempt to extend the use of their applications to the clinical practices connected to their institutions. The projects include:

* A team at Vanderbilt University designed a PHR application to help children with cystic fibrosis play a larger role in self-care. Team members developed a device that can be incorporated into a stuffed animal or cell phone to work with the PHR to help children take the right medications at the right times, alert parents and caregivers if doses are missed and manage refills.

* The University of Rochester team designed a prototype system that uses a “conversational assistant” to provide congestive heart failure patients with a “daily check-up.” Through voice-activated questions and responses or text-typed chat, patients share information relevant to their condition. The computer interprets that input to provide personalized recommendations based on established guidelines and collects longitudinal data to share with the patients and their care providers.

* Stanford University and Art Center College of Design designed a set of multimedia PHR tools to help adolescents with chronic illness communicate with their providers and others about their health.

* T.R.U.E Research Foundation designed a PHR to help people with diabetes understand and track their self-care.

Plenty more here:

http://www.healthdatamanagement.com/news/PHR26962-1.html?ET=healthdatamanagement:e604:100325a:&st=email&channel=consumer_health

It is well worth exploring all this to see the range of ideas that are emerging as people progressively understand just where PHR technology may fit and the places it may make a difference.

David.

Useful and Interesting Health IT Links from the Last Week – 21/09/2008

Again, in the last week, I have come across a few reports and news items which are worth passing on. Interestingly an all Australian set of reports this week!

These include first:

Investigation into medical files

Posted Fri Sep 12, 2008 7:11pm AEST

A federal government office will investigate the management of disused medical files in South Australia after concerns were raised about a large number of private medical records at a rented home in Adelaide.

The former doctor who lives at the house is mentally ill and is about to move out of the house.

The landlord is unsure what to do with the files that are likely to be left behind.

It is the second case of its kind in recent years and the issue has been referred to the federal privacy commissioner.

More here:

http://www.abc.net.au/news/stories/2008/09/12/2363397.htm

Yet again those paper records cause a problem. It seems clear that these paper records need to be secured and each patient be informed as to the fact a record exists so if they select a new GP the record can be forwarded to them for their GPs use.

Second we have:

Rush to build personal e-health records risky

Karen Dearne | September 16, 2008

LOCAL software developers clamouring to build personal e-health records risk creating new silos of unconnected patient information, warns Neil Jordan, Microsoft's managing director of worldwide health.

While progress on a national e-health record system has stalled, Jordan says he is slightly concerned "that everyone I've spoken to here wants to build a personal health record (PHR)".

"That's okay, but don't build them all separately or you will end up with the same problem you currently have with e-health records - they're in a whole load of silos," he says.

"There's never going to be one personal health record in a country the size of Australia, because a diabetic is going to need something quite different from someone who is obsessed with fitness and does lots of monitoring while working out."

With most personal health records now held in GPs' computers, Jordan says the person "who is ultimately funding GPs is going to benefit by putting such a platform in place".

More here:

http://www.australianit.news.com.au/story/0,24897,24348898-24169,00.html

I could not agree more with the headline – while being a little alarmed at the lack of understanding of the Australian Health IT world made apparent by the fly-in Microsoft expert in his remarks. Fortunately it is only a few weeks until the National e-Health Strategy being developed by Deloittes will be handed to Government and hopefully such silos will be one of the first issues addressed!

Third we have:

HealthSmart boss resigns

Renai LeMay, ZDNet.com.au

17 September 2008 08:52 PM

The public servant in charge of Victoria's mammoth HealthSmart electronic health initiative has resigned for what the state's health department today said were personal reasons.

Fiona Wilson had led the troubled project since mid-2003 in her capacity as the director of the Office of Health Information Systems within the Victorian Department of Human Services. However a spokesperson for the department told ZDNet.com.au tonight that Wilson had grown weary of the regular commute from Auckland where her partner resided.

More here:

http://www.zdnet.com.au/news/software/soa/HealthSmart-boss-resigns/0,130061733,339292039,00.htm

It is a pity to see yet another senior e-Health player decide to leave the field. While I have, and have expressed, strong reservations about the strategy adopted by HealthSmart, there is no doubt this was an effort of serious intent with the right objectives in upgrading the Health IT in Victorian public hospitals. Maybe a mid-course review and possible correction at the time of this leadership change could smooth the path to ultimate success.

Fourth we have:

Prescriptions to go digital in the coming year

Thursday, 11 September 2008

DESPITE financial disagreements between project partners and a government delay in announcing research findings, e-scripting will be available to GPs as early as next June, says the project’s main promoter.

Australian software company Fred Health’s e-script plan, which will allow general practitioners to send prescriptions to pharmacists over the internet, stalled when their joint development partners put the project on hold.

Amid ongoing uncertainty over the government’s interest in the technology and without any clear financial security plan, GP software vendor Health Communications Network and pharmacy software vendor Corum withdrew from the original JV project, dubbed ScriptX.

However Fred Health chief executive Paul Naismith is optimistic the new JV, eRx Script Exchange, with New Zealand-based software company Simpl and the Health and Human Services division of Microsoft, will be available as early as June next year.

“The original ScriptX proposal had different partners who felt the proposal at this stage was too large a risk for them. We felt differently so we reformed it and set out to deliver electronic scripts with eRx the way ScriptX had intended,” he said.

“It’s our current project plan to be delivering e-scripts by mid next year, certainly within the next 9-10 months.”

More here:

http://www.consultmagazine.net/StoryView.asp?StoryID=269477

Additional coverage is here:

Private e-scrips to launch

Karen Dearne | September 16, 2008

PHARMACIST Paul Naismith is taking a punt on launching a privately-owned electronic prescribing project, ahead of the release of a KPMG review on options being considered by the federal Government.

Mr Naismith, chief executive of pharmacy IT supplier Fred Health, said improving "basic safety" by reducing medication errors was too important to delay.

Fred Health and the newly established eRX Script Exchange are wholly owned subsidiaries of PCA Nu Systems, in turn controlled by parties associated with the Pharmacy Guild.

A Health Department spokeswoman said a range of approaches to e-prescribing were being explored, and the private proposal supported by the Pharmacy Guild "had been looked at". "The KPMG report is being considered as part of broader activities in progressing e-prescribing within Australia," she said.

Full, in depth, article here:

http://www.australianit.news.com.au/story/0,24897,24351225-15306,00.html

Bluntly there is no way this project should be allowed to proceed. It is my view the central infrastructure for e-prescribing should be Government controlled and regulated (I have no problem with the service delivery being outsourced). The service should be run for the benefit of consumers, doctors and pharmacists, not as a profit making project for commercial interests and such vested interests as the Pharmacy Guild.

Fifth we have:

Cloud computing may draw government action

U.S. government policy makers will soon focus on the privacy, security and other implications of cloud computing, some experts say.

Grant Gross (IDG News Service) 15/09/2008 09:17:00

Cloud computing will soon become an area of hot debate in Washington, D.C., with policy makers debating issues such as the privacy and security of data in the cloud, a panel of tech experts said Friday.

There are "huge challenges" facing policy makers in the next year or two as cloud computing becomes increasingly popular, said Mike Nelson, visiting professor for the Center for Communication, Culture and Technology at Georgetown University and a former tech policy advisor for U.S. President Bill Clinton.

Among the major policy issues to be worked out: Who owns the data that consumers store on the network? Should law enforcement agencies have easier access to personal information in the cloud than data on a personal computer? Do government procurement regulations need to change to allow agencies to embrace cloud computing?

Cloud computing is "as important as the Web was 15 years ago," said Nelson, speaking at a Google forum on the policy implications of hosted applications and services. "We don't have any idea of how important it is, and we don't really have any clue as to how it's going to be used."

Despite the growing number of people using cloud services such as hosted e-mail and online photo storage, many consumers don't understand the privacy and security implications, said Ari Schwartz, vice president and chief operating officer of the Center for Democracy and Technology, an advocacy group focused on online privacy and civil rights. So far, U.S. courts have generally ruled that private data stored in the cloud doesn't enjoy the same level of protection from law enforcement searches that data stored on a personal computer does, he said.

More here:

http://www.computerworld.com.au/index.php?id=833256149&eid=-255

This issue is a real sleeper. I believe when people realise just how much of their personal information is out there ‘in the cloud’ there may indeed be some pressure for regulation. This is, of course, even more so once private health information is involved as with MS Vault and the Google PHR.

Last we have the slightly more technical article for the week:

SOA deployments: What actually works

After several years of hype, the results of SOA efforts have been a mixed bag. SOA expert explains how to get SOA right

Dave Linthicum (InfoWorld) 17/09/2008 08:46:00

SOA may have seemed the savior of bad software architecture and poor development project planning, but the reality is that it's a complex and difficult venture. Thus, the number of failed SOA projects is about equal to the successful ones. In other words, you have a 50 percent chance of failing, and the odds of failure are even greater if you work within a larger Global 2000 organization or within the government.

But key patterns are emerging from the successful SOA efforts, patterns that can help you determine whether your SOA is a failure or a success.

The most important lesson from these patterns is that SOA is as much about old-school IT disciplines as it is about new, inventive technology. Moreover, it's about changing an organization from the people down to the technology, driving a systemic and valuable change. The patterns of success likewise follow that change from the people on down to the technology.

Much more here:

http://www.computerworld.com.au/index.php?id=1246639526&eid=-255

This is a useful review showing that for Service Orientated Architecture initiatives to succeed you need to get the basics right. The failure rate in large projects is worrying – especially with the commitment we seem to have from NEHTA to use this approach pretty much exclusively in what are looking like very big projects.

Last a brief happy birthday for the Integrated Circuit (IC)

Integrated circuit turns 50

• Saved

September 14, 2008

The computer chip industry on Friday celebrated the 50th birthday of the integrated circuit, a breakthrough that set the stage for the internet and the digital age.

A half-century ago a young engineer named Jack Kilby first demonstrated an integrated circuit he designed while working through the summer at his Texas Instruments job because he didn't have enough vacation time for a holiday.

More here:

http://www.smh.com.au/news/technology/integrated-circuit-turns-50/2008/09/14/1221330704451.html

More next week.

David.

A Big Week for Patient Quality Reporting in the USA.

There has been a lot of movement in definition of quality standards supported by health IT in the last week it seems.

First we have this.

Federal Register: August 29, 2008 (Volume 73, Number 169)

 [DOCID:fr29au08-82]                         

=======================================================================

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Agency for Healthcare Research and Quality

Common Formats for Patient Safety Data Collection and Event  Reporting

AGENCY: Agency for Healthcare Research and Quality (AHRQ), DHHS.

ACTION: Notice of Availability--Common Formats for Safety Data  Collection and Event Reporting.

-----------------------------------------------------------------------

SUMMARY: The Patient Safety and Quality Improvement Act of 2005  (Patient Safety Act) provides for the formation of Patient Safety  Organizations (PSOs), which would collect and analyze confidential  information reported by healthcare providers. The Patient Safety Act  (at 42 U.S.C. 299b-23) authorizes the collection of this information in  a standardized manner, as explained in the related Notice of Proposed  Rulemaking published in the Federal Register on February 12, 2008: 73  FR 8112-8183. 

As requested by the Secretary of DHHS, AHRQ has  coordinated the development of a set of common definitions and  reporting formats (Common Formats) which would facilitate the voluntary  collection of patient safety data and reporting of this information to  PSOs. The purpose of this notice is to announce the initial release of  the Common Formats, Version 0.1 Beta, and the process for development  of future versions.

DATES: Ongoing public input.

ADDRESSES: The Common Formats can be accessed electronically at the  following Web site of the Department of Health and Human Services: 

http://www.pso.ahrq.gov/index.html.

E-mail: psoc@ahrq.hhs.gov.

The full text is available here:

http://frwebgate3.access.gpo.gov/cgi-bin/waisgate.cgi?WAISdocID=15395113822+2+0+0&WAISaction=retrieve

and then there is this:

NATIONAL QUALITY FORUM ENDORSES NATIONAL CONSENSUS STANDARDS FOR HEALTH INFORMATION TECHNOLOGY

Structural measures help create system of high-quality, patient-centered care by sharing and managing information electronically

Washington, DC - To improve quality and efficiency and reduce errors and unnecessary treatments across the healthcare system, the National Quality Forum (NQF) has endorsed nine new national voluntary consensus standards for health information technology (HIT) in the areas of electronic prescribing, electronic health record (EHR) interoperability, care management, quality registries, and the medical home. These HIT structural measures are intended to help providers assess the efficiency and standardization of current HIT systems and identify areas where additional HIT tools can be used.

Adoption of HIT by clinicians has been shown to reduce medical errors by increasing access to information thereby improving response times to abnormal results, eliminating repetitive testing and providing clinical decision-support tools to facilitate evidence-based care.

Evidence has shown a decrease in medication errors by up to 20 percent and a decrease in per admission costs by more than 12 percent when clinicians use HIT.

“If we hope to achieve high-quality, patient-centered care, we need interoperable HIT that can help us share information electronically and track patients throughout the delivery system – all of which can reduce errors and overuse and increase measurement across the continuum of care,” said NQF President and CEO Janet Corrigan. “These newly endorsed measures can provide important information on effective use of health IT for both early adopters of HIT and those who are just beginning to implement HIT systems.”

Blackford Middleton, MD, director of clinical informatics research and development at Partner HealthCare System in Massachusetts, and Joel Slackman, MS, managing director of the Blue Cross Blue Shield Association, co-chaired NQF’s steering committee on HIT structural measures.

“NQF-endorsed HIT structural measures will help the practice of medicine move forward with the adoption of information technology in healthcare,” said Middleton. “This allows us to better understand how widely healthcare information technology is being used in care delivery, and is a critical first step toward transforming healthcare.”

E-Prescribing

Electronic prescribing improves quality by reducing legibility errors, providing interactions and dosing alerts, and reducing costs by comparing equally effective alternative medications. The two e-prescribing measures endorsed by NQF encourage the adoption of either a stand-alone e-prescribing tool for providers without EHR systems or the enhanced use of e-prescribing within an EHR for early adopters of HIT.

Electronic prescribing measures endorsed by NQF were developed by Quality Insights of Pennsylvania (QIP) and the New York Department of Health and Mental Hygiene.

Interoperability of EHRs

The interoperability of electronic health records –EHRs that can share information between clinics, offices, and laboratories – improves quality by increasing timely, efficient, evidence-based care. NQF endorsed two measures to increase adoption of interoperable EHRs: the first measures adoption of an EHR to manage clinical data within a practice, the second measures receipt of clinical data such as external laboratory results into an EHR. NQF aligned these measures with Certification Commission for Health Care Information Technology (CCHIT) recommended EHR- certification criteria whenever possible.

Measures for the interoperability of EHRs endorsed by NQF were developed by the Centers for Medicare & Medicaid Services (CMS) and QIP.

Care Management

Electronic care management tools improve quality by improving patient-centered care that is coordinated and evidence-based. Too often information about patients falls through cracks in the delivery system.

Both of the care management structural measures endorsed by NQF measure the use of HIT to identify specific patients in need of care, track their preferences and laboratory results, and assist the clinician in providing evidence-based care according to national guidelines using automated alerts and reminders. To measure care management across and between settings, the first measures HIT used during a patient- clinician visit and the second measures clinical results between visits.

These care management measures endorsed by NQF were developed by CMS and QIP.

Quality Registries

Sharing information through electronic quality registries allows for increased care coordination by tracking patients in need of care throughout the delivery system and giving feedback to providers. Registries also assist in data collection on the safety and effectiveness of care to guide quality improvement efforts. The two structural measures for quality registries endorsed by NQF assess clinician participation in quality registries at the local, statewide, and national levels.

These measures endorsed by NQF were developed by CMS.

Medical Home

The medical home is a broad model of primary care that aims to improve quality by providing coordinated, effective, continuous, patient-centered care. Many of the measures endorsed by NQF in this set of HIT structural measures assess technology tools that are central for creating a medical home that is patient-centered and drives toward coordinated care.

NQF has endorsed a Medical Home System Survey that will allow clinicians to assess whether their practices are functioning as a medical home by providing ongoing, coordinated, and patient-centered care. The survey specifically includes measurement of key HIT functionalities, such as the use of electronic-based charting tools to organize clinical information, the use of tracking tests and referrals, and the adoption and implementation of evidence-based guidelines.

The Medical Home System Survey endorsed by NQF was developed by the National Committee for Quality Assurance (NCQA).

The full release and details of the requirements are here:

http://www.qualityforum.org/news/releases/082908-endorses-health-it.asp

I see this activity as the next step beyond the basic standards setting processes. What is happening here is the definition of how information that is being collected can be used to guide operational improvement and safety – which is, after all, what we are all working towards.

It will be an important activity of whatever flows from the National E-Health Strategy that these issues are addressed as soon as basic e-Health capabilities are developed.

David.

Lorenzo Has Arrived – Well Almost!

The following commentary was published a few days ago.

Lorenzo Studio

11 Sep 2008

It has been a long time coming, but an initial version of Lorenzo has finally gone live in one part of South Birmingham Primary Care Trust. It is still very early days - a full care records system remains a long way off - but at last there is something called Lorenzo that is now in use by at least some NHS staff.

If, as expected, University Hospitals of Morecambe Bay NHS Trust becomes the first acute trust to go live with a product called Lorenzo this autumn, its developers and the National Programme for IT in the NHS will be able to claim the first signs of momentum.

After four years of delays, during which Lorenzo has been promised as the “strategic” system for three out of five of the national programme’s regions, it might, finally, have reached the end of the beginning.

Live from down under

But ensuring the full delivery of the full Lorenzo Care Records System to the NHS is only the beginning of IBA Health Group’s lofty ambitions. In an exclusive interview, carried out days ahead of the go-live at Birmingham, an ebullient Gary Cohen spoke to E-Health Insider from Sydney about the company’s plans.

The group’s executive chairman said the first part of iSoft’s Lorenzo product suite will be Lorenzo Studio, which is set to be launched internationally at the Medica trade show this November. He said Lorenzo Studio has the potential to become a common “health operating system”, able to utilise web services to link together a range of legacy systems.

Indeed, he bullishy laid out ambitions for Lorenzo Studio to become nothing less than the common platform for healthcare internationally. “It will have a valuable role in transforming healthcare worldwide,” he predicted.

There is a lot more here:

http://ehealtheurope.net/comment_and_analysis/347/lorenzo_studio

Reading the article I am feeling rather encouraged – as it sounds like the worst is well and truly over in the development of what must be one of the very few advanced Health IT systems developed from the ground up over the last few years. (This is a very expensive and complex undertaking as many who have previously have said.)

To me using a services approach makes a great deal of sense – especially if it is to be architected in such a way as other specialist system providers can add to the IBA / iSoft core as required.

As I said months ago – delivery will be key to IBA’s success – and it looks like this just got a little closer. Given they are an Australian owned company one can only wish them luck!

David.

(Usual disclaimer of owning a few IBA shares applies).

Health Affairs Provides Contributions to Approaches and Use of Health IT.

In their September / October issue Health Affairs have provided some very interesting articles on the concept of the Medical Home and the place of Health IT is assisting the quality, safety and efficiency of chronic care delivery.

The Washington Post provides some useful coverage here:

Patient-Centered 'Medical Home' Models Lag in Key Areas

Wednesday, September 10, 2008; 12:00 AM

WEDNESDAY, Sept. 10 (HealthDay News) -- Many large physician groups in the United States lack the essential elements needed to create patient-centered "medical homes" designed to put primary-care doctors in charge of coordinating care, says a new study.

The medical home model is seen by many health-care providers, businesses and patients as a promising way to address problems with the country's health-care delivery system. It's believed that comprehensive primary care can ensure the best outcomes for patients.

But this study of large medical groups with at least 20 physicians found that the practices are lagging in key areas needed to created a medical home.

Between March 2006 and March 2007, researchers at the University of California, San Francisco, the University of California at Berkley, and the University of Chicago surveyed all large physician practices across the United States that treat patients with asthma, diabetes, congestive heart failure and depression.

The researchers focused vital elements of the medical home model: whether physicians work closely with other health-care providers in patient care teams; how well care is coordinated and integrated; whether care is delivered in ways that maximize quality and safety; and whether patients can reach physicians by e-mail or other nontraditional ways.

The use of electronic medical records, disease registries, patient reminders, performance feedback and distribution of educational materials to patients was also examined in the study.

…..

Overall, the largest medical groups in the study (those with more than 140 physicians) and those owned by a hospital or health maintenance organization (HMO) scored highest on the four critical areas of a medical home model. This may be because they have more resources to invest, the study authors said.

…..

More information

The Patient-Centered Primary Care Collaborative has more about the patient-centered medical home model.

More here:

http://www.washingtonpost.com/wp-dyn/content/article/2008/09/10/AR2008091001482.html

Coverage of another article is found here:

Report: Potential of Health IT Depends on Technical Standards and Policy Objectives

By Annie Johnson, CQ Staff

Focusing solely on the technical aspects of health information technology without also developing policy standards will not transform the nation’s health care system, according to an online report published this month in Health Affairs.

The report cites “serious structural barriers to the use of IT that have nothing to do with technology.” Obstacles include financial and legal incentives currently in place that don’t encourage information sharing across institutions, it said. In addition, many physicians and hospitals wonder how to shoulder the financial burden of implementing health IT, while consumers are concerned about privacy and security issues surrounding use of their medical information, the report said.

Initially adopting a minimal set of standards could pave the way to using health IT to overhaul the health care system, said the report’s authors, Carol Diamond, managing director of the Health Program at the Markle Foundation, and Clay Shirky, an adjunct professor at New York University. The authors suggests that information policy decisions should be made openly and not backed into through technology choices; that incremental changes have a greater chance of success; and that standards alone can’t compensate for the lack of a business case for sharing health information.

More here:

http://www.cqpolitics.com/wmspage.cfm?docID=hbnews-000002947413

For those who can access the full text the following look to be the most important articles.

Health Affairs Table of Contents

A new issue of Health Affairs is available online:

Overhauling The Delivery System:

September/October 2008; Vol. 27, No. 5

The below Table of Contents is available online at:

http://content.healthaffairs.org/content/vol27/issue5/

From the Editor

Innovations: ‘Medical Home’ Or Medical Motel ?

Susan Dentzer

Health Affairs 27(5): 1216-1217

http://content.healthaffairs.org/cgi/content/full/27/5/1216

Medical Home

The Medical Home

Health Affairs 27(5): 1218

http://content.healthaffairs.org/cgi/content/full/27/5/1218

A House Is Not A Home: Keeping Patients At The Center Of Practice Redesign

Robert A. Berenson, Terry Hammons, David N. Gans, Stephen Zuckerman, Katie Merrell, William S. Underwood, and Aimee F. Williams

Health Affairs 27(5): 1219-1230

http://content.healthaffairs.org/cgi/content/abstract/27/5/1219

Continuous Innovation In Health Care: Implications Of The Geisinger Experience

Ronald A. Paulus, Karen Davis, and Glenn D. Steele

Health Affairs 27(5): 1235-1245

http://content.healthaffairs.org/cgi/content/abstract/27/5/1235

Measuring The Medical Home Infrastructure In Large Medical Groups

Diane R. Rittenhouse, Lawrence P. Casalino, Robin R. Gillies, Stephen M. Shortell, and Bernard Lau

Health Affairs 27(5): 1246-1258

http://content.healthaffairs.org/cgi/content/abstract/27/5/1246

Perspective

The Patient-Centered Medical Home For Chronic Illness: Is It Ready For Prime Time?

Jaan E. Sidorov

Health Affairs 27(5): 1231-1234

http://content.healthaffairs.org/cgi/content/abstract/27/5/1231

Web Exclusives

Health Information Technology: A Few Years Of Magical Thinking?

Carol C. Diamond and Clay Shirky

Health Affairs 27(5): w383-w390

http://content.healthaffairs.org/cgi/content/abstract/27/5/w383

Health Information Technology: Strategic Initiatives, Real Progress

Robert M. Kolodner, Simon P. Cohn, and Charles P. Friedman

Health Affairs 27(5): w391-w395

http://content.healthaffairs.org/cgi/content/abstract/27/5/w391

The Alternative Route: Hanging Out The Unmentionables For Better Decision Making In Health Information Technology

David C. Kibbe and Curtis P. McLaughlin

Health Affairs 27(5): w396-w398

http://content.healthaffairs.org/cgi/content/abstract/27/5/w396

There seems little doubt that the concept of a ‘Medical Home’ is gaining traction in the USA. I believe Dr Oliver Frank of Adelaide University is seeking similar outcomes. See the following:

Big step to improving patient care

10-Sep-2008

By Dr Oliver Frank

I BELIEVE patient enrolment is the biggest single step we can take towards improving our ability to provide all appropriate care for our patients.

We would know, for instance, that our practice is the only one responsible for providing all routine care for the patient. This includes preventive care and all routine consulting. Hospitals will no longer have to wonder who the patient’s usual GP is. They will be able to look it up.

If we want to send recall notices to the patient for some aspect of care, we will know that no other practice is likely to be doing so.

And we would know we would be paid for performing the various care plan items for the patient rather than finding out its been done by someone else.

More here (subscription required):

I think he is right and that any steps on the part of Ms Roxon to fracture the single responsible doctor as care co-ordinator for individual patients would be a very, very bad thing. We need more, not less co-ordination to improve health outcomes.

David.