Nat'l Health IT Week from DC

I'm here at the National Health IT Collaborative for the Underserved in Washington today. The meetings are lasting all day, and I am a member of the Policy workgroup. Members of the workgroup come from a variety of places; provider networks in Californiaand Michigan, Morehouse, The Office of Minority Health and Capitol Hill. Much of this morning's discussion was about ARRA funds and how the remote, rural and underserved community providers would access those funds.

Those at the table from the Hill were pretty energetic about the ARRA funding allocations to regional health networks. They feel that the RFPs have been written to such a tight profile as to be "self selecting." It is already known which big players in health management will qualify. There are now discussions in California to enable access to these funds through "subcontracting" to local networks. There is a requirement that for a Regional network to qualify, it must have a minimum of 100,000 people. By aggregating these "local"'s numbers, the big players can then have the qualifying numbers, and the local clinics can access funding.

There was also a strong sentiment about bringing the smaller, rural/remote providers together to examine their HIT wants and needs. By documenting this aggregate market, vendors can be educated to develop and deliver more integrated and interoperable technologies---This is very reminiscent of last week's article on the Canadian market. MORE ON THAT LATER.....

"Meaningful Use:" Meaningful to Whom?

In the States, ARRA has authorized funds to assist organizations implementing EHRs. ARRA requires "Meaningful use." The healthcare Information technology Standards Panel (HITSP) has just defined seven core types of data exchange; prescriptions, lab results, clinical data summaries, biosurveillance data, immunization registries, public health and quality measurement. [Full article here] Clearly a committee was involved--certainly prescription data, clinical summaries and labs would enable healthcare while reducing potential misidentification issues.

But what do immunization registries do for patients or providers? public health data? And biosurveillance is about accessing multiple data sources to identify trends or potential outbreaks; so that means making the electronic record readable for "phishing," not improving the care of the patient. Is that wrong?

The American Health Information Management Association (AHIMA) commented to The National Committee on Vital and Health Statistics on this (April 2009, AHIMA), and had some very interesting points. Sandra Fuller delivered a very thorough discussion of both the product and the process to arrive at "meaningful use." AHIMA felt that public funding should be used to drive improved care as well as the public interest.

To improve care, they spoke of prescriptions, labs and results and discharge data. These are all considered core elements of care-information communication and patient transfer (provider to technician, provider to pharmacist, provider to provider) and areas of greatest risk of error.

The report looked beyond the patient--to both public-health policy and to patient-care policy. To serve public health interests (and after all, this is being publicly funded), AHIMA recommends investment in development of improved reporting methods and systems with coordination through the HIEs being developed (and funded) with other ARRA resources. But, at the end, AHIMA circled back to the patient;

Be relevant to consumers: Taxpayers are funding these investments as a prerequisite to effective health reform. More broadly, this is an extraordinary opportunity to be transparent and to increase public recognition of the challenge and opportunity of an interconnected health system and the progress that is being made.

All in all, a very interesting and valuable report--check it out

Well, the committee got to it and politics seems to have moved things to the, if you will, "right." Immunization records should certainly be part of the patient record, but is it really a priority element for standardization? Discharge summaries fell out, but biosurveillance got in. Should readability by outside agencies be a "core element" of meaningful use? If an EHR is about communicating patient data (and it is usually thought of as an active process, not a passive one), then is anxiety overwhelming the mission? Or is this use of "surveillance" simply a way to get Homeland Security behind the drive for a national standards for data formatting and encoding? After all, the multiple-vendor system has led to a wide variety of proprietary methods that inhibit data communication and portability. And are we still in the times of driving by fear? Thoughts?

RECs--What, Who and How?

The American Recovery and Reinvestment Act of 2009 (ARRA) has more than just EHR money in it. The act also seeks to encourage the establishment of "regional extension centers" (RECs) to provide support and assistance. Funding is being made available to organizations who meet certain requirements, and this funding is to range from $1-10 Million per year in two-year awards. So far, the government has published some criteria and guidelines for preference. Among other things, they are proposing to give preference to:
• Organizational plans and implementation strategies that include multi-stakeholder collaborations that make use of local resources, such as universities with health-related programs; medical or professional societies; state primary care associations; state or regional hospital organizations; large health centers and networks of rural and/or community health centers; state Area Health Education Centers; HIEs; and government entities such as public health agencies, libraries and information centers with health professional and community outreach programs, and consumer/ patient organizations.
• Applicants identifying viable sources of matching funds, including but not limited to grants from states and not-for-profit foundations, and payment for services from providers.

(as reported by Helen Pfister of Manatt Health Solutions. For her full write up, see ihealthbeat)

Historically, Federal programs have accede to state and local organizations--particularly in matters of geography. And in this instance, as is often seen as sensible, preferred organizations would be those connecting to and working with "local resources, such as universities...and consumer/patient organizations." And while extant organizations may understand their populations, local universities are often restricted in whom they can serve and where they can operate--to the state or locality in question. "State/local organizations" are often funded to serve--and only serve--residents of their state or locality.
In regional community healthcare services, all of this is counterintuitive to success. Providers serving similar populations in similar environmental and economic environments face the same problems and work towards similar solutions. Environments and economies do not stop at the legal boundaries of local or state government. The circumstances and life issues of The Blue Ridge Mountains extend across township, county and even state lines. Providers know this fact that bureaucrats miss. According to a survey of providers and provider organizations released by eHealthinitiative last month (available here), "Nearly half of respondents said that regional extension centers should not be constrained to a specific metropolitan or state boundary." In the eHealth survey, "local government-sponsored entities," are found very poorly suited to manage RECs by 42% of respondents.

The RECs are to provide support, guidance and knowledge-management resources to regional organizations receiving funding. Traditionally, providers have largely depended on publications, conferences and vendors for guidance on industry trends and software support. And vendors certainly meet the
other requirements to;
• Describe proposed levels and approaches of support for providers to be served;
• Address how the applicant would structure its organization and staffing to ensure providers served have ready access to reasonably local health IT "extension agents" and provide training and ongoing support for these critical workers;
• Demonstrate the capacity to facilitate and support cooperation among local providers, health systems, communities and health information exchanges ("HIEs");
• Demonstrate that the applicant is able to meet the needs of providers prioritized for direct assistance; and 
• Propose an efficient and feasible strategy to furnish deep specialized expertise (in such areas as organizational development, legal issues, privacy and security, economic and financing issues, and evaluation) to all providers served, as well as intensive, individualized, "local" presence from an interdisciplinary extension agent to smaller groups of providers assigned to individual agents.

And while vendors are experienced at offering service and support, providers are not that trusting. The absolute last choice by providers and provider groups to manage RECs was vendors--71% of those surveyed find them to be the MOST poorly suited. (Strangely, as to those who DO trust them, only 9% of those surveyed thought they were best suited. Note: Technology vendors made up 11% of the survey).

So who then is to create and manage the RECs?
Associations? HIEs? Not for Profits? Or will new things be formed among vendors, state agencies and inter-jurisdictional NGOs? The comment period for the regulations close at 5pm ET today. It will be interesting to see what people (and vendors, associations and providers) have to day...What do you all think?