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24 posts categorized "E-Prescribing"

July 14, 2010

Meaningful Use: The Final Rule

Wordle: Meaningful Use Final Rule

Meaningful use was given its final definition yesterday, in the meaningful use final rule released by HHS.  Secretary Sebelius, CMS Adminsitrator Berwick, ONC chief Blumenthal and the two Reginas spoke -- U.S. Surgeon General Regina Benjamin, and Regina Holliday, whose late husband's last days were complicated by the failure of health care facilities to release and share health records.  Berwick, in his first full day on the job as CMS Adminstrator, waxed rhapsodic about the pleasures of practicing as a pediatrician at Harvard Community Health Plan using its pioneering electronic health record system.  (Years later, I am still a patient at Harvard Vanguard Medical Associates, which used to be part of HCHP, and I am still spoiled by the EHR system there.)  Blumenthal and Benjamin also spoke about how and why they came to use EHRs in their clinical practices, and why they wouldn't have it any other way.  (The rule will be published in the Federal Register July 28.)

Also released was the proposed permanent EHR certification rule.  (Last month, the federales released a temporary version of the EHR certification rule, so that there would be standards in place for providers seeking HITECH Act incentive payments for 2011 meaningful use of certified EHRs.)  Taken together with the draft regulations updating HIPAA privacy, security and enforcement rules under the HITECH Act announced last week, these rules outline the future of health care IT in this country.

Not surprisingly, after receiving over 2,000 comments on the draft definition of meaningful use released over six months ago, the feds revised the rule considerably, loosening the definitions of Stage 1 Objectives (i.e., the criteria by which 2011 compliance and eligibility for the full incentive payments will be judged), among other things.

The HHS fact sheet (available on the relatively new CMS EHR Incentive Programs web page) describes some of the key components of the rule as follows:  

  • For Stage 1, CMS’s proposed rule called on physicians and other eligible professionals ("EPs") to meet 25 objectives (23 for hospitals) in reporting their meaningful use of EHRs. The final rule divides the objectives into a “core” group of required objectives and a “menu set” of procedures from which providers can choose.  This “two track” approach ensures that the most basic elements of meaningful EHR use will be met by all providers qualifying for incentive payments, while at the same time allowing latitude in other areas to reflect providers’ varying needs and their individual paths to full EHR use.
  • In line with recommendations of the Health Information Technology Policy Committee, the final rule includes the objective of providing patient-specific educational resources for both EPs and eligible hospitals and the objective of recording advance directives for eligible hospitals.
  • With respect to defining hospital-based physicians, the final rule conforms to the Continuing Extension Act of 2010. That law addressed provider concerns about hospital-based providers in ambulatory settings being unable to qualify for incentive payments by defining a hospital-based EP as performing substantially all of his or her services in an inpatient hospital setting or emergency room only.
  • The rule makes final a proposed rule definition that would make individual payments to eligible hospitals identified by their individual CMS Certification Number.  The final rule retains the proposed definition of an eligible hospital because that is most consistent with policy precedents in how Medicare has historically applied the statutory definition of a ”subsection (d)” hospital under other hospital payment regulations.
  • Under Medicaid, the final rule includes critical access hospitals (CAHs) in the definition of acute care hospital for the purpose of incentive program eligibility.
  • The final rule’s economic analysis estimates that incentive payments under Medicare and Medicaid EHR programs for 2011 through 2019 will range from $9.7 billion to $27.4 billion.

Not only did the government go the "Chinese menu" route in allowing providers to customize the standard set that will be applicable to them; it also made the standards much less stringent (e.g. threshhold of 40% e-prescribing vs. 75% in the draft rule; though one must wonder whether this is mere window dressing, as an EP with an e-Rx system in place would not be likely to use it for anything less than 100% of patients)That's not to say that qualifying for the incentives will be a breeze, though some naysayers are criticizing the feds for that reason.  On the other hand, there are plenty of voices out there decrying the difficulty providers will face in trying to qualify for the full incentive payments in the time remaining.  Finally, there are those who still question the value of this whole exercise, seeing it as a Recovery Act handout for the EHR vendors more than anything else, wondering when and where the clinical benefits will materialize.

The EHR vendors that are guaranteeing compliance with meaningful use are now in overdrive, working on the interim certification for their products, and looking to sign up providers now that the meaningful use rules have been finalized.  Hospitals and EPs that are not already in the midst of implementation may be hard-pressed to achieve meaningful use of a certified EHR before the first deadline in 2011.  Most will be able to pull it off by 2015, when the incentives for EHR adoption switch over to penalties for failure to get wired.  (The cynics among us may see a future legislative deferral of the penalty provisions, just as we have been getting used to regular last-minute deferrals of SGR formula-driven physician reimbursement cuts.)  Some vendors are offering advances against incentive payments, in addition to compliance guarantees (see, e.g., GE's healthymagination program).

The FDA did not insert itself into the final rulemaking process, as some had hoped or expected.  The FDA has asserted jurisdiction over EHRs as "devices" and the regulated community would sure as heck like to know sooner, rather than later, just what the FDA has in mind for regulating EHRs (no pre-market approval, methinks). 

Finally, the criteria established and to be met are not ends in themselves, but a means to a further end: the improvement of quality while reducing cost -- two legs of the proverbial three-legged stool.  (The third leg, access, may be improved through other aspects of the Obama administration's health reform initiatives.)   As the meaningful use rule and the revised HIPAA rules come together in seeking to promote a migration of health data to a near-universal online, interoperable state, some e-patients and patient advocates will measure the success of the implementation by its satisfaction of the Declaration of Health Data Rights.  Let's hope that the deferral of PHR-EHR connection requirements don't sidetrack the patient empowerment side of this rule.

There are many, many other issues dealt with and implicated in the more than 800 pages of the final rule, and many other commentators writing about them.  I invite you to peruse the rule and some of the other materials linked to in this post, and to offer your thoughts on the rule and its implications below.

For further reading:

The Stage 1 Meaningful Use objectives and associated measures, broken out by "core" and "menu" set are found in Table 2, beginning on page 221 of the final rule PDF released yesterday.

A helpful side-by-side comparison of final vs. proposed rule Stage 1 objectives and measures may be found at Keith Boone's blog (together with an analysis of the certification rule).

Another helpful meaningful use summary (courtesy of the federales) is available via the New England Journal of Medicine.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

May 05, 2010

HIT incentives in Massachusetts: Less carrot, more stick

Health care providers all over the country are all worked up because they say that the federales' regulations on meaningful use of certified EHRs go too far, too fast

They should be glad they're not in Massachusetts, where EHR use will soon be required as a condition of licensure of physicians, hospitals and community health centers. 

The word got out, thanks to Secretary of Health and Human Services JudyAnn Bigby, who spoke at last week's HIT conference hosted by Governor Deval Patrick and the MA Health Data Consortium.  This seemed to be news to some folks out there, but these requirements are deep in the heart of Part II of the Massachusetts health reform law (Chapter 305 of the Acts of 2008).  Much of the coverage in August 2008 didn't mention the EHR-for-licensure provisions, but the HealthBlawg post at the time highlighted the EHR requirement as a condition of licensure as one of the important bits enacted in Chapter 305.  Another helpful bit: $25 million available in grant monies to providers to help implement EHR systems -- a drop in the proverbial bucket.

Here is the statutory language imposing the requirements:

SECTION 15.  [M.G.L. c. 112, s. 2 is amended to read in part:]  The board [of registration in medicine] shall require, as a standard of eligibility for licensure, that applicants show a predetermined level of competency in the use of computerized physician order entry, e-prescribing, electronic health records and other forms of health information technology, as determined by the board. [Effective January 1, 2015, per Chapter 305, Sec. 58.]

SECTION 36.  Notwithstanding any general or special law to the contrary, on or before October 1, 2012, the department of public health shall adopt regulations requiring hospitals and community health centers, as a standard of eligibility for original licensure and renewal of licensure, to implement computerized physician order entry systems as defined by the department. The systems shall be certified by the Certification Commission for Healthcare Information Technology or a successor agency or organization established for the purpose of certifying that health information technology meets national interoperability standards.

SECTION 37.  Notwithstanding any general or special law to the contrary, on or before October 1, 2015, the department of public health shall adopt regulations requiring hospitals and community health centers, as a standard of eligibility for original licensure and renewal of licensure, to implement interoperable electronic health records systems, as defined by the department.  The system shall be certified by the Certification Commission for Healthcare Information Technology or a successor agency or organization established for the purpose of certifying that health information technology meets national interoperability standards.

To review:  Deadlines start hitting in less than 18 months.

October 1, 2012

Massachusetts hospitals and community health centers must be using interoperable CPOE systems, as defined by DPH, that are CCHIT-certified, as a condition of licensure.

January 1, 2015

Massachusetts physician licensure is conditioned on demonstration of competency in using CPOE, e-prescribing, and other forms of HIT, as determined by the Board of Registration in Medicine. 

October 1, 2015

Massachusetts hospital and community health center licensure is conditioned on implementing interoperable EHRs, as defined by DPH, that are CCHIT-certified.

So here's my take on some of the problems with this legislation.  First of all, there are a few holes in the system: 

  • Facilities other than hospitals and community health centers provide a great deal of health care -- e.g., freestanding clinics, including diagnostic imaging centers, cancer treatment centers, ambulatory surgery centers.  If you're going to mandate EHRs, better go whole hog.
  • Practitioners other than physicians provide a heckuva lot of health care services, too -- same argument as above applies to nurse practitioners, optometrists, etc.
  • Certification by an alternative to CCHIT, if recognized by HHS under the HITECH Act, would not be recognized under this law, which refers to CCHIT "or a successor."
Second, the CCHIT certification system is more focused on the large enterprise "legacy" EHR systems, as is the NHIN structure that's been described by the federales.  The one encouraging note on that front is the development work being done on NHIN Direct, explained in a lucid post by David Kibbe at The Health Care BlogNHIN Direct will be providing some of the "backbone" and "handshake" hardware and software needed to make interoperability work for many health care providers.  At this point, it's hard to say what CCHIT certification standards will look like three to five years from now, and whether they will make sense for all providers covered by the Massachusetts law.

Bottom line: An interesting model put out there by the Commonwealth for the rest of the country to consider . . . and more moving parts to keep track of for Massachusetts health care providers.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

March 16, 2010

David Harlow quoted on Electronic Health Records implementation and incentives in Mass. Medical Law Report

Just a few days before the comment period closed on the draft regulations defining meaningful use (see all meaningful use comments), the Massachusetts Medical Law Report ran a piece on the HITECH Act incentives for implementation of electronic health records systems, quoting me and a couple other usual suspects.  I highlighted some shortcomings in the proposed rule, and also noted that health care providers need to be implementing EHRs not just for the stimulus kicker ... that alone is not worth it:

[T]he regulation calls for all physicians to use e-prescribing 75 percent of the time by 2012.

David Harlow, a Newton-based lawyer and health care consultant, said that this won’t be an easy task, noting that Massachusetts is considered a leader in e-prescribing even though only 10 percent of prescriptions are submitted electronically.

At the same time, other benchmarks seem pointless in light of what many physicians – especially specialists – do on a regular basis, Harlow said.

He referred to a requirement that electronic reminders for preventative care and follow-up be sent to at least 50 percent of all patients age 50 or older.

“Why would, say, an orthopedic surgeon be sending out reminders based on age?” he asked. “That’s really geared toward primary care, yet it’s a measure that’s required in order to get an incentive payment.”

. . . 

Harlow warns that a physician practice should not even attempt to roll out an EHR system if the physicians are only in it for the incentive payments. Though an effective system should ultimately start paying for itself through the internal office efficiencies it creates, a $44,000 maximum incentive payment won’t cover the implementation costs.

On the positive side, there are certainly reasons for moving forward with EHR implementation -- as you can read (or hear) in my recent interview with Partners Health Care CIO John Glaser -- though not all health care providers are able to absorb the costs as Partners can.  In the long run, however, there are certainly many strong arguments on a variety of fronts about the value of EHRs.  I heard some of those arguments this morning from folks in the patient-centered medical home camp who I saw at a Mass. Technology Leadership Council event -- including Paul Grundy, patient-centered medical home evangelist from IBM, who I interviewed last year.  Time will tell whether the widespread adoption of EHRs will truly fulfill their promise, but we are certainly well on our way to finding out. 

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

September 30, 2009

Whither meaningful use of the certified, interoperable EHR?

Paul Roemer asks:

Have you ever been a part of a successful launch of a national IT system that: 

  • required a hundred thousand or so implementations of a parochial system?
  • has been designed by 400 vendors?
  • had 400 applications based on their own standards?
  • has had to transport different versions of health records in and out of hundreds of different regional health information networks?
  • needed to be interoperable?
  • could have resulted in someone's death if it failed?
Me neither.

The challenges are many, yet many health care systems already are, or soon will be, moving to implement pieces of this national system.  Are they motivated by the HITECH Act promise of up to $44,000 per physician for meaningful use of a certified EHR?  Perhaps, but that won't cover the cost.  The real value is in the ability to manage a patient's care effectively, efficiently and seamlessly across practice sites and, beyond that, to learn from population-level data. 

The federales already know this -- check out the recent All Things Considered piece on the Medicare claims database.  The aggregators of de-identified data putting it to secondary uses already know this, though their work may be made more complicated by the new HIPAA and Son of HIPPA rules out from HHS and FTC.  Some health systems know this, and are prepared to match the federales' incentive payments to docs who get on the bus (adding some Stark, fraud and abuse and tax issues to the already-heavy load of considerations).

Health care provider systems are ready to get with the program, but may need some guidance in negotiating the regulatory and operational minefields as they move to implement EHR systems. 

If you're part of a system looking for some ground-floor planning and strategic thinking on this thorny set of issues, please get in touch with Paul or me.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

April 21, 2009

HealthCamp Boston / SocialPharmer Boston Twitterstream via Cover It Live

HealthCamp Boston and SocialPharmer Boston are taking place today.  For those of you on site, please live tweet using hashtags #hcbos or #socpharm.  For those of you following along at home, please follow those hashtags in your reader of choice, or right here.  Separate windows are provided for #hcbos and #socpharm (each will have more than one thread, so mashing them together seemed too unwieldy).  The twitterstream will be archived here for future reference.  Information on audio and video archives will be available via the event website at some point in the future.



David Harlow
The Harlow Group LLC
Health Care Law and Consulting

April 20, 2009

HealthCamp Boston April 21 - Come join in the fun, or follow along at home

HealthCamp Boston and SocialPharmer Boston are happening tomorrow, April 21.  If you can't make it in person and would like to follow the events of the day, check back here at HealthBlawg for CoverItLive windows: one will be set to follow the #hcbos twitterstream, the other, the #socpharm stream.  If you are on twitter, use your reader of choice.  The tweets will be archived here for future reference.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

March 19, 2009

Health Wonk Review: Spring has just about sprung

Michaels S C Welcome to Health Wonk Review, where everyone is above average.  We enjoy above-average health care costs per capita, above-average uninsured rates, and above-average obsession with health care reform.  That's what it's like today in America.  Our president has said, Change has come to America.  In the words of Robert Hayden's [American Journal]:

america     as much a problem in metaphysics as
it is a nation earthly entity an iota in our
galaxy     an organism that changes even as i
examine it     fact and fantasy never twice the
same     so many variables

Like Schrodinger's cat, America's health care system seems to change in the changing light as we examine it; one thing we can all agree on is that it needs some work. 

Franz Kline Steve Martin We begin with some broad brush strokes on form and amount of spending:

Len Nichols presents HEALTH REFORM: Moving Past the Impasse on the Public Plan | New America Blogs posted at New Health Dialogue

Maggie Mahar presents Health Beat: Thinking About Dr. Atul Gawande’s Congressional Testimony Part 1: Why Health Care Reform Will Require Additional Spending at Health Beat.

Lewis Hine Mechanic One cost, no matter what the payment system, is labor.  Lynn Nicholas, President of the Massachusetts Hospital Association writes about some pending changes to labor laws that might make it easier for labor to unionize, presenting the favored position of a non-union shop as one of worker, rather than employer, preference.  See Keeping Communication Lines Open in the Healthcare Labor Debate at CommonHealth, the Massachusetts health care reform blog of WBUR (a Boston NPR affiliate).

Who Will Pay for Prescription Drugs? asks Adam Fein at Drug Channels. CMS projections show that the government will have a very strong hand in managing retail drug spending and shaping the future of drug channels.  How will that affect pricing and R&D?  Richard Fogoros (DrRich) presents A Brilliant Plan For Preserving Pharmaceutical Progress at The Covert Rationing Blog, saying, The title says it all. Can we have our cake (drug price controls) and eat it too (continue drug innovation)? DrRich says, yes we can!  Check out his proposal.

Pills My dad used to say he wanted to listen to a radio station that broadcast only good news (not Good News, just good news).  Merrill Goozner, of GoozNews, suggests this week that there ought to be a journal dedicated solely to publishing negative results -- as soon as they're known -- as he is all hopped up due to delayed publication and/or suppression of data on adverse effects of drugs.  These issues in general, and a couple of current cases he discusses, have policy implications for the new leadership at the FDA.

At InsureBlog, Mike Feehan has a piece on Wellpoint's recent spinning off of its in-house PBM, About Wellpoint's PBM Auction, and future implications for prescription costs.

8907bread_line

Ill and Uninsured in Illinois gives us a simple but eloquent presentation of the difficulty of accessing specialty care while uninsured: The Wait for Cook County Health Care.

At the other end of the spectrum, Health Access WeBlog's Beth Capell asks What are gold-plated benefits anyway? An interesting question, now that the president has indicated that he is open to signing a bill including taxation of health benefits.  (As an aside, Obama's approach -- White House Health Care Summit with stunning transparency, concluded with an invitation to Congress to send him a bill consistent with the policies he articulated throughout the campaign -- is both a refreshing change from the Clinton years and a strategy likely to insulate him from criticism on the exact contours of the plan when it reaches his desk.)

Mao_tse_tungJared Rhoads presents Less government, not more at The Lucidicus Project, discussing the recent report by Physicians for a National Health Plan (the single payor proponents).  I spoke with PNHP's David Himmelstein a little while back, and while he has a compelling argument for adopting a single-payor plan in this country (the savings would be impressive), I still believe that the more pragmatic approach is to make incremental changes in the system before us. 

Taking our cue from Dr. Himmelstein, we begin a bit of a grand tour by visiting our neighbor to the north. 

North of the border, Sam Solomon asks Can Canadian doctors fire their patients? at Canadian Medicine, and says in short, yes, but carefully.

At BNET Healthcare, Ken Terry writes that Massachusetts Needs to Deal With Primary Care Crisis, saying that while proponents of the healthcare reform program in Massachusetts tout it as a model for the entire country, and detractors point to the program's rapidly rising costs, neither side is really focusing on the need for better access to primary care in the state. He also observes that retail clinics are expanding in Massachusetts, and community health centers are pulling in federal cash for expansion.  One observation: retail clinics in Massachusetts are not currently expanding as they cannot find nurse pratitioners to hire.  Also, on a national level, Minute Clinic recently shuttered 90 sites for the season.  Even if they were growing, they are no substitute for primary care.

Looking at a new model of physician practice -- available 24/7, untethered to most of the traditional trappings of a physician practice (including that old-fashioned trope of accepting insurance payments), Ted Eytan, MD is Now Reading: Take Two Aspirin And Tweet Me In The Morning: How Twitter, Facebook, And Other Social Media Are Reshaping Health Care.

Great_Dictator_globe_scene_academy_print_bigGrrlScientist shares her overseas medicine story, Finnish Emergency Medicine: One American's Experience at Living the Scientific Life.  Seemed to work well for her without instantaneous contact back home.  (See my own tale of a close ecounter with an overseas health care system last year as well.)

Here at HealthBlawg, I recently interviewed the CEO of Satori World Medical, a medical tourism company that offers a twist: through an HRA, it funds patients' future years' insurance premiums with a portion of the savings their employers or insurers enjoy as a result of their overseas medical procedures.

Closer to home, many doctors are now leery of online ratings sites, and have started using a service, Medical Justice, to get patients to agree not to post negative reviews as a condition of being taken on as patients.  Dmitriy at Trusted.MD has been following this issue for a while and offers some insights.

Marx Brothers (A Day at the Races)_04_scrubbed_in Jaan Sidorov presents The Worrisome Outpatient Trend: What Does Disease Management Have to Offer? posted at Disease Management Care Blog.  Chronic care consumes 75% of the health care dollar in this country, and needs to be better managed.  Outpatient chronic care is a significant part of the equation.

Care management is also the theme of Julie Ferguson's post on The effect of obesity and other comorbidities on workers comp at Workers' Comp Insider.  In light of a new report which shows that workers comp medical claims can cost three times as much when the injured employee is obese, she makes the case for breaking down the silos between employer-based occupational health and general health programs.

David Williams' post on Wal-Mart and eClinicalWorks over at Health Business Blog concludes with a healthy bit of skepticism about this new EHR offering to small physician practices.

Using the cost per doc put out by Wal-Mart, John Moore does some calculations, and shows in his post The HITECH Challenge: Is $19B Enough to Drive HIT Adoption at Chilmark Research that docs getting wired and getting HITECH incentive dollars will be engaged in a money-losing proposition -- they'd actually be better off financially not implementing EHRs and getting hit with the penalty a few years down the road. 

Speaking of Wal-Mart, it bears mentioning that this day in history marks the anniversary of the Civil War Battle of Bentonville (No, not that Bentonville; the battle was in North Carolina.)

Tinker Ready, at Boston Health News, shares some insights from John Glaser, CIO of Partners Healthcare, on getting HIT right.

Shahid N. Shah presents Client/Server vs. ASP/Web-Based in Healthcare IT posted at The Healthcare IT Guy, since with the HITECH Act and stimulus bill making news, many users are asking if they should purchase software and use it on premises or if they should use a "cloud" package or an ASP/web-based solution.

Metropolis5 In addition to jump-starting HIT, current legislation is giving a boost to research funding.  One pot of funds is time-limited; Glenn Laffel looks at Beaker Ready projects ready for NIH funding at Pizaazz.

Jason Shafrin reviews some of the pros and cons of establishing a government body to conduct cost effectiveness research in Should the U.S. get NICE? at Healthcare Economist.

In The Color of Money: What Sort of School Doesn't Pay Its Faculty to Teach? Roy Poses at Health Care Renewal puts academic medicine on the spot, saying that some leaders have abandoned core missions in favor of collecting "taxes" from medical faculty, which makes faculty more dependent on commercial interests.  Strong words indeed, and an issue that needs to be rolled out front and center together with other payment issues if there is to be a wholesale revamping of health care financing in this country.

For those brave enough to enter the land of credit default swaps, Joe Paduda, at Managed Care Matters, examines the reasons for propping up AIG and why it may fail anyway.

And finally, to leave you with some doom and gloom from The Health Care Blog to ponder, Brian Klepper and David Kibbe ask Is the healthcare economy rightsizing?

Thanks for visiting HealthBlawg for this edition.  Please see me on twitter too, and join us again next time for Health Wonk Review.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

March 04, 2009

Dan Greden, head of eHealth Product Management at Aetna, speaks with David Harlow about PHRs and patient engagement

Dan Greden, Head of eHealth Product Management at Aetna, spoke with HealthBlawg last week about Aetna's PHR system, its above-average rate of adoption by members, and the benefits that it provides to members, clinicians and ultimate payors.

The audio file of my interview with Dan Greden (about 30 minutes long) is available for download/podcast. A full transcript is at the end of this post (and in the linked transcript).
  

About 11% of Aetna's subscribers are active users of the Aetna PHR system (vs. well under 5% PHR adoption by the population at large).  The PHR is automatically populated with data from providers' clinical systems, including prescription information and lab results.  As Greden explains in greater detail, the PHR system is bolstered by an evidence-based medicine expert system that generates patient-specific alerts to patient and/or clinician (depending on the urgency of the alert), and allows for members to be more fully engaged in active management of their own health care.  This increased level of engagement is beneficial both to the management of members' health and to the management of the cost of care.  As more employer health plans steer members into HDHP/HSA combinations, members are becoming more cost-conscious, and have become more interested in learning about quality and cost-effectiveness when it comes to managing their own health care.

Aetna's system allows members to delegate access to their PHRs to clinicians and family members in a variety of controlled ways, limiting access where the member so desires (or where the right to impose limits is required by law -- e.g., for records relating to minors' reproductive health issues).

Greden stressed that the records belong to the individual members, and that in case of a change in insurance coverage a departing member may arrange for his or her PHR to be ported to HealthVault.

As the entire country has become focused on EHRs and PHRs thanks to the HITECH Act (which, by the way, brings PHRs into the big HIPAA tent), it is instructive to look at successful implementations of PHRs such as Aetna's, which has been in place in one form or another for over two years, in order to consider how the HITECH Act's billions might best be spent.  For example, the architects of the new system should consider in very concrete terms the improvements to patient care that are enabled by PHR systems such as Aetna's and the accompanying EBM expert systems and logic, and the minimum infrastructure necessary to enable such improved coordination of care and better outcomes, both on the patient side and on the provider side. 

David Harlow
The Harlow Group LLC
Health Care Law and Consulting


Interview of Dan Greden, Head of eHealth Product Management at Aetna

February 26, 2009

David Harlow:  This is David Harlow on HealthBlawg and I am speaking today with Dan Greden who is the head of eHealth Product Management at Aetna.  Good morning, Dan.

Dan Greden:  Hey, good morning.

David Harlow:  Well, thank you for taking the time to be with us this morning, Dan. I had the pleasure of hearing you speak at a recent conference on Health 3.0 and while we may debate the definition of Health 3.0, what I heard from you about what you are doing at Aetna was fascinating. I would like to ask you to speak a bit about your work in connection with the personal health records online access tools for Aetna members and how that allows them to be engaged with their physicians managing their own healthcare.

Dan Greden:  Great.

David Harlow:  So I wonder if just for starters if you could describe what the tool is and how patients are accessing it?

Dan Greden:  Sure, David.  We built our PHR as part of our Aetna Navigator secure website and that was a deliberate decision from the beginning that it should be part of the rest of our members’ online experience. You know, it’s not a separate tool, it’s highly integrated into all their other interactions, and what we focused on was building a tool that helps them be better consumers of healthcare and providing them a resource to make decisions, to be more engaged with health care providers, and so our approach was really beyond just putting the data on a secure site.  What we chose to do is really marry the data that we all really have through our normal healthcare plan operations with our care engine, the analytical engine that our Active Health Management subsidiary provides us, so we could really guide our members by continually analyzing their records and reaching out to them and/or their physicians when we find an opportunity to improve their care or be more engaged to better manage their care through that analysis of their records.  So even though we call it a PHR, it’s really much more than just a record online, it’s really a tool and resource that our members can use to be more engaged and better consumers of their healthcare resources.

David Harlow:  And what about their clinicians?  What access or inputs to the PHR do the clinicians have, and how do they use that information?

Dan Greden:  Well, the first and the primary way that a member shares their information with their physicians is by printing it out; we had that ability in the product the day we launched, which was just over two years ago, February 14th of 2007.  Since then we have added additional capabilities to have the physician access the record when the member provides that to the clinician. So the member is always in control of who sees their records; they have to formally delegate the access to someone else, whether it be a physician, whether it be a family member.  The way it works electronically is that a member can go online, choose the physician that they want to access their records and then when, if the physician is using our Aetna provider portal which is part of a larger package of resources that Navimedix provides -- it’s a company that provides tools for physicians to automate their practices -- when the physician staff or office is going on and doing something like an eligibility verification prior to the visit or even perhaps submitting a prior claim, if the member has delegated access to the PHR it will show up as part of that activity and there will be a prompt that asks the office: hey, your patient, your member has asked to share this with you, click here to print it.  We also can send care alerts -- or what we call care considerations -- that the care engine identifies to the physician in that way.  So if there is an opportunity to improve care we deliver it via that channel as well.

David Harlow:  That’s a very interesting additional tool.  Now, how are those care alerts generated and what are they based on?

Dan Greden:  Well, what the care engine does is it takes the claims-derived data from a multitude of sources. It’s not just medical claims but also pharmacy claims.  We look at lab claims, often we have lab results as well, and it goes through and does several types of analysis.  The first is it will go through and try and identify a potential presence of certain medical conditions and so it’s not just taking the way the claims are coded as the basis for the presence of the medical condition, you have to look for more evidence beyond that so if we use the example of a diabetic, we’ll see whether the claim coding, the ICD-9, or the CPT-4, or whatever, suggest the presence of diabetes, but those are often rule-out diagnoses the way the physicians code the claims so we’ll also look to see, all right, do I see prescriptions that would be consistent with someone managing diabetes, do I see lab results that would be consistent with someone  managing diabetes and based on what that analysis provides, the care engine may say you know I have reasonable cause to suspect this member has diabetes.  I am going to go through and do an additional set of analyses to make sure that all the best practices of care related to a patient with diabetes are being followed. So, for example, is this patient taking a low dose of an ACE inhibitor?  There have been recent studies that have proven that a very low dose of lisinopril, for example, five milligrams for example, can in the long run significantly prevent complications with kidney function, and if the member has taken a scrip that’s great, no action will be taken.  But if we see that the member has not taken it we will send a note to the physician as well as to the member, just informing them of this potential opportunity. You know, we are not drawing any conclusions; we are just introducing the topics for further discussion and further exploration between the member and their physician.  So that’s an example of how diabetes would work.  There are literally hundreds of different opportunities to improve care that are analyzed and dozens more medical conditions that have care management protocols or alert potentials in place.

David Harlow:  I’m wondering whether you have the potential to overload physicians with information about these various alerts, alerts that go to physicians or that go to patients as well.

Dan Greden:  The potential is there to overload physicians with the result of this analysis.

David Harlow:  Yeah, there is a potential, it seems to me, to provide so much information that the physicians could potentially be overloaded with information on a variety of conditions for a large number of patients.

Dan Greden:  First of all that’s a great question, and the way that that’s been managed is two-fold.  One, I mentioned how the analysis for the presence of the condition is fairly rigorous, it doesn’t just look for the claim coding, it looks for other data that would corroborate the presence of the condition, so it reduces errors that way, but I think the primary way that that’s mitigated is through what we call the alert urgency; we don’t send physicians just routine and preventive care, and the way that the alerts are communicated to the physicians  is also a function of the criticality.  So level one urgency is a life-threatening situation that we may have identified, whether it’s a drug-to-drug interaction risk or a drug-to-medical-condition interaction risk, or in rare cases, a drug-to-family-history interaction risk, the type of thing a physician may not have recognized on their own but it is potentially life-threatening, that will typically be made through a phone call with follow-up fax.  But less urgent ones are typically sent by mail or fax, and the ones that really involve the member being proactive, or engaging in preventive care, are not sent to the physician. So through the urgency of the alert and the means through which the alert is delivered we have been able to manage that pretty well I think. Active Health has been running the care engine for, boy, a little over five years now, I think about five years, and so it’s a staff of physicians who run this part of that business so it’s been pretty sensitive to what warrants an outreach and what a proper form of outreach is based on the content. 

David Harlow:  And the care guidelines that they use are based on peer review journals or data from your network or a combination of both or how does that work?

Dan Greden:  They are really more expert than I am on this but I know that they continually review peer-reviewed journals and include that.  There is analysis going on of informatics work within our databases but it’s really -- a lot of the feedback that they get suggests that this is a means for physicians to learn about new findings in various fields, and the ACE inhibitor one is a good one. That’s a couple of years old, still being understood throughout the physician community that treats people with diabetes, and so they often get the feedback on care consideration from the physicians, like: thanks, I didn’t know the study, your note prompted me to look into it and I am going to start changing my treatment approach.

David Harlow:  This system has been in place for two years now, and I am wondering whether you have done any sort of systematic review of quality of care improvements, cost of care reductions, any sort of tracking that’s been done to date?

Dan Greden:  We track that extensively, but because we started our pilot two years ago we’ve really only had a meaningful user base for about a year.  We are just now starting to see some early indicators of the improvements in care and so we are really at, we think, the tip of the iceberg on that but what we are seeing is a few things.  People who use our PHR generate significantly more of those care considerations, those care alerts that I talked about.  That’s a good thing for medical costs, because we have seen through other work in the care engine, Connected Health Management, which has been up and running about five years, that the more alerts that are generated, the more opportunities we have to improve care and lower costs. So the PHR makes that care engine program and its ROI more effective.  We have also found that the compliance with those alerts is higher for people who use our PHR. We think it’s for a few reasons, but one of them is that we are sending the notice to both the physician and the member in some cases so there is better follow-through. That improvement is over four percent so early indicators are that the users of our PHR are much more likely to have a medical condition and the PHR helps them be more engaged with their care, so we do expect, as we have had more of a experience base to do our informatics work on, that will continue to see very specific cost savings.

David Harlow:  I see, now you say this is now this was done as a pilot for a year and it’s been out of pilot so how many patients or what proportion of your membership is using this actively and how do you measure that?

David Harlow:  Yeah that’s still changing pretty rapidly because, like I said, so many of these deployments have happened recently.  I mean, to give you a specific number, about eighty-five percent of the membership who has our PHR have had it for seven or eight months or less, so it’s relatively new to most of these people.  In terms of how we measure this, we don’t just measure what percent of the people who have the PHR have used it.  Now obviously we’d do that too but what's more relevant to us is who are they, what is the value delivered to these members through the PHR and then really focusing on making sure that we continue to build out the right capabilities to help them be better consumers of their healthcare.  As an example, we have much higher than normal usage among people with a medical condition.  Also we see higher usage among mothers with children.  They are doing things like accessing immunization records or other health data across multiple kids or even a single kid, and we also see the pre-retirees use it more.  Now what's important to note there is that while there are similarities there is different value delivered to each of these members based on how they are using the tools.  So our measurements around adoption really tend to focus more on who is using it and what they are using it for and what the value delivered from that is.

David Harlow:  Sure, now do you have a sense of what proportion of your membership is using this in some regular fashion?

Dan Greden:  Again,  it continues to grow significantly every month and we do measure this regularly, right now over ten percent of our subscribing members -- these are the ones who you know subscribe directly to the health plan  --  have accessed  their PHR,  and that’s higher than the industry average, and we expect that to continue growing.  A little clarifying point is that those are the members who are easier for us to communicate to, those are the ones who through their employer subscribe to the plan and you know their dependants for example, their minor dependants have a PHR but the parent accesses it for them, but we have to count those.

David Harlow:  You are not counting those other family members in your percent?

Dan Greden:  That’s right I mean we do when we look at that as well, but I think the more relevant measure is the one that I gave you.

David Harlow:  Subscriber rather than the member, I guess. Okay.  Have you thought about additional bits and pieces of functionality that could be added on?  You said a moment ago that different people access this and use it in different ways depending on their personal situations. Has looking at that given rise to thoughts about expanding the functionality of the tool?

Dan Greden:  Oh yeah, we have a very long list of enhancements on our product plan in the forward years.  I think the best way to describe it is our plan, which is based on an assumed evolution of this because it’s a new tool right now, is just simply building awareness of the tool and what it can do for people.  So a lot of more recent enhancements have been to help people delegate access to a record or bring other people to access their record.   You know, we just talked about how there is a tool for a member to delegate access to their physicians but we haven’t talked about a new capability we launched where a member can delegate access to their family members.  So, for example, I went on when we shipped this enhancement a few months ago, and all right, now my wife can access my record.  I don’t know whether she has done the same for me, and I have to check, but what's interesting about that is if a member does that and their spouse or other adult dependent for whatever reason isn’t registered on our websites yet, we built it in such a way that they can invite that member by sending an e-mail to any e-mail address that’s from the member themselves and it’s an invitation to come online with Aetna and access their PHR.  We borrowed from a lot of other social networking sites, such as Facebook, in designing that so our focus has really been on how do we just create awareness in that initial experience with the PHR and then down the road we’ll be building a lot more integration of the PHR to other activities within the health plan.

David Harlow:  I see.  The other area that I was interested in thinking about here is plans for the future in the context of new legislation.  Now I know it may be too soon to be planning this out since I don’t think the legislators who voted on this have even read it yet – let alone the rest of us.

Dan Greden:  It’s my sense that it’s very directional at this point but more detail to come.

David Harlow:  Right.  There are a couple of areas that I did want to sort of explore with you a little bit. The first of those has to do with security, the online security of this information, which I imagine has been a big part of the design upfront.  The HIPAA regulations in the future look like they will have more technology-specific direction in there whereas up until now it’s really been technology-agnostic, if you will, and HHS is being directed to come up with more specific requirements that will be updated on an annual basis in conjunctions with industry stakeholders.  So as an industry stakeholder, I am wondering if there is a particular architecture that you are more comfortable with, or security architecture and systems, and whether you have some cause for concern where this could be changing on an annual basis.

Dan Greden:  Again, it’s really too early to have concern but I know that in our case we have invested heavily in security not just in the technology framework but also in operational protocols and protections and processes, long before we even had our PHR, so what we found is that this is a logical extension to our security environments already.  I know that in the case of the data-sharing work that we have done is part of the AHIP working group, the America's Health Insurance Plans working group, I think that was a very good approach in defining an industry standard that works well amongst the larger community of stakeholders and so if we see something like that evolve out of this I expect that would be constructive.

David Harlow:  Yes, and hopefully that will evolve.  As you said, it is very early.

Dan Greden:  One thing I also see is that something like a PHR – obviously not limited to that --  this is very new to everybody and so it’s an opportunity for the whole healthcare community to really raise awareness among the rest of the population that doesn’t think about this stuff all day long, to explain the benefits and so on.

David Harlow:  Right.  Now one of the other issues that jumped out of me was a section of the new law that addresses the ability of an individual to restrict access to information in his or her medical record, and that is a patient can ask an individual provider not to share information with insurance companies if it’s not for purposes of treatment or payment, and I imagine that currently the PHR that you describe, that you are using, captures a lot of such information and I am wondering whether you have had any pushback or feedback from members about what information should or should not be in this PHR?

Dan Greden:  In the way we approach that is, once again, we make it clear over and over again that the patient or our member owns their record.  They are in control of it.  They are in control of what’s in it.  They are in control of who sees it.

David Harlow:  Yeah.  You are much clearer about that than many others.

Dan Greden:  Yeah, that’s true, and I think there are a few reasons for that.  I mean, we are not a hospital, so I think potential confusion about the ownership of data that others might have doesn’t exist for us.  In terms of the details of the language, we already support the idea that a member can choose to not share parts of the record or does not just share the record at all.  We even have built the capabilities, say for whatever reason the member wanted to exclude parts of the record from a specific delegation, a specific sharing, they can do that.  So I think generally it’s consistent.  I would add that we encourage sharing the whole record.  A lot of what we are doing here is trying to encourage more open and constructive dialogue about members’ health but -.

David Harlow:  It’s hard to connect the dots if you don’t have access to all of them.

Dan Greden:  Yeah.  I will also give you a very specific example of how we really pushed for some of that. You know, state privacy laws are such that there is a lot of information about minors that can’t be disclosed to anyone by us, including their parents.  So we built, instead of taking the choice and saying all right, well we just, parents can’t access their minor child’s PHR, which obviously isn’t the right thing for a lot of people, we started to build some additional capabilities in order to comply with state privacy laws where types of information that are specifically addressed in the law are filtered out of the view, and the parent is still seeing ninety-eight or ninety-nine percent of most records but specific content about whether it would be reproductive help or substance abuse treatment that state law, state privacy law explicitly addresses, that’s filtered out; so we get the benefit for the vast majority of the people by still having parents be able to access minor child’s PHR and still complying with state privacy law.  To build that capability, we had to spend some of our resources, but we felt it was the right thing.

David Harlow:  Sure.  So that can be applied to any of these other situations where disclosure will be limited or information can be customized to different providers or different folks that would access the information?

Dan Greden:  That’s right and from my perspective the fact that the legislation doesn’t even have  -- fostering the discussion of this is a great thing.

David Harlow:  Yeah, is it your sense or do you just say that you know it would make sense for people to share information more clearly, do you have a handle on whether that is in fact what's being done or whether people are keeping some information close to the vest, if you will?

Dan Greden:  Yeah, in our case a lot of the sharing features are fairly new so it’s hard for me to know.  I don’t have enough data to really draw any conclusions yet but what I can tell you is that when it’s shared, sharing it by paper is still the most common.  It’s an interesting thing, but when we did research not long ago, the vast majority of physicians, even those that practice in an environment that have an EMR, use paper so you know -.

David Harlow:  I am familiar with that in my own paperless office here -.

Dan Greden:  Yeah exactly I have piles everywhere in mine -.

David Harlow:  So that’s the mode of communication.  It’s interesting.  There is a physician module for this, is there not?

Dan Greden:  Well, the way it works is, through Aetna’s provider or physician portal,  we’ve added the delivery of the PHR onto existing workflow that was already built there, so in other words our assumption, our view on this is that we don’t want to ask our providers to take an additional step so when they are -.

David Harlow:  You don’t need to log in somewhere else?

Dan Greden:  Oh gosh, no, they log in the same place and when they are doing other work that they already need to do with us such as verifying eligibility of one of their patients for coverage, in some cases submitting the claim, as they do those other steps we can layer delivery of a personal health record onto that activity without them really having to do any additional work.  You know, classic scenario is, a member of the staff goes in the morning of the appointment, the night before, verifies that there is coverage in place and they verify the eligibility and if the member has delegated the PHR to that physician it’s delivered via that same activity.

David Harlow:  Right.

Dan Greden:  And just to close the loop, what we find is they told us: Yup, and we print it out and we stick it in the folder along with everything else so -.

David Harlow:  I understand  it’s a work in progress and I guess I have asked this another way before, but do you see sort of a particular growth curve in terms of additional functionality or additional utilization by patients and physicians?  This has sort of taken off in the past year and do you see it continuing to grow, or sort of leveling off in the next year or so?

Dan Greden:  No.  I think we are really just getting started in terms of the people who can really benefit from a PHR becoming aware of these tools and what they do.  I’m not one who believes that a PHR is valuable to everyone though, I think -.

David Harlow:  I was just going to ask that, is it the goal to have a hundred percent adoption?

Dan Greden:  No I would think there are better ways that we can engage those -- we call them young and invincibles -- but realistically some are at a point in their life where for whatever reason they are not even generating medical claims -- obviously we would like if they were doing their preventive care but you know there is a lot of our population who just don’t use their clinician resources and medical resources at all.  We have different ways to engage them that are more effective and more relevant than the PHR, but I think we are really still at the beginning of getting the part of the population that would benefit from the PHR to understand what they are, understand that they have one and then try it and see how it delivers value for them.  In our case, we are continuing to deploy this tool pretty rapidly, but last year -- you know, I think we touched on these numbers earlier --  we went from around a million at the very beginning of ’08 to over seven at the beginning of the year.  We were just deploying it aggressively. We are getting past the mid point so that’s going to slow down then we will start to see a lot of these people who have gotten it recently, have it for some time, have the marketing that we have in place to make them aware would start kick in but we are already seeing a pretty nice growth in the awareness and the adoption.

David Harlow:  Yes, well, very interesting.  It sounds like a very valuable program as it’s being rolled out.  Well thank you.  I have been speaking with Dan Greden, head of eHealth at Aetna.  This is David Harlow on HealthBlawg, and once again, thank you, Dan.

Dan Greden:  Oh, you’re welcome. Thank you.

February 15, 2009

HITECH Act part of stimulus package headed to President's desk: Steady, boys!

Some of us have now had a moment or two to read parts of the stimulus bill. One of the many stimuli included is the HITECH act, a $19 billion electronic health records funding provision.  This sort of action by the federales was long promised by Obama on the campaign trail: spending federal dollars to jump-start the leveraging of technology in order to improve health care quality at lower cost.  Setting aside the question of whether this piece of the bill will stimulate anything in time to help the economy (it won't), the question of the moment is whether this will be money well spent. 

On the one hand, it's designed to subsidize EHR adoption by physician practices and hospitals that otherwise might not be able to afford them (to the tune of up to $40K per doc).  To the extent that we believe that EHR adoption will promote efficiencies in excess of their costs (and yes, you do detect a note of healthy skepticism), that's a good thing.  On the other hand, it will almost certainly result in further entrenchment of current market leaders, to the possible detriment of providers and patients who do not necessarily need the high-cost offerings now on the market that are characterized by some observers as having limited "data liquidity" -- which, if we're looking for interoperability, is a key thing to have.  Consider, for example, John Moore's excellent summary and analysis of the HITECH provisions on his Chilmark Research blog.  He notes that CCHIT certification is cued up to become the de facto template for EHR standards under the new law, and makes a convincing case for why that's not a great idea.  To argue the other side for a moment: if any standard is a couple of years out of date by the time it's adopted, does that mean we should have no standards?  I would think that the nature of the standard needs to be adjusted so that the standards themselves are less technology-specific and more function-centered.  Without some basic standards, we'll be out in the Wild West and interoperability will be a distant dream.

That said, I think John would agree that the standards finally adopted ought to allow for a variety of approaches: full-blown enterprise EHR systems, more compact offerings, and SaaS options as well.  Setting the standards shouldn't result in the ossification of the current selection of offerings out there.

There's an awful lot of money on the table.  Let's hope that it can be spent wisely, on a variety of approaches to an intractable problem: the wiring of this country's health care providers for the benefit of their patients and the collective fisc.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

February 09, 2009

Transforming Healthcare Summit in Boston February 26

I hope to see local readers February 26 at the Transforming Healthcare Summit.  On the program:  Jim Roosevelt (Tufts Health Plan), Charlie Baker (Harvard Pilgrim Health Care), John Glaser (Partners Healthcare), Jonathan Bush (Athena Health) and more.  Check out the blog put together by Steve Wardell, consider my two cents (and others') on what Obama should focus on in health care, add your own two cents in the comments, and submit and/or vote on questions to be put to the panel.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting