Tuesday, February 26, 2008

Microsoft's new Health Vault Fund

On February 25, Microsoft announced a $3 million dollar effort called the Microsoft HealthVault Be Well Fund. The initiative is designed to "empower providers with targeted funding to stimulate the research and development of online tools that improve health." Microsoft expects to fund approximately 20 qualified institutions with an average award of $150,000 (maximum of $500,000). Indirect costs are not funded by the Microsoft proposal. Proposals must be submitted by May 9, 2008 12:00 (noon) PST and notification will occur no later than July 1, 2008.
Microsoft envisions a range of application areas, including but not restricted to (quoting):

Primary Prevention Applications (Track 1)
Proposals targeting primary prevention could help people and caregivers create and maintain strategies that prevent or delay onset of disease by reinforcing healthy lifestyle factors and addressing modifiable risk factors such as hypertension and weight.

Secondary Prevention Applications (Track 2)
The identification of major modifiable risk factors (such as dyslipidemia, hypertension, smoking, obesity and inactivity) is a prerequisite to the implementation of preventative interventions — known as secondary prevention. Proposals in this category could help people and their caregivers measure things such as blood pressure, lipid profile components (LDL and HDL cholesterol and triglycerides), diet and nutrition, weight, smoking, and activity level to create the optimal plan to prevent or delay morbidity and acute care.

Acute Care Applications (Track 3)
Certain conditions require immediate diagnosis and treatment, whether at the doctor’s office or in an urgent care setting. Proposals targeting acute care scenarios might track progress, improve communication and share data between the silos in the healthcare system, providing caregivers with a longitudinal view of a patient’s health history that ultimately may lead to superior outcomes.

Juvenile Disease Management Applications (Track 4)
Health conditions in children often require specialized detection, diagnosis and treatment. Parents typically become eager partners in the plan of care, and seek information specifically related to their child’s condition. Proposals focusing on juvenile disease management might provide age-appropriate tools to help children, parents and caregivers understand and manage their conditions.

Women’s Health Management Applications (Track 5)
Women’s health issues can be complex and are often influenced by biopsychosocial and environmental factors. Proposals targeting this track might choose to create online tools or services that help manage health within the context of lifestyle and family.

Community and Social Health Applications (Track 6)
Patients and caregivers dealing with illness or people interested in wellness are increasingly sharing information and support with each other through various Web-based social applications. Proposals targeting this category might include applications for health in areas such as collaboration, communication and the use of social relationships to improve care.

Monday, February 25, 2008

AT&T / Tennessee: Removing the Impediment of Connectivity

Today AT&T announced a major program with the State of Tennessee.

Pertinent links:
Here's a portion what the AT&T press release said:

AT&T is actively engaged with the state and health care providers statewide in building the eHealth Exchange Zone. Plans call for eHealth applications to be phased in as participation by health care providers grows.

The AT&T solution features a secure online collaboration center — a Virtual Private Network (VPN)-based portal — designed to safely and securely enable such applications as:
  • Prescribing pharmaceuticals online (also known as "ePrescribing").
  • Securing clinical messaging among the state's health care providers.
  • Sharing high-density images, including X-rays, MRIs and CT scans.
  • Exchanging patient information via portable health records, which provides patient profiles, medical history, prescriptions, etc.
  • Delivering telemedicine applications for remote diagnostics and care.
  • Accessing Tennessee Department of Health applications, including the immunization registry, disease registries, death certificate applications and processing and medical license renewal.
  • Accessing other health care applications and systems, including laboratory systems.
The network has an added component especially for protecting health information provided by the Covisint OnDemand Platform. The platform is a hosted solution that provides dual-factor authentication of health care providers using the VPN-based portal, which supports HIPAA privacy requirements. It also centralizes, automates and streamlines the access to information across health care communities statewide by giving physicians the ability to use many health-information applications with a single sign-on. The platform from Covisint, a division of Compuware Corporation (NASDAQ: CPWR), provides an on-demand, industry-leading infrastructure for secure collaboration and interoperability among health care providers.

Reading carefully, the AT&T announcement does not declare an intention to become the "exchange zone," to provide health care applications, or do more than two very important things: 1.) establish Internet connectivity for providers who do not have this capabilities because of locale; 2.) work with Covisint to provide dual-factor authentication - a critical aspect of any future health care application (don't you want to be sure that clinicians accessing your personal health information are who they say they are?) Covisint has been active in this area. See, for example, the testimony of their Chief Security officer to the U.S. Senate Judiciary Committee on the Future of e-Prescribing of Controlled Substances.

Reading carefully, the AT&T announcement does not seem to be exclusive, but potential grants from the state may be available to those who wish to use this network or switch to AT&T from their current means of Internet access.

According to the TN eHealth Council physician connectivity grant Web site, the State of Tennessee will distribute through intermediary organizations connectivity grants designed to "offset the costs offset the costs of connecting health care providers to Tennessee eHealth resources" including "hardware, software, peripherals, broadband connectivity, and HIPAA compliant authentication." The grant contract funding includes $3,500 per actively practicing physician as well as $6,000 per site.

This is a boon especially to rural practitioners who at this date do not have access to high-speed internet services in their community. It is not clear how much practitioners will be charged for this connectivity, nor is it clear how the Covisint authentication will work, but both seem to be good ideas in selected circumstances.

But what are the requirements?

Excerpting from the sample grant contract at the TN eHealth site one notes the following conditions:
  • A.3.d Grantee agrees, for a period of two (2) years, to actively participate in electronic prescribing (ePrescribing) and capturing prescription information to populate a patient’s medication history as directed by the eHealth Council. Grantee should use a software application with SureScripts and/or RxHub certifications.
  • A.3.d.1. Electronic prescribing, as defined by the National Council for Prescription Drug Programs (NCPDP), is two way [electronic] communication between physicians and pharmacies involving new prescriptions, refill authorizations, change requests, cancel prescriptions, and prescription fill messages to track patient compliance. Electronic prescribing is not Faxing or printing paper prescriptions. ePrescribing also includes the potential for information sharing with other health are partners including eligibility/formulary information and medication history.
  • A.3.e. Grantee agrees to participate in discussions with any health information exchange “HIE” or regional health information organization “RHIO” operating in that geographic area.
  • A.4. Grantees, who are TennCare providers, must adopt the health information technology in accordance with TennCare metrics. When serving TennCare patients, Grantee agrees to use an electronic medical record to document and track pertinent preventive health services (e.g. immunizations, pap smears, mammograms) and/or access and populate (as appropriate) a claims-based electronic health record for the same purpose.
What are the implications of these provisions? Here's one person's guess:

This measure will ensure that e-prescribing is adopted in a way that ensures security and authentication. This measure will place practitioners ahead of the curve - particularly if controlled substances and stronger authentication are required. One problem with the current system: It is not clear how many rural pharmacies are ready to accept e-prescriptions. Progress in the chains is striking and growth of adoption in independent pharmacies is rapid, but some communities may have to await new initiatives by independent pharmacists to achieve Internet connectivity and upgrade their systems.

E-prescribing brings new opportunities to communities. Because the linkages are between the prescriber and the pharmacy (with eligibility checks via RxHub or SureScripts in some instances), there is the potential for a leaner system and new methods of ensuring better compliance with needed medications. Remember, the real "quick win" with e-prescribing may be simplifying refills and ensuring that patients take the meds required to avoid long-term complications.

One unknown: it is not clear what "population of a medication history" means. This will be resolved. But clearly both providers with e-prescribing and plans have these data and additional overhead does not seem warranted.

This caveat seems to urge collaboration but does not impose additional burdens on practitioners. It is not clear which "RHIOs" are really valid here - and which are even exchanging data. It is assumed that the list includes initiatives in Memphis, Knoxville, the Tri-Cities area, and the Shared Health Initiative.

This clause focuses on TennCare. It is not clear what "TennCare metrics" are, but the need to document care for these patients is acute. One requirement is that for TennCare patients, providers must "use an electronic medical record to document and track pertinent preventive health services (e.g. immunizations, pap smears, mammograms) and/or access and populate (as appropriate) a claims-based electronic health record for the same purpose."

Optimists can read this as a means of enabling choice among ambulatory care systems, although it's not clear how such systems will transmit "TennCare metrics" to the State. The only "claims-based electronic health record" available is Shared Health. Cynics can argue that such a requirement limits choice. In reality, it all depends on the extent to which the state encourages open choices among exchanges. The objective - improving the care of TennCare patients - seems a good one.

The Suggestion of a Framework

There are several different components that are alluded to in these documents:
  • The "back end" - a database that TennCare uses to document care and quality
  • One or more "health information exchanges" - the means by which health care providers (and someday consumers) communicate their information among authorized parties
  • Authentication mechanisms - means by which one can be sure of valid communications
  • Authorization - means by which policies and technologies ensure that the person authenticated is authorized to transmit or receive information
  • The "front end" - the means by which data are captured by clinicians, consumers, and fiscal intermediaries

Aligning all of these moving parts is complex and involves assuring that components at each layer are able to communicate with others. Such "interoprability" is important so that each consumer and provider can chose systems best suited for these needs. (Example: as much as we Tennesseans like Nissan, I don't think we all want to drive a Tundra, nor do we want excessing intrusion into our auto purchasing decisions.)

Unanswered Questions

This program seems worthy of strong consideration by practitioners who do not at present have access to the Internet. Among the unanswered questions are:
  • Internet connectivity is essential to health care delivery. But what of those who already have such access by some other means? In essence, receiving grant funding would require them to change carriers to AT&T. And what about pharmacies, nursing homes, and other essential care sites? Ultimately, every care provider is going to have to pay their way, so understanding the total cost of participation - over a 5 year period - would be valuable.
  • Authentication is a vital service. Can a physician gain access to these services without using AT&T? Is there any grant funding for this? Will other means of authentication be developed over time, or is Covisint the only authorized authentication broker?
  • Choice is important. Many practices are adopting comprehensive electronic medical record systems? How will these systems interact with the authentication mechanisms proposed? How will exchanges collaborate? How will the public's concerns over privacy and confidentiality be addressed?
Each of these topics has been the matter of hard work and collaboration. It may take time for answers to emerge.

This announcement should be viewed as a part of a broader framework enabling better care. Putting the pieces together will be somewhat a process of trial and error; that's the price a state pays for staying ahead of the curve.

Wednesday, February 20, 2008

GAO's Latest ONC Report

The considerable progress in health information technology correlated with the HHS Office of the Network Coordinator is summarized in the most recent GAO report on this office. This report describes a "numerator" of programs funded by ONC, but fails to include the "denominator" that would include the far greater degree of innovation congruent with the Secretary's vision but equally the product of thousands of professionals and consumers across our country who - on their own and without strong government mandate - have concluded that a more effective health care technology infrastructure is essential to any improvements in our ailing health care system.

A "coordinator," one could argue, should address how the growing momentum created by all of these myriad programs can be harnessed to a greater social good. This writer remains a cautious optimist in this regard.

In testimony before the Senate Committee on the Budget on February 14, Valerie C. Melvin of the GAO summarized the overall HHS efforts, urging again for a national strategy.
The report describes the considerable progress achieved . And it concludes with mention of the strategic planning process underway by the relatively new leadership at ONC.

The report states:

The National Coordinator ...told us that HHS intended to release a strategic plan with detailed plans and milestones in late 2006. Nonetheless, today the office still lacks the detailed plans, milestones, and performance measures that are needed. According to its fiscal year 2009 performance plans, the Office of the National Coordinator has prepared a draft health IT strategic plan, which it intends to release in the second quarter of 2008. If properly developed and implemented, this strategy should help ensure that HHS’s various health IT initiatives are integrated and effectively support the goal of widespread adoption of interoperable electronic health records.

The current GAO report builds on previous reports cited and provides a high-level overview of budgets, progress, and challenges. The report repeatedly makes statements like "HHS has not yet defined detailed plans and milestones for integrating the various initiatives, nor has it developed performance measures for tracking progress toward the President’s goal for widespread adoption of interoperable electronic health records by 2014. "

Since 2002, ONC has received about $200 million and has made considerable progress along several critical areas. Cited in the report are details on the progress made in:
  • Advancing the implementation of both outpatient and in-patient electronic health records
  • Recognition by the Secretary of some interoperability standards
  • Trial "NHIN II" implementations
  • A toolkit and report on the extensive privacy and security efforts at the state and national level
One could challenge the impact of some of these efforts. This writer is of the belief that the NHIN I initiate was conducted in too much haste over too short a time to achieve its true impact. The GAO report states (p 10) that "according to HHS, in early 2007 its contrators delivered final prototypes that could form the foundation (emphasis added) of a nationwide network for health information exchange. The NHIN I summary report cited 24 "core services" 12 "common transaction features," and 14 "annexes on common themes like identity arbitration, consumer data-sharing permission, and data routing. Among these 50 "things" (not counting the many other features and specifications decried by the use cases, one hopes that some immediate and fundamental high priority steps will emerge as initial steps in the road map. This writer believes that about 12 of the core services lists are "must do" high priorities, but that many others may best be left for later consideration.

The report later states (p 11) that at the end of the first contract year (September 2008), "HHS intends for the nine organizations and the federal agencies that provide health care services to test their ability to work together and to demonstrate real-time information exchange based on the nationwide health information exchange specifications they define." The specifications and test materials will be placed in the public domain so that "they can be used by other health information exchange organizations to guide their efforts to adopt interoperable health IT." These documents will be valuable. (One hopes that the NHIN I materials will someday be more easily accessed as well.)

But how should - and how can - even an organization as talented as ONC develop a national strategy. This writer has a few suggestions:

Look to the successes, not just NHIN contractors. A lot is going on in health care delivery organizations, health plans, and exchanges that are funded by AHRQ, private resources, and other sources. Indeed, many of the largest and most vibrant exchanges have chosen not to participate in NHIN at this juncture.

  • Build on the idea - first raised by the Commission on Systemic Interoperability - that strongly suggested the availability of a medication history for every American as a top priority
  • If a second "quick win" is desired, focus the same approach on clinical laboratories
  • Create guidelines for identity management. This is a critical topic for consumers, for e-prescribing, and for other applications. If e-prescribing is expanded to include controlled substances, identity management will become even more pressing
  • Focus on simple core guidelines for confidentiality and privacy that transcend applications that that can serve as a basis for new and revised legislative and policy remedy
  • Focus - as HHS is - on incentives to adopt helpful technologies that foster a more effective system of care
  • Table or adjourn 50% of the discussions taking place on topics that are not "foundational." To paraphrase Governor Phil Bredesen's remarks at the 2007 HIMSS meeting, don't try to build version 6.0 before you've got version 1.0 working.
The literature - and our experience - are full of examples of successful approaches to strategy. Such a strategy is possible in a way that transcends the transfer of power at the executive branch of the federal government and the ongoing changes in states and communities. Central to every approach is a realistic set of expectations, focus, and incremental steps.

Tuesday, February 12, 2008

MidSouth eHealth Alliance Update - February 12, 2008

The MidSouth eHealth Alliance published its first newsletter in January of this year. The newsletter provides some background on the Alliance's recent work and data on our health information exchange in Memphis.

Additionally, the CHCF report was cited today by the Health Affairs blog and makes mention of our work in Memphis.
What can be said of the Exchange in early 2009?
  • Security and confidentiality remain paramount. Use and participation is governed by patietn consent, data sharing agreements, and user agreements
  • Information from the secure Web browser is used to care for 100 - 200 individuals today in most of Memphis' major emergency departments and a growing number of ambulatory settings.
  • Over 2 million events can be accessed on over 1.3 million medical records or demographic files from over 900,000 unique individuals.
  • Over 50 million laboratory tests are available, as well as discharge summaries, radiography reports, some medications, and a range of other clinical data elements.
  • Annual costs are less than $3 per person per year.
  • The Exchange remains committed to the care of every consenting individual without regard to health care coverage.

What are priorities for the year?
  • The Exchange continues to work through integration with an array of ambulatory care systems and providers.
  • The Exchange seeks to follow national guidelines to foster collaboration with other systems and exchanges in the region, the state, and the country.
  • The focus of the Exchange remains identification of ways to improve the quality of care provided to individuals both by presenting valuable clinical information and studying. consumer-driven "version 1.0" markets where patients and providers can focus first on their care and secondarily on the complexities of reimbursement.