The committee provided $344 million in development funds for the integrated electronic health (iEHR) record in FY201. This was up from the $92 million from the $252 million VA requested. The money would come with the caveat that no funds be expended on any electronic health record project unless it is an open architecture system that serves both DoD and VA.

At a subcommittee mark-up hearing, John Culberson, R-Texas, chairman of the House Subcommittee on Military Construction, Veterans Affairs and Related Agencies, called the bill a bipartisan success. “Our bill this year has dealt with the failure of DoD and VA to develop a single unified medical record in a very straightforward, commonsense way,” he said.  

The bill, Culberson explained, will limit the funding toward the iEHR to 25 percent — of the $344 million requested. The agency will not receive the remaining dollars until they can prove to both agency subcommittees that they’re actually implementing a plan to create and roll out a single, unified medical record.  

In April, Defense Secretary Chuck Hagel told members of the House Appropriations Defense Subcommittee that he had deferred planned Pentagon procurements for a new Defense electronic health record because “I didn’t think we knew that the hell we were doing.”

He also told subcommittee members that he had assumed personal responsibility for the iEHR project and promised a decision within 30 days.

The House Appropriations Committee in its version of the fiscal 2014 VA spending bill said it will require Defense and VA to provide it with a defined iEHR budget and a timeline for deployment.

Language in the House bill also would require Hagel and VA Secretary Eric Shinseki to jointly certify in writing to the House and Senate Appropriations committees prior to using development funds that the proposed integrated electronic health record will be the sole electronic health record. Use of the funds will be confirmed by the Government Accountability Office.

Overall, the bill allocates $3.6 billion, plus reimbursements to VA information technology systems, one being the iEHR.

The bill also rescinds money that was not spent on certain projects, or what Culberson called a “use it, or lose it” requirement. The bill rescinded $1.4 billion of the $43.6 billion in discretionary funding requested for VA medical services; $100 million in medical support and compliance funding; and $250 million in medical facilities funding.  

VA pitched its decades-old Veterans Health Information Systems and Technology Architecture (VistaA) to Defense as an EHR candidate on Feb 27, and earlier this month the VA notified vendors it needed to re-compete technical support and maintenance of VistA.

VA awarded Hewlett-Packard a 10-year VistA technical support contract valued at $784 million in March 2004. That deal hits its limit next March. The new VistA support contract is likely to be a key vehicle for the future iEHR, depending on whether or not Defense decides to go with the VA system.

In April 2009 President Obama called for a “unified lifetime electronic health record” to be shared by Defense and VA, but on Feb. 5, the top leadership of both departments agreed to forgo plans to build a new iEHR and instead pursue less expensive technologies to make their respective systems more interoperable.

On Feb. 28, Roger Baker, then the VA chief information officer, said the departments dropped their grand development plans because estimated costs had soared to $12 billion from earlier estimates of between $4 billion and $6 billion.

“What would you do differently if you assumed the patient knew nothing about healthcare and it was totally your responsibility as the healthcare provider to meet them where they are and not where you wish they were in terms of health literacy?” Stephen Harden, chairman and CEO of LifeWings Partners asks.

Harden’s company began helping hospitals improve patient safety in 1999 as a department of Crew Training International, Inc. (CTI). The world’s largest provider of teamwork and communication training services, CTI, established in 1992, is the primary provider of teamwork-based safety programs to the U.S. Air Force, NATO, numerous international air forces and other U.S. government organizations such as the Federal Aviation Administration (FAA).

In the course of his work with the aviation industry, Harden identified a similar need for better communications within the healthcare industry, particularly in the age of healthcare reform.

In 2013, government regulators will penalize 1,427 U.S. hospitals because too many of their patients are re-admitted to the hospital for follow-on care. For hospitals with lots of Medicare patients, hundreds of thousands of dollars are at stake, money that could be spent on safety and quality. In all, the Medicare penalties tie almost $1 billion in payments to hospitals to the quality of care provided to patients as measured by readmission rates.

Beyond the penalties imposed by Medicare, LifeWings says that hospitals waste almost $73 billion a year simply because patients do not understand what physicians and nurses are saying to them. The company believes that  if these communication breakdowns could be fixed, it would dramatically improve readmission problems.

The LifeWings training is based on 7 low cost, or no cost, simple things that can be done to improve readmission issues:

1. Take responsibility for the patients’ health literacy. This is a small change in thinking with huge implications for safety. Most hospitals approach the problem as if it were solely the patients’ responsibility to make themselves smart about their care. Physicians and medical teams need to communicate on the patient’s level, or to make sure the patient understands what they have just been told.

It is the experts (doctor’s) responsibility to make sure the listener (the patient) understands. If patients cannot understand the plan of treatment, they won’t follow through properly, and hospitals will have more readmissions, thus less money for safe, high quality care.

2. Write all instructions about the plan of care and medications at the 5th grade level. Analysis of health care literature for patients reveals that almost all of it is written at the eleventh grade level. The truth is that 93 million Americans read between the third and fifth grade level. Thirty-four percent have low literacy when it comes to reading forms or documents. An astonishing 55 percent have low literacy when it comes to numbers.

3. Use 14-point type or larger. Most health care instructions are written in 10-point type. This is too small for most patients and they don’t even try to read it.

4. Use plain English words and avoid medical jargon. Use terms like earache not “otitis media”. Use language you would use among friends and family. Use directions a 12-year old could understand when giving out discharge instructions.

5. Always tell your patients “Why.” Offer an explanation to the patient and explain exactly why this medication will help them have a longer and healthier life. Have a strong dialogue that draws patients into the cause of better health and this will get better compliance.

6. Get a “read-back” from your patients. Explain the discharge instructions to the patient. Have them repeat back in their words what you told them. Go back and forth until you are confident the patient understands. This takes extra time but less time than a re-admit. Limit the discharge instructions to three “need to know” messages.

7. Use the phrase, “What questions do you have?” Don’t ask, “Do you have any questions,” as patients are likely to simply say “no,” even if they don’t understand. This is a technique used by professional pilots in the cockpit after their crew briefing. LifeWings also teaches surgeons to use this question after their WHO Safe Surgery Checklist briefing. They have discovered that using the phrase, “What questions do you have?” always generates more questions and discussion than “Do you have any questions?”

Harden explains why hospitals are not doing these things already. “Health care staff are very well educated. Many of them think that writing at a lower grade reading level or using plain language is ‘dumbing down,’ and that using plain language that is easy to read is unprofessional and insulting. Actually, writing simply and clearly is very difficult. 

“Many healthcare professionals have the mistaken belief there is no need to do these things,” he adds.

”They think that most patients understand what they’re saying to them or their patients would be asking more questions. In reality, patients often just nod their heads because they don’t want to appear uneducated.”

The framework includes information about many of the organizational, security, business, and technical principles that organizations need to consider before implementing and sustaining an HIE.

In September 2012, ONC announced that it would not issue federal regulations for health data exchange but instead would support other organizations’ efforts to establish health information exchange governance.

In a “HealthITBuzz” blog posting, ONC head Farzad Mostashari said, “We’ve published this framework to provide a common foundation for all types of governance models. Entities that set health information exchange policy should look to the framework’s principles as a way to align their work with national priorities. It is critical that we are all working from a similar understanding of the expectations for nationwide electronic health information exchange.”

According to the blog post, the framework describes “milestones and outcomes that ONC expects for and from [health information exchange] governance entities.”

The guidance recommends that the HIE’s policy organization should operate transparently and ensure that they are adhering to state laws and any applicable HHS regulations.  Whether the driving force is a hospital system looking to connect locally, an independent non-profit, or a broader state-wide initiative, the organization should promote inclusiveness, participation, and proper stakeholder representation while making sure that its oversight is consistent and equitable.

In terms of data, trust is the fundamental prerequisite for a successful system.  “Trust starts with patients.  Without trust, the ultimate success of an electronic HIE initiative could be jeopardized,” the guidelines say.  Participants should be able to access a notice of data practices that explains how data is used, stored, shared, and protected. 

ONC suggests an opt-in model to inspire patient confidence and give them control over their participation.  Patients should be able to request a correction of inaccurate data and also be able to limit the exchange of sensitive data, such as substance abuse information or mental health records.

A successful HIE relies on financial sustainability and sound business principles, including cooperation between all stakeholders. “Responsible financial and operational HIE policy is vital to improving care coordination, improving the efficiency of health care delivery, and mitigating behaviors that could result in proprietary networks and resistance to exchanging information even when it could enhance patient care,” the document asserts.

Fee standards and open access to services provide a foundation for transparency and fairness.  HIEs should maintain up-to-date information about compliance with relevant statutory and regulatory requirements; available standards; potential security vulnerabilities, and best practices, as well as the number of patient participants and exchange volume.

Lastly, successful health information exchange requires a robust technical infrastructure that has been comprehensively planned and rigorously tested.  The technical base of the HIE should ensure privacy and support the trust and business principles.  Standards-based architecture will be the most successful, and adoption of voluntary consensus standards can work to further interoperability and integration nationwide. 

“Take an active role in development and implementation of conformance assessment and testing methods,” the guidelines suggest, “and utilize (or promote the use of) testing methods developed to assess compliance with federal standards.”

“I want to emphasize that we intend for the Governance Framework to be a living document,” Mostashari notes. “As we learn with you, we will consider updating these principles over time to reflect policy changes, technological maturity, and market innovations, as necessary. We look forward to discussing the Governance Framework with all stakeholders.”

NYeC is the driving force behind the EHR/HIE Interoperability Work Group (IWG), a consortium of 19 states, 20 EHR vendors and 22 HIE vendors that are collaborating on practical solutions to advance interoperability.

Together with Healtheway, the nonprofit entity that operates the eHealth Exchange (successor to the Nationwide Health Information Network Exchange), IWG has contracted with the Certification Commission for Health IT (CCHIT) to test and certify EHRs and HIEs for interoperability.

Under terms of its ONC grant, NYeC agreed to perform certain tasks related to provider directories, an essential component of secure clinical messaging, and patient matching, which is needed for query-based information exchange.

Specifically, NYeC will conduct pilot projects showing methods to optimize use of a provider directory during exchanges of messages that use the Direct Project secure messaging protocol. And it will conduct a learning forum to identify and improve patient-matching practices when sharing clinical information within and across communities. Both of these activities will take place from July to December 2013.

ONC said its NYeC task force is recruiting five to seven participants for the provider directory pilots. These participants will be states and vendors that may or may not be IWG members. They will test various models for querying provider directories to support exchange of Direct messages both between EHRs and health information service providers (HISPs) and between HISPs. HISPs are the entities that convey Direct messages between trusted healthcare parties.

The results of these pilots will be fed back to ONC and incorporated into IWG’s Direct Specifications Implementation Guide by February 2014.

DirectTrust is accrediting HISPs and registration and certification authorities in conjunction with the Electronic Healthcare Network Accreditation Commission (EHNAC). Its ultimate goal is to enable HISPs to exchange information freely without having to create costly, time-consuming trust agreements with one another.

ONC gave DirectTrust a grant to support that work. So far, DirectTrust, which includes about 40 HISPs, HIEs and other entities, has accredited one HISP, and has accepted seven other HISPs and registration authorities as candidates for accreditation, according to DirectTrust president and CEO David Kibbe.

This effort aims to reduce the burden of multiple quality reporting initiatives.

For eligible hospitals, by 2013, hospital value-based purchasing and inpatient quality reporting program clinical quality measures reported on Hospital Compare will be aligned.

By 2014, inpatient quality reporting will introduce electronic health record-based reporting. After 2014, clinical quality measures will be transitioned to EHR-based reporting in the EHR Incentive Programs. 

For individual eligible professionals, by 2013, the physician quality reporting system-(PQRS) EHR Incentive Program Pilot will be implemented. By 2014, PQRS EHR reporting options align, including clinical quality measures, reporting criteria and reporting mechanisms, in the 2013 physician fee schedule and the stage 2 rules.

By 2013, for eligible group practices, the PQRS group practice reporting option web interface clinical quality measures will be aligned with those in the ACO GPRO measure set and the physician value-based modifier GPRO measure set.

In 2014, eligible group practices will be able to report clinical quality measures as a group directly to CMS to fulfill the requirement of the clinical quality measurement component of meaningful use for the EHR Incentive Programs.

Initially launched in November 2012 in select cities, the program is now available to physicians and clinics across the United States to support providers delivering care to underserved and uninsured communities.

“The response we’ve received since launching McKesson Gives Back has truly been remarkable. We’re thrilled to expand this offering to support deserving health practitioners across the country who truly are paying it forward every day in communities,” said Patrick Leonard, president, McKesson Revenue Management Solutions.

Physicians and clinics selected by the McKesson Gives Back program are provided with McKesson Practice Choice™, a fully integrated, web-based electronic health record (EHR) and practice management solution.

The solution gives providers clinical, financial, operational and patient tools to help manage their practices and provide quality care. Bread of Healing, a charity clinic with three locations throughout Milwaukee, Wisconsin, was the first of the McKesson Gives Back recipients. The clinic received a free 26-month license to McKesson Practice Choice to better connect its clinics and serve its community.

“Expanding clinician access to practice management solutions is critical to empowering health care professionals to better serve patients, coordinate care and improve outcomes,” said Leonard.

By providing this resource to physicians, McKesson is enabling recipients to better deploy their already limited resources to more effectively and directly benefit patients in their communities.

The program aligns with McKesson’s Better Health 2020™, an initiative designed to help healthcare providers achieve better patient care, better business health and better connectivity in their communities.

Acceptance into the program is on a rolling basis until 100 providers are selected.

To qualify for the software, physician practices must be primary care, internal medicine, family practice, gynecology, or pediatric practitioners; be in private practice, (not hospital employed); work in a 1-10 physician practice; have a demonstrated history of providing unreimbursed care to the low-income community for six months or more; and have broadband or high speed Internet connectivity in the location where the physician expects to use the software. 

To learn more about the program or to complete an application, visit www.mckessongivesback.com.

The company commissioned Harris Interactive to poll 3,700 physicians from eight countries between November and December 2012 and reported a 32 percent rise in the number of doctors that use healthcare information technology, 93 percent for EMR and 45 percent for HIE.

According to the findings, 76 percent of doctors claimed the use of EMR and HIE had helped to reduce medical errors and 74 percent said the services improved the clinical research data.

The survey revealed U.S. physicians saw a 32 percent rise in healthcare information technology usage, 65 percent in e-prescribing and 78 percent in entering of data electronically, representing a 34 percent annual rise.

Moreover, the findings showed 45 percent of doctors adopt healthcare IT to receive alerts while meeting patients and 57 percent use electronic lab orders, a 21 percent increase year-on-year.

A majority of U.S. doctors also reported receiving clinical lab test results and other data electronically, reflecting a 24 percent rise.

Farzad Mostashari, MD, the national coordinator for health information technology, announced earlier this month that the products did not meet the established standards and as such, providers cannot use them to meet the requirements of the Medicare and Medicaid EHR Incentive programs.

EHRMagic-Ambulatory and EHRMagic-Inpatient, both developed by EHRMagic Inc. of Santa Fe Springs, CA, no longer meet the EHR certification requirements. The EHRs must be certified by a certification body (ACB) authorized by the Office of the National Coordinator for Health IT (ONC) before regaining certification.

Both ONC and an ONC ACB, InfoGard Laboratories Inc. (InfoGard), received notifications that the EHRMagic products did not meet the required functionality and the products should not have passed certification. InfoGard analyzed the additional information from the notification and contacted EHRMagic, launching the ONC authorized certification body required surveillance activities. InfoGard concluded that it was necessary for the EHR products to be retested for select requirements. EHRMagic, Inc. participated in retesting and failed.

To date, EHRMagic has not commented on ONC’s decision. As of last week, the company’s website was still touting the benefits of its EHR systems.

Records with the California secretary of state list the 4-year-old company’s corporate status as “suspended,” which means that the business entity’s powers, rights and privileges were suspended or forfeited in California either by the Franchise Tax Board for failure to file a return and/or failure to pay taxes, penalties, or interest; and/or by the Secretary of State for failure to file the required Statement of Information.

 “We and our certification bodies take complaints and our follow-up seriously. By revoking the certification of these EHR products, we are making sure that certified electronic health record products meet the requirements to protect patients and providers,” Mostashari said in his statement. “Because EHRMagic was unable to show that its EHR products met ONC’s certification requirements, the EHRs will no longer be certified under the ONC HIT Certification Program.”

According to an ONC spokesperson, no provider has attested to using the system for EHR Incentive Payments, though he did not comment on what a provider should do in the event that their system ends up being retroactively decertified.

In a recent Health IT Buzz blog posting, ONC’s Director of Office of Certification and Testing Carol Bean and Program Analyst Asara Clark reiterated that certification is an ongoing process at the ONC, not something that ends once a complete EHR or EHR module has passed the certified testing procedures.

In their post, Bean and Clark explained that when an EHR certification-related complaint is received by ONC, it is reviewed by ONC and may be forwarded to the appropriate Authorized Certification Body (ACB).

Depending upon the complaint, the ACB may conduct surveillance activities. Bean stated that ONC is currently developing guidance on surveillance of certified EHRs to provide more consistency as well as to provide guidance to the ACBs on surveillance.  Bean said she expects the guidance to be issued later this year.

“We are also going to monitor certified EHRs to determine whether they continue to meet our requirements,” Bean said in her post. “The doctors, hospitals and other providers that are adopting – and have already adopted – EHRs deserve this and should feel confident that the tools they are using are up to the job of helping their patients get the best care possible. If they don’t, we want to hear about it.”

Copyright 2013 Algonquin Professional Publishing, LLC

“CMS is dedicated to the transition to ICD-10,” said Buenning at the ICD-10 CM/PCS and CAC Summit sponsored by the American Health Information Management Association (AHIMA). “Given that ICD-10 is essential to greater interoperability, information sharing and ultimately providing better patient care and lowering healthcare costs, we are continuing to move forward with our ICD-10 implementation efforts in full anticipation of the October 1, 2014 compliance date.”

ICD-10 is an integral part of CMS’ E-Health initiative, which includes meaningful use, electronic quality measures and payment reform. Buenning said that ICD-10 implementation will make clinical records come alive, adding that the increased detail from the ICD-10 codes will provide a more accurate assessment of population health.

Pointing to CMS’ comprehensive implementation plan, Buenning added that the Medicare implementation of ICD-10 is on track for the October 2014 compliance date, but will continue to work in partnership with industry to assist all health care segments, and especially small providers, with making a successful transition to ICD-10.

“We have struggled to get notification of our discharges in a timely manner,” says Pam Bluford, the Care Coordinator at Summit View Clinic. “Typically it was just done kind of ad lib through fax machines, which would shoot that information to us.  The information would then get put into the medical records and then placed in a doctor’s box for review and not a lot was done with it.”

To ensure more effective care and treatment of its patients, Summit View, a nine-provider practice based in Puyallup, WA that serves 19,000 patients, chose the Emergency Department (ED) Notification solution from Clarity. The solution provides physicians with details about their patients’ diagnosis, background, contact information, and discharge summaries.  Having all of this information in one organized place helps the physicians ensure their patients are receiving proper follow-up care, and saves time for the physicians and patients.

When they began the search, the Clinic realized it didn’t have to look far. Summit View had been a Clarity Health customer since 2009, when it switched to Clarity’s Referral Management system.  Clarity, a Seattle-based company, asked Summit View to participate in a satellite program involving the Emergency Department Notification system.

At the same time, Bluford realized that the Clinic needed to totally revamp the way it handled patient information via coordinated care and decided it was time to give ED Notification a try. 

From the start, Bluford liked the simplicity and straight-forward design of the system and believes that it helped make the transition and implementation of the system much smoother.  Summit View’s health providers had a 15-minute training session and demonstration with one of the IT representatives from Clarity and Bluford says that the system was running smoothly in about a month and a half, a time in which the new program was integrated into Summit View’s existing system.

When designated Summit View clinicians log on to the ED system, they are taken to a dashboard that details patient ER activity.  This summary includes patient demographics, contact information, and a discharge summary that includes the date and time of the patient’s admittance. 

Also included are a description of the health concern and the provider’s diagnosis and treatment.  All of this is updated in real-time.  “The hospital’s information is downloaded four times a day into Clarity, so we get an update pretty regularly,” said Bluford.

Summit View has a team of nurses who are responsible for overseeing the ED Notification system.  “Our team of nurses is able to keep Clarity dashboard up as well as our EHR up on their laptops and can toggle between the two.  They can see if a patient is in the ER at the time or if they’ve been recently discharged.  They can also see the status of where they’ve been, if they are at home or at the hospital, etc.  So they’re able to see the disposition of the patient just in the dashboard, which is very helpful for us,” explains Bluford.

Bluford says that the team also reaches out to the patients after they have been seen.  “The team does some follow-up with the patients to help them with any outstanding information they need, such as information regarding their prescriptions, any questions they may have, help setting up a follow-up appointment, or even letting them know the clinic’s hours of service.”

Another benefit that Bluford has noticed is that Summit View is able to prevent many of their patients from visiting the Emergency Room for non-threatening ailments or for problems that can be treated by urgent care centers.  This has helped to not only cut down on patient costs, but also helped to educate the patients about their options and how and where they can be best served.

Since the implementation of the ED Notification system, the physicians at Summit View have appreciated the fact that they feel better prepared as they treat patients because the information from other providers is now readily available.  Previously, the system for getting the doctors the information was not very developed and often information would not reach the doctor in a timely manner.  That is not the case anymore, as the information from external providers is updated in a rapid and organized manner.

Bluford says implementation was a little difficult at the beginning as the Clinic worked out the growing pains of adapting to a new system. “At first, it was a little tough. It was a new software program, something new being added on to plate of people who already work really hard. We’ve had to reconfigure our work flow to make it more of a priority, but we’re seeing that it is helpful.”

Bluford estimates that about 80 percent of Summit View’s patients go to Good Samaritan Hospital in Puyallup.  She hopes that eventually, the system will include clinics in neighboring areas as well, so Summit View will be able to broaden their coordinated care even further.

--Correspondent Ben Schwartz

Copyright 2013 Algonquin Professional Publishing, LLC