Honorable Mention

Who should be the next National Coordinator for Health Information Technology (HIT), i.e., the Director of the Office of the National Coordinator for HIT (ONC)? My name appeared recently on a list of 24 individuals nominated as a potential replacement for the current National Coordinator, Dr. David Blumenthal, who is leaving the post next month to return to academia at Harvard University.

Well, the results of the voting are in, and I was flattered to finish fifth, capturing 5.6% of the 736 votes cast. The winner of the poll was Jessica Kahn, Technical Director for HIT for Medicaid at the Centers for Medicare and Medicaid Services. Following in a close second was Dr. Marc Chasin. Vice President and Chief Medical Informatics Officer at St. Luke's Health System in Boise, Idaho. I am delighted to report that Dr. Chasin is a former student of mine, having taken the 10x10 ("ten by ten") course.

I have to admit that I am ordinarily unswayed by magazine or Web polls that are completely unscientific and really just popularity contests. Still, I was flattered to be part of this. Perhaps, as they say in show business, any publicity is good publicity.

This all said, I don't think I will be leaving Oregon Health & Science University any time soon. I have waited my whole career for the situation I and the department I lead are currently in, seeing the maturation of our field and the resources now available to support education and research endeavors within it.

I also do not envy the person who actually replaces Dr. Blumenthal. Clearly the HITECH Act has, to use the terminology of Gartner Hype Cycle, hit its peak of expectations. Some of the programs are down in the trough of disillusionment, although I am confident that most if not all of them will eventually level off in the plateau of productivity. Given the current political state of Washington, DC, where scoring political points seems to have overtaken governing and producing value from government programs, the next National Coordinator is likely to spend a good deal of time in non-productive Congressional hearings. It's not that I don't think government bureaucrats, like everyone else, need to be held accountable, but it is unlikely the primary purpose of those hearings will be to report on the value to healthcare and economy that HITECH has wrought.

Being the optimist that I am, I am not dwelling too much on the current poisoned atmosphere in Washington, DC. I will certainly defend to anyone the productive investment that has been made the federal government in HIT. In our programs funded by educational grants, skills and leadership have been imparted on a new cadre of individuals, and the curricular materials we are producing will have a lasting impact on the primary goal of biomedical and health informatics, which is to improve human health, healthcare, biomedical research, and public health with information.

HITECH: Improving Healthcare Through Data and Action

Every now and then, I am asked to give an overview of the Health Information Technology for Economic and Clinical Health (HITECH) Act of the American Recovery and Reinvestment Act (ARRA, also known as the “economic stimulus bill”). The centerpiece of HITECH is a plan to vastly expand the adoption and “meaningful use” of electronic health records (EHRs) [1], based on a growing body of research demonstrating that EHRs, especially when combined with clinical decision support (CDS), can improve the quality, safety, and coordination of healthcare [2, 3]. Similar to other areas related to technology and/or healthcare, the US has become a laggard in the adoption of EHRs, falling behind most other developed countries [4].

HITECH provides up to $27 billion for eligible professionals and hospitals to receive incentives for achieving the meaningful use of EHRs [5]. Meaningful use is a critical concept. The goal of HITECH is not just to put computers into physician offices and on hospital wards, but rather to use them toward five goals for the US healthcare system: improve quality, safety and efficiency; engage patients in their care; increase coordination of care; improve the health status of the population; and ensure privacy and security. As such, every criterion in meaningful use (e.g., drug-drug interaction checking) must tie back to a healthcare goal (e.g., improve quality, safety and efficiency).

Government funds for HITECH incentives will be distributed through the public Medicare and Medicaid reimbursement systems. Depending on choice of funding through Medicare or Medicaid, eligible professionals can receive $44,000-$63,000, while eligible hospitals can receive $2-9 million between 2011 and 2018. The main purpose of these incentive funds is to cover the costs of investment in EHR systems. It is anticipated that further costs will become part of the "costs of doing business" for healthcare.

The HITECH legislation recognizes that incentives alone will not be enough to achieve all the goals of meaningful use. As such, HITECH allocates an additional $2 billion for various human and organizational infrastructure elements to attain its mandates. A critical portion of this infrastructure is the ability to achieve health information exchange (HIE), which is the secure flow of data to wherever it is needed for patient care, including across traditional business and other boundaries in the healthcare system [6]. About $547 million is allocated to states for HIE development.

Another critical piece of the infrastructure is the provision of technical support to achieve meaningful use. This is done with the allocation of about $677 million to 62 regional extension centers that are providing a variety of forms of assistance, mainly to small primary care practices [7].

An additional portion of the required infrastructure is a competent professional workforce to develop, implement, and train users of EHR and related systems. It has been estimated that the HITECH agenda will require an additional 50,000 professionals trained in fields such as biomedical informatics and health information management [8]. About $118 million has been allocated for both short-term training programs in community colleges as well as longer programs mostly at the graduate level in universities. My institution, Oregon Health & Science Univeristy, is playing a major role in this program.

The HITECH legislation also recognizes that additional research and development is required. As such, $60 million has been allocated to establish four collaborative research centers focusing on the topics of security and health information technology, patient-centered cognitive support, health care application and network design, and secondary use of EHR information. A related funding initiative is the Beacon Communities Program, which has funded about $250 million for 17 advanced demonstration projects “shine the light” forward.

Just as meaningful use connotes that EHR adoption is not just about installing computer technology in clinical settings, there are related initiatives in the United States that will synergize with the substantial HITECH investment. One initiative from the Institute of Medicine aims to develop the “learning health care system” that learns from the growing volume of captured data what does and does not work in healthcare [9]. This is closely related to the growing push for “comparative effectiveness research” that aims to compare tests, treatments, and other medical activities in head-to-head studies carried out in real-world settings [10]. This infrastructure will also likely contribute to the growing push for translational research, as exemplified by funding for the Clinical & Translational Science Award (CTSA) program of the National Institutes of Health [11].

Taken collectively, all these programs from HITECH to ACA, the learning healthcare system, and CTSA provide a vision of a new healthcare system that learns from its successes and changes based on its mistakes. This vision uses data as the critical enabler of coordinating, measuring, and researching care. HITECH is indeed a grand experiment, and it is likely be that some elements of this experiment will succeed whereas others fail. But in the end, the healthcare system should benefit this unprecedented investment in information systems, human capital, and goals for improving health.

References

1. Blumenthal D, Launching HITECH. New England Journal of Medicine, 2010. 362: 382-385.
2. Garg AX, Adhikari NKJ, McDonald H, Rosas-Arellano MP, Devereaux PJ, Beyene J, et al., Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. Journal of the American Medical Association, 2005. 293: 1223-1238.
3. Goldzweig CL, Towfigh A, Maglione M, and Shekelle PG, Costs and benefits of health information technology: new trends from the literature. Health Affairs, 2009. 28: w282-w293.
4. Schoen C, Osborn R, Doty MM, Squires D, Peugh J, and Applebaum S, A survey of primary care physicians in eleven countries, 2009: perspectives on care, costs, and experiences. Health Affairs, 2009. 28: w1171-1183.
5. Blumenthal D and Tavenner M, The “meaningful use” regulation for electronic health records. New England Journal of Medicine, 2010. 363: 501-504.
6. Vest JR and Gamm LD, Health information exchange: persistent challenges and new strategies. Journal of the American Medical Informatics Association, 2010. 17: 288-294.
7. Maxson E, Jain S, Kendall M, Mostashari F, and Blumenthal D, The regional extension center program: helping physicians meaningfully use health information technology. Annals of Internal Medicine, 2010. 153: 666-670.
8. Hersh W, The health information technology workforce: estimations of demands and a framework for requirements. Applied Clinical Informatics, 2010. 1: 197-212.
9. Eden J, Wheatley B, McNeil B, and Sox H, eds. Knowing What Works in Health Care: A Roadmap for the Nation. 2008, National Academies Press: Washington, DC.
10. Murray RK and McElwee NE, Comparative effectiveness research: critically intertwined with health care reform and the future of biomedical innovation. Archives of Internal Medicine, 2010. 170: 596-599.
11. Zerhouni EA, Translational research: moving discovery to practice. Clinical Pharmacology and Therapeutics, 2007. 81: 126-128.

Reflections at the End of Another Amazing Year for Informatics

Last year, in wrapping up the first year of the Informatics Professor blog, I marveled at how amazing the year of 2009 had been. I noted that the year started with both uncertainty and hope; the former fueled by the recession and the precarious financial state of Oregon Health & Science University (OHSU) due to that recession and the latter driven by the excitement of the election of President Barack Obama and (at least for me) the hope for real change. By the end of 2009, it was clear that profound change had indeed occurred, if not generally then at least in the biomedical and health informatics field.

The hope and change, of course, were driven by the HITECH program with the president's economic stimulus package. At the end of 2009, the path forward was clear: health information technology would be driven by the concept of "meaningful use," and the part nearest and dearest to my heart, education and training, would be driven by the ONC Workforce Development Program, which itself was driven by Section 3016 of the HITECH Act that I played a role in influencing.

I spent the latter days of 2009 and early part of 2010 writing proposals, in particular for the curriculum development program and the university-based training program. With the Funding Opportunity Announcements (FOAs) for these and other programs, such as Beacon, SHARP, and regional extension centers, released in December and due in January, many in the informatics field lamented that ONC stood for the "Office of No Christmas." I spent a good part of my winter break last year working on these proposals. The only enjoyable aspect of the process was that they allowed us to envision how we could implement the educational programs we always dreamed of if we ever had the money, which now it looked like we did.

The most harrowing part of the year was the time between the submission of the proposals and receiving word about funding. As well-positioned as we were to receive these competitively awarded proposals, there was an undercurrent of fear that perhaps we forgot to address some required aspect of the program or that some reviewer felt we had taken the wrong approach. In all honesty, it would have been quite an embarrassment to not be selected for funding, since OHSU's program laid the groundwork for some of the thinking that had emerged surrounding health IT workforce development.

All the agony came to an end on Friday, April 2nd, when I awoke in the morning to find out that both OHSU proposals had been funded. For the curriculum development project, we were not only funded as one of the five curriculum development centers, but also chosen as the lead National Training and Dissemination Center (NTDC). For the university-based training program, we were one of nine programs selected for funding tuition assistance in our graduate program. A common quip in academia is that the downside to getting grants funded is that you then have to do the work. However, this was literally a dream come true. Between both grants, we were funded for $5.8 million to do what we always envisioned we could do if we had the funding. While the short-term emphasis of the funding (due to their being stimulus funds) required us to make some decisions we might otherwise not make, it was still a great position in which to be.

Also on the second to last day of 2009, the preliminary meaningful use rules were released. These were followed by a 60-day comment period, modification of the rules, and the release of the final rules on July 13th. I happened to be in a hotel room in Singapore (10 pm local time, 10 am Eastern time) when listening to their unveiling. While everyone had qualms with this criteria or that criteria, I believe that the majority of people were content with the approach to meaningful use taken by ONC.

With our own projects, we hit the ground running. Out of the gate, the curriculum development project required the most work up front. After a two and a half day workshop in Washington, DC the second week of the grant, we began our long quest that would result in the first version of the curriculum being developed and handed off to the community colleges by the end of October. Being the NTDC, OHSU also had to organize a training event for community college faculty in August and launch a Web site for dissemination of the materials around that time, both of which we did. We even added an aspect to the project of creating an educational version of the VA VistA electronic health record system.

The university-based training grant project was a little slower to get started, but not by much. With funding for 135 Graduate Certificate and 13 master's degree students over three years, our plan was to use the funding mainly as a form of tuition assistance for new students entering the field. We started providing support for students in the summer academic quarter and really ramped up in the fall. The main regret is that we have received two to three times as many qualified applicants as we having funding to accept. A decent proportion of those individuals have enrolled as self-funded students.

While a good proportion of my year was spent around these ONC initiatives, there were other achievements as well. Due to ONC and other funding, the Department of Medical Informatics & Clinical Epidemiology catapulted to second among the 25 departments at OHSU in external funding. We have many other initiatives in comparative effectiveness research, bioinformatics, and related areas. The big challenge for the department in 2011 and beyond is how to consolidate and build upon the success of the stimulus-era funding. I am confident we will find ways to do this, as the need for our disciplines to advance healthcare, personal health, and biomedical research will not diminish even as the federal budget tightens.

The coming year will also be an interesting one for the informatics world. How many eligible professionals and eligible hospitals will achieve meaningful use? What unforeseen bumps in the road will emerge? How will healthcare reform impact the use of health information technology? What will happen to healthcare reform itself? One thing is certain: we will live through exciting times!

I have now been writing this blog for almost two years. I have been pleased to have this type of forum to share my views on various aspects of my work. I am also pleased that others have noticed, not only the 129 people who follow the blog, but also winning awards like being on the list for the 2010 Top Math & Science Professor Blogs Award.

I plan to keep running the blog pretty much like I have been, with a fewer number of more substantive posts than the stream of consciousness approach used by many other blogs. I do hope to branch out a little bit more this coming year beyond workforce and education, as I occasionally did this year.

Meaningful Use Rules Finalized!

July 13, 2010 was, at least for those of us in the informatics field, a historic day: the release of the Stage 1 meaningful use rules by the Office of the National Coordinator for Health IT (ONC) and the Center for Medicare and Medicaid Services (CMS). These rules define explicitly what healthcare professionals and hospitals must do to quality for the incentive funding under the HITECH Act. As I have written before, the meaningful use framework is an excellent construct, enshrining the notion that HITECH is not just about adopting technology, but rather insuring it gets used in ways that benefit human health. As much as we love technology, we can never lose sight of the notion that, at least in healthcare, the goal of its use is to improve the care that people get. We do not always succeed at that, but it should always be what motivates us.

The final rules also demonstrate some other positive attributes about people, organizations, and governments. Most critical of these was that ONC and CMS listened, recognizing that the initial proposed rules were a little too much, too soon. So they dialed back, but not to the point of making the criteria too easy, which could have effectively turned the program into a government boondoggle, i.e., a subsidy for healthcare organizations. The whole ONC process has been very open and deliberate, involving many thoughtful people and organizations.

So what do the rules actually say? Before we get into the details, let's step back and look at the big picture. It is estimated that if every eligible professional and hospital meets the criteria, the cost of the program will be about $27 billion. When you add in the additional $2 billion invested in infrastructure (regional extension centers, HIE funding for the states, SHARP research projects, Beacon demonstration projects, and workforce development), the total cost will be $29 billion. That is no small sum of money, but is one of the those situations where the market would be unlikely to bring about this change. True to the American Recovery and Reinvestment Act (ARRA) from where it was legislated, the program certainly has created jobs and will likely create more.

As always with health IT, you can find a great deal information about the rules on the Web. One place to start, especially if you have a lot of time on your hands, is the full text of the final meaningful use rule (officially called the CMS Electronic Health Record Incentive Program, which also has an official Web site) and the final standards rule (officially called the Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology). However, for those of us with other things to do than read federal rules documents hundreds of pages long, concise early summaries are available from a number of places, including:

• An article in New England Journal of Medicine (NEJM) by Dr. David Blumenthal, National Coordinator
  
• Postings by Dr. John Halamka (Geek Doctor) on the meaningful use and standards rules, along with the beginnings of a frequently asked questions (FAQ) list
  
• A succinct overview from the Mr. HISTalk blog

The overall requirements from the ARRA legislation are of course still intact. The overall requirements for meaningful use involve:

• Use certified EHR technology in a meaningful manner
• Use certified EHR technology connected in a manner that provides for health information exchange to improve the quality of care
• Using certified EHR technology, the provider submits information on clinical quality measures

A certified EHR is a qualified EHR approved by an ONC- recognized certifying body. A qualified EHR is an electronic record of health-related information on an individual that includes patient demographic and clinical health information, such as medical history and problem lists and has the capacity to:

• Provide clinical decision support
• Support physician order entry
• Capture and query information relevant to healthcare quality
• Exchange electronic health information with, and integrate such information from, other sources

The incentives will be provided through increased Medicare or Medicaid reimbursement to eligible professionals (EPs), who include:

• Medicare: Physicians, Osteopathic Physicians, Dentists, Podiatrists, Optometrists, Chiropractors
• Medicaid: Physicians, Pediatricians, Dentists, Certified Nurse Midwives, Nurse Practitioners, Physician Assistants operating at an FQHC/RHC

As well as to eligible hospitals (EHs), which include:

• Medicare: hospitals paid under inpatient prospective payment system, critical acess hospitals; within the 50 states or DC
• Medicaid: acute care hospitals, childrens' hospitals

What follows is an overview of the criteria required to achieve meaningful use in Stage 1. The text that follows is gleaned most verbatim from Dr. Blumenthal's NEJM article as well as two PDF tables sent by email (can't find them on the Web) by ONC from the final regulations with the criteria sorted by core and menu items and by method of measure. An additional table from ONC compares the preliminary and final rules.

The rules are now organized so that in order to achieve meaningful use, an EP or EH must achieve 14 (EH) or 15 (EP) core rules and then five additional menu rules. There are also some additional twists on the menu rule. For example, some of them apply only to EPs while others apply only to EHs. In addition, one of the menu items selected must be a public health measure. This means that EPs must submit data to an immunization registry or syndromic surveillance registry, while EHs must submit to either of these or a reportable lab registry. However, if a state or regional public health agency is not prepared to accept such data, the EP or EH will not be penalized.

The 14-15 core measures must be achieved by all EPs and EHs in order to qualify for incentive payments. These include:

• Record patient demographics (sex, race, ethnicity, date of birth, preferred language, and in the case of hospitals, date and preliminary cause of death in the event of mortality) data - More than 50% of patients’ demographic data recorded as structured
• Record vital signs and chart changes (height, weight, blood pressure, body - mass index, growth charts for children) - More than 50% of patients 2 years of age or older have height, weight, and blood pressure recorded as structured data
• Maintain up-to-date problem list of current and active diagnoses - More than 80% of patients have at least one entry recorded as structured data
• Maintain active medication list - More than 80% of patients have at least one entry recorded as structured data
• Maintain active medication allergy list - More than 80% of patients have at least one entry recorded as structured data
• Record smoking status for patients 13 years of age or older - More than 50% of patients 13 years of age or older have smoking status recorded as structured data
• For individual professionals, provide patients with clinical summaries for each office visit; for hospitals, provide an electronic copy of hospital discharge instructions on request - Clinical summaries provided to patients for more than 50% of all office visits within 3 business days; more than 50% of all patients who are discharged from the inpatient department or emergency department of an eligible hospital or critical access hospital and who request an electronic copy of their discharge instructions are provided with it
• On request, provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, medication allergies, and for hospitals, discharge summary and procedures) - More than 50% of requesting patients receive electronic copy within 3 business days
• Generate and transmit permissible prescriptions electronically (does not apply to hospitals) - More than 40% are transmitted electronically using certified EHR technology
• Computer provider order entry (CPOE) for medication orders - More than 30% of patients with at least one medication in their medication list have at least one medication ordered through CPOE
• Implement drug-drug and drug-allergy interaction checks - Functionality is enabled for these checks for the entire reporting period
• Implement capability to electronically exchange key clinical information among providers and patient-authorized entities - Perform at least one test of EHR’s capacity to electronically exchange information
• Implement one clinical decision support rule and ability to track compliance with the rule - One clinical decision support rule implemented
• Implement systems to protect privacy and security of patient data in the EHR - Conduct or review a security risk analysis, implement security updates as necessary, and correct identified security deficiencies
• Report clinical quality measures to CMS or states - For 2011, provide aggregate numerator and denominator through attestation; for 2012, electronically submit measures

EPs and EHs must then select any five choices from the menu set. Criteria applicable to both EPs and EHs include:

• Implement drug formulary checks - Drug formulary check system is implemented and has access to at least one internal or external drug formulary for the entire reporting period
• Incorporate clinical laboratory test results into EHRs as structured data - More than 40% of clinical laboratory test results whose results are in positive/negative or numerical format are incorporated into EHRs as structured data
• Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach - Generate at least one listing of patients with a specific condition
• Use EHR technology to identify patient-specific education resources and provide those to the patient as appropriate - More than 10% of patients are provided patient-specific education resources
• Perform medication reconciliation between care settings - Medication reconciliation is performed for more than 50% of transitions of care
• Provide summary of care record for patients referred or transitioned to another provider or setting - Summary of care record is provided for more than 50% of patient transitions or referrals
• Submit electronic immunization data to immunization registries or immunization information systems - Perform at least one test of data submission and follow-up submission (where registries can accept electronic submissions)
• Submit electronic syndromic surveillance data to public health agencies - Perform at least one test of data submission and follow-up submission (where public health agencies can accept electronic data)

Additional menu criteria for EHs include:

• Record advance directives for patients 65 years of age or older - More than 50% of patients 65 years of age or older have an indication of an advance directive status recorded
• Submit of electronic data on reportable laboratory results to public health agencies - Perform at least one test of data submission and follow-up submission (where public health agencies can accept electronic data)

Additional criteria for EPs include:

• Send reminders to patients (per patient preference) for preventive and follow - up care - More than 20% or patients 65 years of age or older or 5 years of age or younger are sent appropriate reminders
• Provide patients with timely electronic access to their health information (including laboratory results, problem list, medication lists, medication allergies) - More than 10% of patients are provided electronic access to information within 4 days of its being updated in the EHR

In my postings ahead, I will explore the meaningful use criteria in more detail, especially from the standpoint of the competencies requires of informatics users, organizations, and systems.

ONC Grant Provides Financial Aid for Clinical Informatics Education

My last posting noted that Oregon Health & Science University (OHSU) was awarded two grants totaling $5.8 million in American Recovery and Reinvestment Act (ARRA) funds to advance health information technology (HIT) education. In this entry, I will begin to describe the details, especially for those who might be eligible for this funding. This posting contains the initial text of what will be a continually updated page for those interested in the program.

One of the grants is for direct financial aid for students studying in HIT-related fields. In the case of OHSU, this funding will support the education of approximately 150 students over the next three years in OHSU's Biomedical Informatics Graduate Program. These funds will support tuition and fees for about 45 new students per year to enroll in and complete the university's online Graduate Certificate Program in Biomedical Informatics. The funding will also enable two cohorts of around students to enroll in OHSU's on-campus Master of Biomedical Informatics (MBI) Program, including a stipend and student health insurance. This funding is provided via a training grant from the Office of the National Coordinator for Health IT (ONC).

There are some restrictions on this funding beyond the usual program requirements:

1. Students must be U.S. citizens or permanent residents.
2. Students must not have been enrolled in the OHSU or any other informatics or health information technology educational program on or before December 17, 2009 (i.e., current students are not eligible). This restriction does not apply to students who have completed only the OHSU-AMIA 10x10 Program.
3. Students pursuing the Graduate Certificate Program must complete the program within one academic year.
4. Students pursuing the Master of Biomedical Informatics (MBI) Program must enroll as full-time on-campus students to receive the stipend and student health insurance.
5. Students must declare one of six job roles defined by ONC and follow a course of study commensurate with that role.

Students who are not eligible or who are interested in other areas of biomedical informatics (such as bioinformatics) should apply to the existing program.

Details of the admissions process are being finalized and applications will be available in mid-May for Fall 2010 admission. Please check this page frequently for more details. By mid-April, this page will include a sign-up form for students who wish to receive email updates on the status of the program.

ONC Program Details

OHSU's eight-course Graduate Certificate Program is entirely online and can be completed in two to four academic quarters. Students who are funded through this program will receive support for their tuition expenses and must complete its requirements within one year. (The Health Information Management Track of the Graduate Certificate Program requires additional courses which will be fully funded under this program.)

The Master of Biomedical Informatics (MBI) degree program requires about 1 1/2 years of full-time study. The funding provides MBI students with tuition support, a stipend and student health insurance.

Students receiving financial aid will be required to choose among six career paths defined by ONC:

• Clinician/public health leader
• Health information management and exchange specialist
• Health information privacy and security specialist
• Research and development scientist
• Programmers and software engineer
• Health IT sub-specialist

Students will be able to enroll in the new programs Fall 2010. More information about applying, degree requirements and financial aid will be available on this page in mid-May, 2010.

More About Our Program

OHSU offers a full range of graduate programs in biomedical informatics for cutting-edge and rewarding careers using information and associated technologies to advance individual health, healthcare, biomedical research, and public health. There are two main tracks in the program: clinical informatics and bioinformatics/computational biology. The clinical informatics track, with the exception of the PhD program, is available via distance learning. Other forms of financial aid, such as our National Library of Medicine Training Grant, are available for full-time on-campus PhD or postdoctoral master's students in both tracks.