U.S. Should Focus on Primary Care

A new study conducted by the Commonwealth Fund was published by Health Affairs and it showed that the U.S. lagged behind other nations in some very important ways that affect health and access to quality health care. The study surveryed over 10,000 primary care physicians in Australia, Canada, France, Germany, Italy, the Netherlands, New Zealand, Norway, Sweden, the United Kingdom, and the United

Certification Verses Meaningful Use

Recently, clinicians have asked me "why should I implement my organization's preferred EHR when I've found a less expensive vendor that promises meaningful use?"

This illustrates a basic misunderstanding of the difference between Certification and Meaningful Use.

The certification process will be codified in a December 2009 Notice of Proposed Rulekmaking (NPRM) and will define the process for certifying electronic health records including modular and open source approaches. (The Standards for data exchange will be codified in a December 2009 Interim Final Rule and become law immediately.) We know that ONC will specify certification criteria and that NIST will oversee certification conformance testing which will be performed by multiple organizations. However, we will not have the final certification criteria or the defined process until Spring after a period of comment on the NPRM.

Meaningful Use is about electronic documentation to enhance quality/efficiency and actual data exchange among payers, providers and patients. The definition of meaningful use will be codified in a December 2009 Notice of Proposed Rulemaking. We will not have the final meaningful use criteria until Spring after a period of comment on the NPRM.

Thus, it is too early for any software company to declare their product will meet all Certification criteria. In the interim, a vendor can claim product conformance with the latest CCHIT criteria, which is the best indicator of functionality we have at the moment.

Meaningful Use is not about products but about processes - how the software is used and how data flows in an ecosystem of stakeholders. Vendors should not be making claims about meaningful use.

Take a look at the data exchanges in the August 2009 recommendations for meaningful use:

ePrescribing

Sending reminders to patients

Checking insurance eligibility

Submitting claims

Providing patients with an electronic copy of their record

Providing patients electronic access to their records

Capability to exchange key clinical information (e.g., problem list, medication list, allergies, test results) among care providers and patient authorized entities

Capability to submit data to immunization registries

Capability to provide syndromic surveillance data to public health agencies

To achieve these 9 data exchanges, multiple sending and receiving parties need to participate.

In the case of Beth Israel Deaconess, achieving this level of interoperability by 2011 will require that we focus on a small number of software vendors. Over time, as standards and implementation guides become more specific and widely implemented, it will be easier to add additional vendors. However for now, we are focusing on getting the work done with our home built EHR and one purchased EHR (eClinicalWorks). Given scope, time, and resources, there is no way we can implement all 9 data exchanges among payers, providers and patients with another purchased EHR in time for Stimulus funding.

Thus, as you make decisions about what EHR to use, remember that certification describes the features of a product. Meaningful use describes actual data capture and exchange among multiple stakeholders in an entire healthcare ecosystem.

Products may be certified in a single clinician office, but meaningful use "takes a village". It cannot be promised by a vendor.

It's Post Secret Day

Check it out every Sunday.

When to Take Tamiflu

With the H1N1 flu season hitting most communities, the question of when to give patients Tamiflu comes up for physicians. Tamiflu is the antiviral medication that can shorten the severity of flu symptoms by...drumroll...one day. To be effective it should be given within the first 48 hours of symptoms.There are no medical guidelines for who should take Tamiflu. If patients have symptoms severe

Cool Technology of the Week

On November 4, I met with my director of IS at Needham hospital and we discussed the effort involved in creating a lab ordering/resulting dictionary that links together clinician offices, Meditech sites, and commercial labs. Imagine a spreadsheet with 3 columns of lab codes that is 12000 lines long!

Clem McDonald, who oversees the Lister Hill National Center for Biomedical Communications at NLM and is the developer of Logical Observation Identifiers, Names, Codes (LOINC). Using data from several sources, including the Indiana HIE, United Healthcare and a few other sources, Clem and his team were able to identify a set of about 300 LOINC order codes that cover about 98 - 99% of the most common laboratory orders.

On November 2, several members of the HITSP Care Management and Health Records TC met at the National Library of Medicine to discuss the development of a value set for creating an common interoperable set of laboratory order codes. Present at this meeting was an unprecedented collaboration of people representing healthcare providers, laboratory vendors, HIT Vendors, HIE developers and payers.

You'll find the details in Keith Boone's blog.

When I described the notion of a single lab compendium for the country, eliminating the need for custom mappings at every institution and clinician's office, my Director of IS agreed - that's cool!

Let's hope we can get rapid adoption of a universal lab ordering compendium in labs, hospitals, and clinician offices. Time and money will be saved, quality and safety will improve.

Who Sues for Malpractice?

There are a lot of myths out there about which patients are most likely to sue a doctor for malpractice. Many doctors think it is "poor patients on welfare." They would be wrong. Evidence shows that low income patients on Medicaid are actually less likely to sue than others. But there are some patients and situations that should raise a red flag for physicians that they could bring a

The H1N1 and Seasonal Flu Vaccines

On Monday, I received the 2009 Live Attenuated Intranasal (LAIV) H1N1 vaccine and the 2009 injectable seasonal flu vaccine.

As a healthy clinician under 50 who sees pediatric patients (mushroom and plant toxicology cases), I'm in the initial tier who qualify to receive the intranasal H1N1 live attenuated vaccine.

The experience of intranasal administration is interesting - inhaling an aerosolized liquid that slowly drips from your nasopharynx down your throat is not the most pleasant sensation. I suspect that pediatric patients will prefer the intranasal approach to an injection.

For 12 hours after receiving the vaccine, I experienced slight nasal congestion and mild fatigue. The complete fact sheet about risks and side effects is given to every patient.

During the same visit I received the 2009 Seasonal flu injection, an inactivated (killed virus) vaccine. Other than mild soreness at the injection site, I had no symptoms.

For me, the vaccines were a positive experience and will ensure that I am not a viral vector (call it personal anti-virus software) in the season ahead.

Since vaccine supplies are limited, it is important to understand the epidemiology of H1N1 (rates of reported cases per 100,000 population)

0 to 4 years — 22.9
5 to 24 years — 26.7
25 to 49 years — 6.97
50 to 64 years — 3.9
≥65 years — 1.3

You'll find a great UptoDate summary online.

Also, Harvard Health Publications has launched an iPhone App to provided the latest information about H1N1.