Health Informatics Response Blog

An outline on medication history requirements

2009-09-20T11:01:00.000-07:00

I've written a lot about the need for a national medication history effort - both in prescription drugs and over-the-counter medications.

Government HealthIT piece
BAH "data liquidity" white paper

We as a nation have the standards and the data but seem to lack the will to make data "liquid" to support essential services. I was recently asked to create a one-page outline on my thoughts. Here it is..

Primary rationale for HIT includes:

Safe medication use
Effective management of transitions in care
Efficient use of resources

Although individual hospitals and organizations have demonstrated medication safety improvements through HIT and closed loop medication management, improved efficiency across transitions in care, automated medication reconciliation, and efforts to promote medication adherence, no systematic approach is available; every organization and state are doing this on their own. No systematic approach to the data vital to achieve patient safety and health care efficiency goals has been implemented.

Achieving these aims under the accelerated ARRA timelines requires that a number of resources for which high-level policy is best set at the national level. These include:

A comprehensive prescription medication history
Knowledge of over-the-counter medications, including aspirin, herbals, and other drugs
Availability of laboratory information required to adjust drug doses based on kidney function and liver function
Availability of drug and other allergy information
Weight and other factors that influence the administration of medication

At a minimum, a national effort is required to create a reliable and affordable resource where authorized individuals can access at a reasonable cost:

A prescription medication history
Pertinent laboratory tests

States and health care delivery organizations can improve safety and gain efficiencies by building programs on these data. These programs include:

Medication reconciliation at transitions in care
Patient counseling
Medication adherence programs
Accurate and timely controlled substances use information

Where prescription medication histories are concerned, if SureScripts is to become a de facto national monopoly, means must be found to ensure affordable access to these data. Such data are available at the time of e-prescribing, but means must be found to make these data available in support of adherence programs, medication counseling, and medication reconciliation. Vendors and organizations might be able to access these data on a variety of subscription basis. But to provide a "safety net" for all providers, states many want to consider a program that includes:

Access to medication history at state-authorized care provision and service sites for counseling, medication adherence programs, and medication reconciliation
Automatic population of state-managed controlled substance databases regulated by state laws

States would pay for this service based on some formula that includes a reflection of some of the same critical priorities set by ARRA (e.g., underserved, rural). Usage fees could be collected from various entities within the state (or through some form of transaction tax). These fees would be regulated by the state.

A Tennessee Not-For-Profit

2009-08-09T06:31:00.000-07:00

The Office of e-Health formed a not-for-profit steering committee. This group was charged with creating the incorporation documents and proposed foundational documents. Committee members finalized decisions around the items needed for incorporation and the initial foundational documentation to hand off to the not-for-profit’s board of directors. Included in the Committee’s decisions were recommendations on the make-up and membership of the not-for-profit’s board of directors.

The new board of directors will be:

Patrick Willard, AARP
Dr. Robert Mandel, BlueCross BlueShield of Tennessee
Bob Gordon, MidSouth eHealth Alliance & Baptist Memorial Health Care
Dr. Robert McLaughlin, Cigna
Dr. B.W. Ruffner, Tennessee Medical Association
David Sensibaugh, Eastman Chemical
Doug Varney, CareSpark
Dr. Reginald Coopwood, Tennessee Hospital Association
Rick Sain, Tennessee Pharmacist Association
Dave Goetz, Tennessee Department of Finance and Administration
Dr. Veronica Gunn, Tennessee Department of Health
Melissa Hargiss, Office of e- Health Initiatives, ex-officio member
Mark Bengel, Tennessee Department of Finance and Administration, ex-officio member.

Workgroups include:

Privacy and Security
HIT Adoption, Clinical Objectives
Technical Architecture
Financing,
Governance
Evaluation and Assessment
An Internal State Workgroup.

Update on TN ARRA Funding - June 30

2009-06-30T10:36:00.000-07:00

On June 30, the Federal Government announced $16.7 m in Recovery Act Capital Improvement Program (CIP) grants to the State of TN. These grants will support the construction, repair and renovation of more than 1,500 health center sites nationwide.

Current totals of health-related awards to TN are approximately $650.7 million.

For an update, see the transparency.cit.nih.gov site for the state of TN

NQF Report and Meaningful Use

2009-06-11T11:06:00.001-07:00

A June 9 NQF report has some good criteria outlining how a limited set of metrics can be defined as a foundation for quality reporting aspects of the ARRA "meaningful use" criteria:

Follow this link to the report - a must read

The high-level framework (page 50) is as follows quoted verbatim:

Criteria for prioritizing measures for retooling

Is the measure related to a national priority or high impact condition? Does it explicitly impact value/cost?
Does the measure effectively leverage HIT?
Does the measure reflect a more credible representation of quality?
Is the measure sensitive to effective coordination of care or data sharing across sites,providers and patients?
Does the measure reflect the use of innovative, patient‐centered data sources (bidirectional)?

Health IT sensitive criteria may include the following criteria:

Does the measure depend on the presence of an EHR and its effective use? In order to efficiently report on the measure and demonstrate good results, theorganization would need to have implemented a capable EHR and the clinicians wouldhave to be using it effectively

Does the measure reflect the use of innovative, patient‐centered data sources?

Examples:
Measure includes assessment of patient home monitoring (e.g., blood glucose monitoring)
Measure includes patient‐reported health status (e.g., completion of PHQ‐9 depression screening tool by patients)

Is the measure sensitive to effective coordination of care or data sharing across sites and providers?

Examples:
Coordination of care examples: measures include information that would need to beshared across sites (e.g., medication reconciliation), coordination between clinicians(e.g., timely receipt of consult notes).
Data sharing example: Percent of surgical site infections (SSIs) occurring within 30 daysafter operative procedure if no implant left in place – includes capacity to captureinfection information from ambulatory care to calculate accurate SSI rate.

With more than 500 measures in the NQF portfolio, available measures could be deemed “healthIT sensitive.” The health IT‐sensitive starter set should be comprehensive and applicable across health care settings. These measures will require the inclusion of key clinical data only available in electronic health record systems (e.g., data from problem list and medication lists), and that encourage use of essential components of the EHR.

California Working Groups

2009-06-02T12:18:00.000-07:00

In a June 1 memo, Johan Frohlich, Deputy Secretary, Health Information TEchnology, California Health and Human Services Agency, announced the formation of four work groups funded by the California Healthcare Foundation. Details can be found at http://www.hie.ca.gov.

The topics of the work groups are:

Regional Extension Centers: The workgroup will develop a plan to develop regional extension center(s) that meet Federal and State requirements and support provider adoption of electronic health records (EHRs) and information exchange
EHR Loan Program: The workgroup will develop a plan to establish a California Health Information Technology Loan Fund
Workforce Training and Development: The group will develop a strategic plan to establish Centers of Excellence for Health IT workforce training
Research and New Technologies: The workgroup will develop a plan to create a California Center for Information Integration. The Center’s objective will be to generate innovative approaches to healthcare information enterprise integration, support research into human-computer interface technologies, software interface technologies and other relevant research

Broadband

2009-05-21T05:32:00.000-07:00

Catherine Rampell in the NY Times on May 20 posted a nice summary of Economix data on broadband access.

There are no real surprises in these data and many explanations, but, combined with other reports from various industry reports, emphasizes the uneven distribution of access to high-bandwidth services. Without such services. it will be difficult to envision a connected health care system.

New ARRA documents - Breach and rendering documents undecipherable.

2009-04-18T06:02:00.000-07:00

A note from the eHealth Initiative announced the release of two early ARRA documents. Both are open to public comment.

The first is from the FTC and concerns the obligations PHR providers will have to notify individuals of breach.

Follow this link to the FDA site page

The second addresses three means of making document unreadable, undecipherable, or unusable. They include de-identification, destruction, and encryption.

Follow this link to the PDF HHS document

NCVHS Meaningful Use Disussions - April 28, 29th

2009-04-16T08:48:00.000-07:00

The National Committee on Vital and Health Statistics' Executive Committee will be holding two days of hearings from April 28-29, 2009 at the Washington Marriot Wardman Park in Washington, D.C. to discuss the definition of "meaningful use.",

The meetings will run from 9:00 a.m. - 4:00 p.m. on Tuesday, April 28th and from 9:00 a.m. - 1:00 p.m. on Wednesday, April 29th. The NCVHS Subcommittee on Quality previously held a preliminary discussion on meaningful use at its February 26th meeting.

Follow this link to the meeting Schedule

Uninsured in Tennessee

2009-04-01T06:27:00.000-07:00

Thanks to a Families USA analysis of Census data, we have a snapshot of the uninsured in Tennessee.

What does the report assert for the year 2007-2008?

Population under 65 was 5,314,000
Uninsured in that group are 1,722,000 (32.4%)
72.9 % of these are uninsured for six months or more (1,225,338 people)
74.7% of those uninsured for some or all of the year were members of working families
The remainint 25.3% were either actively searching for employment or were disabled, chronically ill, family caregivers, or not seeking employment for some other reason. (the number of unemployed actively seeking work was not estimated because of sample size considerations)
50% of those below 200% of federal poverty level were uninsured
22% of those above 200% fpl were uninsured

States or Regions?

2009-03-30T16:41:00.000-07:00

Current legislative language offers some choices between state and regional efforts. This is a sensible thing for the usual reasons:

Change always has a strong local component
Some regions span multiple state boundaries
States, on the other hand, have financial and legislative frameworks regions do not.
Medicaid is a primary driver for health care and is a state-level effort leveraged by federal FMAP funds

As financing models for health information exchange (the verb) evolve, it will be important to understand the tensions between regional and state effort and to learn from them. Every state (almost) has boundaries: rural vs. urban; east vs. west; up-state vs. down-state and within every state there is significant heterogeneity in cultural, policy, and technical readiness to accelerate efforts.

California - always a leader - is one state where such differences are playing out. Several blog postings and testimonies serve as a starting-point for understanding California efforts from afar.

There are differences of opinions here, different models, different versions of success and failure, and different views on how technologies should be governed. The California eHealth Collaborative is new but represents the common collaboration among a number of accomplished efforts. CalRHIO is a more long-standing effort to coordinate these same efforts from a top-down perspective.

What is more important, perhaps, than favoring one view over another is to recognize that different views exist and that the right outcome is not clear. Clearly the balance is important.

Time to dust of your copy of the Federalist Papers. Because of the pace of economic stimulus and sense of urgency, these controversies are coming to your state soon. Hopefully, we will all learn from one another.

Mark

PQRI: A Foundation for "Meaningful Use"?

2009-03-23T10:29:00.000-07:00

Although it is not clear when the term "meaningful use" will be defined by CMS and when it will be implemented, HHS no doubt is under some pressure. If forced to build on an established program, it would seem, according to some experts, that the Physicians Quality Reporting Initiative may be a starting point.

Those wishing to read more about this can consult the PQRI site:

CMS PQRI Site

Videos explaining HIT

2009-03-17T07:55:00.000-07:00

New York State has done a great job developing a video on HIT and distributing it on YouTube.

Follow this link to the YouTube Video

AHIMA Reports on ARRA

2009-03-13T09:36:00.001-07:00

AHIMA has released three reports on ARRA. All are available at:

http://www.ahima.org/dc/CommentsTestimony.asp

They are

An overall summary
A summary of the privacy requirements
A summary of reports mandated by the legislation

Bredesen Appoints Manager for Federal Stimulus Funds

2009-03-09T14:51:00.000-07:00

On March 9, the Nashville Business Journal reported Governor Phil Bredesen's appointment of Charles Harrison to manage Tennessee's stimulus funding. This funding is expected to be in the range of $4.5 billion over the next two years. According to the Business Journal, "Harrison, whose new title is Special Assistant to the Governor for Recovery Act Administration, has served in the comptroller's office since 1969. He will implement the spending plan along with four other people drawn from state government." Each state agency will appoint a representative as a liaison with the new structure.

Follow this link for the complete article in the Nashville Business Journal

NIH and NLM Funding

2009-03-08T13:21:00.000-07:00

source: Valerie Florance (NLM) , 7-March.

Sites:

NIH will receive $10.4 billion through the Recovery Act for use over the next two years (2009 and 2010). About 70% of that will be transferred to the individual Institutes of NIH and to the NIH Common Fund. The remainder will be used for special initiatives from the Office of the Director of NIH.

In general, NIH expects to allocate resources across several major activities, including:
Institutes may choose to fund recently reviewed meritorious R01 applications that have not yet been funded
Institutes may fund new R01 applications, and other similar mechanisms, that have reasonable expectation of making progress in 2 years
Institutes may accelerate the tempo of ongoing science via NIH’s administrative supplement program for currently supported scientists
Institutes may allow currently supported scientists to expand the scope or infrastructure of ongoing science through competitive supplements to existing grants

NIH will support new types of activities such as the new NIH Challenge Grant program, supporting research on problems for which progress can be expected in two years.

NLM will be participating fully in these NIH initiatives, with a particular focus on our research interests, and many other Institutes have informatics research-related initiatives to be funded with Recovery Act funds.

Dr. Valerie Florance, Deputy Director
NLM Extramural Programs

UMass NGA Report

2009-02-25T06:37:00.000-08:00

A report produced by the University of Massachusetts was released today. It is entitled "Public Governance Models for a Sustainable Health Information Exchange Industry."

Follow this link to the PDF report

Although it breaks no new ground, it summarizes at a high level three possible frameworks.

Model 1 – Government-Led Electronic HIE: Direct Government Provision of the Electronic HIE Infrastructure and Oversight of Its Use;
Model 2 – Electronic HIE Public Utility with Strong Government Oversight: Public Sector Serves an Oversight Role and Regulates Private-Sector Provision of Electronic HIE; and
Model 3 – Private-Sector-Led Electronic HIE with Government Collaboration: Government Collaborates and Advises as a Stakeholder in the Private-Sector Provision of Electronic HIE.

Governor Phil Bredesen a Member of NGA Task Force on Health Care Reform

2009-02-23T18:44:00.000-08:00

On February 23, 2009, the National Governors' Association appointed a task force to address Health Care Reform. "The Task Force is designed to identify and define gubernatorial priorities and to inform and advise the work of Congress and the Administration."

Follow this link for the press release

Members of the Task Force include:

NGA Vice Chair Vermont Gov. Jim Douglas, co-chair
Michigan Gov. Jennifer M. Granholm, co-chair
NGA Chair Pennsylvania Gov. Edward G. Rendell
Connecticut Gov. M. Jodi Rell
Georgia Gov. Sonny Perdue
Kansas Gov. Kathleen Sebelius
Massachusetts Gov. Deval Patrick
Minnesota Gov. Tim Pawlenty
North Dakota Gov. John Hoeven
Tennessee Gov. Phil Bredesen
Utah Gov. Jon Huntsman, Jr.
Washington Gov. Chris O. Gregoire

Visualizing the Stimulus Bill - the Hive Group

2009-02-20T14:18:00.000-08:00

During an informal talk, Rob Kolodner showed an interesting graphic developed by the Hive Group to visualize the ARRA. It's worth a look.

http://www.hivegroup.com/stimulus/

Rob tells me it is his brilliant son, Ben, at the U. of Maryland who brought this site to his attention. Bravo, Ben!

for some history, see:

http://www.cs.umd.edu/hcil/treemap-history/

Conference Report on HR1 (February 13, 2009)

2009-02-13T16:09:00.000-08:00

Enclosed is a link to a Microsoft Word version of the report

Conference Report on HR1 (February 13, 2008) - Word document

Bipartisan Agreement and Impact on Health IT (Saturday morning, 2-February)

2009-02-07T07:40:00.000-08:00

The bipartisan agreement announced tonight to amend the American Recovery and Reinvestment Act of 2009 will update a number of provisions in the underlying bill (S. Amendment 98 to H.R. 1).

What follows is a summary gleaned from several sources, including:

My read:

Appropriations Provisions

ONC: $3 billion. This is a $1b over the House language and a $2b reduction from the Senate language (the $18 b or so adoption incentives are presumably still within the appropriations).
AHRQ (NIH, and Secretary of HHS): $1.1 billion for comparative effectiveness research. Despite rumors to the contrary, at this juncture, I infer that the House language has been retained.
Broadband: $7 billion for the National Telecommunications and Information Administration’s (NTIA) Broadband Technology Opportunities Program for competitive grants to increase broadband access and usage in unserved and underserved areas . (Fifty percent of the funds are to be used for projects in rural areas.)
A $2 billion appropriation for broadband through the Department of Agriculture seems to have been removed.

Finance Provisions

Health Information Technology (IT) Rural Critical Access Hospitals: A cap of $1.5 million per hospital is expected to reduce expenditures by $2 billion.

Other Provisions

Public Health and Social Services Emergency Fund (prevention and wellness): These appropriations have been eliminated. (They were $3 billion in the House and $5.8 billion in the Senate).
Public Health and Social Services Emergency Fund (pandemic flu and the Biomedical Advance Research and Development Authority): These appropriations have been eliminated. (They were $900 million in the House and $850 million in the Senate).
Health Resources and Services Administration (HRSA): Appropriation of $1.87 billion for community health centers and infrastructure. Approximately $1.1 billion of House measures (not present in the Senate language) have been removed.

A partial list of cuts posted by CCN on Saturday evening (February 7):

source: CNN: What got cut from the stimulus bill (Saturday, February 7, 5:40 pm EST

Fully eliminated

$2 billion for Health Information Technology Grants
$100 million for National Institute of Standards and Technology
$100 million for distance learning
$98 million for school nutrition
$2 billion for broadband
$200 million for National Science Foundation
$100 million for science
$4.5 billion for General Services Administration
$1 billion for Head Start/Early Start
$5.8 billion for Health Prevention Activity
$40 billion for state fiscal stabilization (includes $7.5 billion of state incentive grants)

The Many Meanings of "Shovel-Ready"

2009-02-01T20:09:00.001-08:00

Those responsible for seeing our federal health information technology expenditures realize their full potential should be mindful of two important realities:

Culture eats strategy for lunch.
Cultural change - even positive change - cannot be accelerated through money alone.

Words mean many things. The challenge to the reader of current economic recovery legislation is not to understand the intent of specific Congressional actions but instead to understand how such intentions will be transformed into effective plans of action that make a difference. Funding for health information technology may indeed be the "best $20b you will ever spend." Or maybe not. Only time will tell.

As our Nation moves from legislation to action, one must be aware that traditional uses of the term "shovel-ready" health IT seem to fall into three loose categories:

Those projects that can be implemented with near-certain success and near-term positive economic consequences
Those projects that can be implemented, have less near-term economic consequences but create an infrastructure for greater efficiency and effectiveness (and hence positive economic consequence) for many years to come
Those projects are products that make sense and might even be proven in limited settings but whose widespread utility with additional funding is far, far, from a sure bet.

I would like to focus on a fourth interpretation of the term:

Can't "shovel ready" be used to describe activities that should be buried or at least put on hold until broader health care reform issues are sorted out?

Much has been accomplished over the past decade. There has been an important shift away from technology for its own sake and toward the use of technology to meet the needs of individuals and societies. This trend is evident as one reads of "data liquidity," personal health records, consumer portals, privacy initiatives, and and other efforts that recognize that policy - not technology - is the major challenge.

But as our sense of urgency to address our dire financial challenges has mingled with a pent-up demand for equally needed social reforms. A climate of deliberation has devolved into a circus carnival and feeding frenzy.

Writing the first draft of this posting on Super Bowl Sunday, this writer feels as if our Nation seeks to crown a Super Bowl champion not through a series of contests each involving two teams and one ball but instead by filling the stadium with eight teams, four balls, four different sets of referees, and every available fan. What on the field may seem like a noble and exciting competition makes little sense when observing from the stands. Popcorn sales will be brisk, but soon hunger will return. Passion on the fields and in the stands will in a matter of time be replaced by dissatisfaction over a lack of a clear and measurable outcome.

Increasingly, voices are being raised asking: will more money - distributed quickly be the best way to improve our economic condition, and serve as a foundation for a more effective and efficient better health care system? Or will additional funding only make things worse by:

Imposing systems that do not address fundamental structural fragmentation and complexity in our health care delivery and financing system?
Imposing information technologies that do not meet the expectations of patients or care-givers because they do not focus on outcomes or address fundamental and very complex work-flow challenges?
Imposing systems that, in their cost and complexity, hinder - and not enable - innovation in health care delivery and financing.?

Remember: complex technologies implemented poorly may impede health care reform proposals from across the political spectrum - everything from consumer-based health savings, first-dollar coverage approaches to single-payer approaches. They will use up our limited funds, breed cynicism, and arguably do little retain costs and improve care quality.

Many have posted or written to me with some surprise over the extent to which well-informed people believe that more standards, more privacy provisions, more incentives, and more certification will solve all. This may be the case, but more likely, a greater degree of focus will be all the more essential if there is more funding rather than less.

Some have argued that all only programs essential to direct economic stimulus should be immediately funded. David Brooks has said it well in speech and writing when he states that even areas in which he has passion (e.g., pre-K education) should not be part of the immediate stimulus package. In testimony before the Senate Budget Committee, Alice M. Rivlin makes the important distinction "between a short-term 'anti-recession package' (aka 'stimulus') and a more
permanent shift of resources into public investment in future growth."

There is consensus we need both. It appears funding will be allocated to both. So we must address both tasks well and with long-term consequences in mind.

So one must ask:

If we are to get out our shovels to build or to improve, aren't there some initiatives, committees, work groups, or programs that should be "buried" or placed in hibernation so that our Nation can focus on critical priorities?

This writer would suggest there are such initiatives (or parts of initiatives) and that adding more zeros to their funding will only worsen things. But this writer is often terribly wrong....

So, how should we apply our fiscal shovels?

We are ready to get to work.

In a February 2, 2009 NY Times article, David Herszenhorn summarizes the situation in the context of the broadband. His analysis can be applied to other areas:

quoting:

But experts warn that the rural broadband effort could just as easily become a $9 billion cyberbridge to nowhere, representing the worst kind of mistakes that lawmakers could make in rushing to approve one of the largest spending bills in history without considering unintended results.

“The first rule of technology investment is you spend time understanding the end user, what they need and the conditions under which they will use the technology,” said Craig Settles, an industry analyst and consultant who has studied broadband applications in rural and urban areas. “If you don’t do this well, you end up throwing millions or, in this case, potentially billions down a rat hole. You will spend money for things that people don’t need or can’t use.”

Dozens of programs included in the stimulus measure could entail a similarly complicated cost-benefit analysis. But with Congress and the White House intent on adopting the economic recovery package by the end of next week, taxpayers are unlikely to find out whether these programs are great investments or a total waste — or something in between — until long after the money is out the door.

Some Criteria for States

2009-01-29T13:31:00.000-08:00

There has been a lot of discussion across the country raising a few disturbing questions:

How will we ensure that health IT expenditures realize public expectation?
What role should States play in ensuring investments are sound?

Here are a few points made by people I've spoken with:

First, the public does not not need to wait for better information for health information technology before moving forward, greater attention must be focused on ensuring these systems are applied effectively. There is justifiable skepticism about accomplishing this on a massive scale.

Second, health care needs should guide technology, not the other way around; eHealth should only be an enabler to "health." There is some legislative language (as of January 29) that suggests an emphasis on objective measurement and re-design, but uncertainty resists.

Third, the State should define health care information technology broadly to include:

Any use of technology to enable better health care.
Work aimed at re-engineering care work flows and processes for greater effectiveness and efficiency. (Sometimes a change in work flow can simplify care tasks so technology change isn’t needed at all. )
Policies and practices affecting all of health care.

Fourth, the state should require any proposed HCIT deployment to provide a site-based plan for how the technology will be used to enhance and improve clinical performance.

Such plans must describe:

how work flows will be changed
how information collected will be used to improve clinical performance
the metrics through which performance will be assessed
how the deployment will accommodate ongoing change in best practice
a plan (and the total cost of ownership) of assuring that quality reporting and reportable disease are integrated into all clinical systems and not just added on at extra charge
a plan to demonstrate use of clinical data in context and not just administrative data
a plan to integrate with improved Medicaid programs (again, not just the status quo)

The State should invest a few percent of any health information technology federal stimulus funding on basic and applied research in as a part of a nation-wide collaboration. This research agenda includes:

simplified and broadly-based metrics for quality
efforts to simplify clinical and administrative processes
security and privacy - specifically authentication, authorization, audits
organizational systems-level research into the design of health care systems processes and workflow
research into computable knowledge structures and models for medicine needed to make sense of available medical data regarding the patient
human-computer interaction in a clinical context

Focus should be on standardized resources for internal state needs that follow national standards. Examples include:

An aggregate, real-time electronic record of each dispensing transaction for use (in NCPDP SCRIPT format) by every state coupled with the commitment of the vendor to provide medication histories where they are needed at no additional charge
Newborn screening databases
EPSDT registries
Immunization registries
Simple registries for cholesterol and diabetes hemoglobin A1C
Reportable diseases

All should adopt standards that conform with national guidelines and that promote integration as part of the core requirements

Privacy update - January 27

2009-01-27T15:23:00.001-08:00

The Senate Judiciary Committee met on the 27th. According to CQ, two of six witnesses "offered criticisms of medical data privacy provisions in pending economic stimulus legislation, but the general tone of the testimony was that the safeguards will do for now and can be improved later through new legislation or regulation." CQ also identified two minor differences between the House and Senate bills:

Senate: providers can charge a "reasonable fee" to patients who request a report on how their electronic records have been disclosed and to whom. The House bill doesn’t allow such a fee.
House: clarifies that patients who request copies of their electronic records don’t waive any other privileges.

Additional summaries from the House

2009-01-22T18:57:00.001-08:00

In a January 22, CQ HealthBeat posting, John Reichard stated that "hospital, insurer, employer and other lobbyists scrambled" to shape and reshape health care provisions in the House economic stimulus package, stating these lobbyists are increasingly focusing for changes in the Senate.

Among the provisions approved by the House appropriations panel:

$2 billion more for the National Institutes of Health,
$1.5 billion to renovate, expand, or create new community health centers
$1.1 billion for studies comparing the effectiveness of medical treatments
$900 million for research relating to a pandemic flu vaccine and defenses against chemical and biological weapons
$600 million to train primary care doctors to practice in rural areas or inner cities

Senate Judiciary Committee: Health IT: Protecting Americans’ Privacy in the Digital Age

2009-01-22T17:55:00.000-08:00

Senate Judiciary Committee will hold a hearing titled “Health IT: Protecting Americans’ Privacy in the Digital Age.” 10 a.m. Eastern, Jan. 27, 226 Dirksen

Speakers

James Hester, Jr. PhD
Director
Health Care Reform Commission
Vermont State Legislature

Adrienne Hahn
Senior Attorney and Program Manager for Health Policy
Consumers Union

Deven McGraw
Director
Health Privacy Project
Center for Democracy and Technology

Michael Stokes
Principal Lead Program Manager
HealthVault
Microsoft Corporation

Prescription Medication Histories - an Approach

2009-01-22T16:20:00.000-08:00

There has been a growing awareness of the value of a prescription drug history in every care setting. Increasingly at least one vendor (SureScripts-RxHub) is collecting such information from the majority of America's pharmacies and a growing number of PBMs. These data are both claims (from PBMs) and dispensed meds in SCRIPT format (from the SureScripts side).

If one uses a certified e-prescribing device, it is said, one will get formulary information (particularly from participating PMBs) and medication histories "for free." This makes sense. After all, despite the prevalent rhetoric on the potential of these technologies to increase the safet of presribing, benefits also accrue the PBMs (through formulary compliance, automated prior authorization, and mail order pharmacy coordination; this was a rationale for the PBM investment) and at least the large pharmacies (through lower labor costs that can be offset by reducing personnel; the latter reductions are the justification for the fees pharmacies are charged when they receive a digital prescription).

But what of all of the other clinical settings in which prescription medication histories are vital? Were I taking medications that could critically influence my care, I'd want that history available in a secure way to anyont authorized to care for me. How will this be done?

One way is simly to charge money for the transaction fee. Prices evidently range from $0.50 per transaction to $3 per transaction. Prescribers ask: "I changed my processes to help PBMs and pharmacies out; the marginal cost to provide a prescription drug history from the service is almost zero (the care facility could incur the cost of authorization and certification); so why do you charge me again for something that I've already contributed to?

At the same time we as individuals are seeking answers to these questions, each state government has developed one or more databases to house prescription drug information for regulatory purposes. The most common example is databases for controlled substances. In most instances, these databases collect batch files of separate fees from pharmacies and, with the help of a lot of often expensive technology consultants (they have to love it), develop their own ad hoc approach. 50 states - possibly 50 different proposals.

So this writer wonders if one can save the states money and serve the public at the same time by taking a more progressive and real-time approach to state needs and setting certain conditions on what the vendor meeting these needs must do in return for the public. The proposal has two parts.

ONE: The States use a uniform approach to data representation and all contract with a vendor like SureScripts-RxHub for real-time feeds.
Among the constraints:

The development of these databases would follow a national architcture and would be funded through the economic recovery legislation
The states would pay a small - and I mean small - annual per capita fee to the vendor (like SureScripts-RxHub). The cost of this fee should be less than the cost of maintaining their current infrastructureus.
The state database would only be used for authorized state purposes; the database would not be used as a "hub" for secondary distribution for clinical purposes
The states get out of the "one off" approach; that's the only way they will save significant sums
The states could also begin, informally, to converge on best practices for use of these data (i.e. narcotics databases, adherence reporting for public health

TWO: The same vendor must gurantee to provide the same feed "for free" to all certified care settings under reasonable authorization and authentication provisions.
This means:

All medication histories are made available from a point-to-point, SCRIPT standard-based "utility."
States stay out of the secondary distribution business
Everyone else more or less stays clear as well of the secondary distribution businessunless they can provide all of the prescription history service to a states' citizens
National standards would be used for "certification." I would think the ones used for e-prescribing today ought to suffice for other care settings. If the don't then perhaps our e-prescribing authentication and authorization methods are too lax

Who won't like this:

Vendors to states databases - they become less critical to software development but have opportunities by making the data more useful to their state clients
Some health plans - perhaps some plans enjoy some advantage by sitting in the middle of the transactions; but claims are the wrong way to present medication histories when dispensed data in SCRIPT format is avilalable
Vendors. Who would not want to get a dollar a transaction and see these mythical revenue forcastes disappear. But the reality, in my view, is that prescribers should not adopt the current e-prescribing approaches unless rules are simplified (e.g., formularies, prior authorization), and unless neither their patients nor their care delivery organizations are forced to pay onerous prices for something that has both been financed and which is a vital public good

Just an idea. But it would seem to this writer that such an approach would help our states do their job, contribute to a national care (e.g., NHIN) infrastructure, reduce complexity, eliminar costly intermediaries, and improve care.

Where do the jobs come from? A perspective from the Information Technology & Innovation Foundation

2009-01-17T07:18:00.000-08:00

In a January, 2009 report entitled "The Digital Road to Recovery: A Stimulus Plan to Create Jobs, Boost Productivity and Revitalize America," Robert D. Atkinson, Daniel Castro, and Steven J. Ezell of the Information Technology & Innovation Foundation estimate jobs produced for broadband, health care and the smart power grid. This report has been referenced frequently in the WSJ and elsewhere.

The Information Technology & Innovation Foundation is a non-profit whose board is composed primarily of active or former legislators as well as some academics, government liaisons (e.g., MIT), and a few major technology firms (e.g., Cisco, Microsoft, IBM).

The report claims that a $10 billion dollar stimulus in Health IT would lead to 212,105 additional jobs (see table).

According to the report, "The complete transition to EHRs for all inpatient and ambulatory care providers is estimated to cost, on average, $7.6 billion annually over 15 years. [Rand Corporation, 2005] Current spending on IT (not exclusively on EHRs) by health care providers and payers is expected to exceed $30 billion in 2008. Spending in this area is projected to grow at approximately 4.5 percent annually over the next 5 years."

According to the report, "approximately 43,400 of these jobs would come from direct spending by hospitals and health care providers on health IT systems. These jobs will come in high-paying industries such as computer hardware manufacturing (5,800), software (10,600), and IT services (27,000). Another 36,000 indirect jobs would be created from spending on intermediate inputs involved in producing hardware, software and IT services. Respending by the additional workers employed by these direct and indirect jobs would create another 79,000 jobs."

The report estimates "at least an additional 33 percent employment gain, or approximately 53,000 jobs." through a network effect. This increase is attributed to the "almost limitless possibilities of using digital health information to advance medical research, drug discovery and evaluation, and even personal health. Thus, for example, advancements in health IT will likely serve as a catalyst for the use of Web 2.0 technologies for health care including health information portals, personal health records, and health-related social networking. Websites such as WebMD and Revolution Health may develop new services for consumers that provide personalized medical information based on a patient’s health data. "

The methods used are well-documented and the limitations of estimates acknowledged.

Although the report suggests a five-year investment of $10b annually, the report is clear that the total number of jobs would equal the number in the first year but this level of total jobs would be sustained over the five-year period. Specifically, a footnote states: "The $50 billion health IT stimulus proposed would consist of a $10 billion stimulus in each of 5 years. Each $10 billion stimulus would create 212,000 jobs that would last for 1 year. Thus, the $50 billion health IT stimulus would create 212,000 jobs that would last 5 years. The $50 billion stimulus would not create 212,000 jobs each year for a total of 1,060,000 jobs."

House Energy and Commerce Committee - January 16

2009-01-16T20:34:00.000-08:00

New files on:

All can be found at:

http://sites.google.com/a/informaticsresponse.org/home/files

House Economic Recovery Bill Released

2009-01-15T11:29:00.001-08:00

The House released the bill on January 15, 2009.

Some quotes from the press release:

LOWER HEALTHCARE COSTS
To save not only jobs, but money and lives, we will update and computerize our healthcare system to cut red tape, prevent medical mistakes, and help reduce healthcare costs by billions of dollars each year.

Health Information Technology: $20 billion to jumpstart efforts to computerize health records to cut costs and reduce medical errors.
Prevention and Wellness Fund: $3 billion to fight preventable chronic diseases, the leading cause of deaths in the U.S., and infectious diseases. Preventing disease rather than treating illnesses is the most effective way to reduce healthcare costs. This includes hospital infection prevention, Preventive Health and Health Services Block Grants for state and local public health departments, immunization programs, and evidence-based disease prevention.
Healthcare Effectiveness Research: $1.1 billion for Healthcare Research and Quality programs to compare the effectiveness of different medical treatments funded by Medicare, Medicaid, and SCHIP. Finding out what works best and educating patients and doctors will improve treatment and save taxpayers money.
Community Health Centers: $1.5 billion, including $500 million to increase the number of uninsured Americans who receive quality healthcare and $1 billion to renovate clinics and make health information technology improvements. More than 400 applications submitted earlier this year for new or expanded CHC sites remain unfunded.
Training Primary Care Providers: $600 million to address shortages and prepare our country for universal healthcare by training primary healthcare providers including doctors, dentists, and nurses as well as helping pay medical school expenses for students who agree to practice in underserved communities through the National Health Service Corps.
Indian Health Service Facilities: $550 million to modernize aging hospitals and health clinics and make healthcare technology upgrades to improve healthcare for underserved rural populations.

also mentioned

$6 billion also recommended for broadband "to expand.. internet access so businesses in rural and other underserved areas can link up to the global economy"

Medicaid. Medicaid Aid to States (FMAP): $87 billion to states, increasing through the end of FY 2010 the share of Medicaid costs the federal government reimburses states, with additional relief tied to rates of unemployment. This approach has been used in previous recessions to prevent cuts to health benefits for their increased low-income patient loads at a time when state revenues are declining.

Medicaid Coverage for the Unemployed: Provides 100 percent federal funding through 2010 for optional State Medicaid coverage of individuals (and their dependents) who are involuntarily unemployed and whose family income does not exceed a State-determined level, but is no higher than 200 percent of poverty, or who are receiving food stamps.

GAO Senate Testimony - 15 January, 2005

2009-01-15T11:12:00.000-08:00

The title is: Health Information Technology: Federal Agencies’ Experiences Demonstrate Challenges to Successful Implementation

Testimony Before the Committee on Health, Education, Labor, and Pensions, U.S. Senate
Statement of Valerie C. Melvin, Director Human Capital and Management Information Systems

See also Peter Neupert's testimony

Issues

Follow this link for the testimony

Three points:

Establishing a foundation of clearly defined health IT standards that are agreed upon by all important stakeholders.
Defining comprehensive plans that are grounded in results-oriented milestones and measures.
Implementing an approach to protection of personal privacy that encourages public acceptance of health IT.

Senate Health Education and Labor PDFs on this site

2009-01-15T11:11:00.000-08:00

see: http://sites.google.com/a/informaticsresponse.org/home/files

Markle Recommendations

2009-01-13T21:26:00.000-08:00

The Markle Foundation has released a concise set of recommendations based on their principles. Is is entitled "Health IT Investments that Improve Health Care:
Critical Information Policy and Technology Attributes and Expectations." Worth a read.

Follow this link

Federation of American Hospitals / Booz Allen Report on Data Liquidity

2009-01-10T13:38:00.001-08:00

On Monday, January 19, Booz-Allen and the Federation of American Hospitals sponsored a 1-hour briefing on their new report entitled "Toward Health Information Liquidity: Realization of Better, More Efficient Care from the Free Flow of Health Information." Although at first glance this report might seem to be a strong support for ongoing certification and standards efforts, it is actually quite different in that it proposes a highly focused and incremental approach to health information technology.

Follow this link to the report

The report recognizes that many things will be changing in our health care system - particularly in the arena of payment and performance - and that these changes cannot be anticipate. It further acknowledges a very real reluctance to adopt EHRs - particularly in small practices - until some of these issues are worked out. Nonetheless, there are topics that can be emphasized now. Although some progress has been made in these topics, this writer believes they have been somewhat submerged by the cacophony of use cases, standards initiatives, and NHIN projects.

A critical theme is "data liquidity." Great benefit to all is realized when health information flows faster and more freely, or becomes more “liquid.” Quoting from the report, "liquid health information can facilitate improvements in healthcare access, quality, safety, efficiency, convenience, and outcomes while opening many doors for new innovations and providing a foundation for a new standard of patient-centered, team-oriented healthcare."

The report defines two broad "accelerators" each with specific actions that can taken now. The report does not claim that nothing is being done in these areas, but instead argues that everyone should focus on these efforts and separate these very important issues from those that may be interesting but are not practical at this juncture.

The first accelerator urges a more intense focus on information flow and communication. It urges:

While adoption is ongoing, additional energy should be devoted to eliminate use of paper-based medicine in critical areas, such as prescriptions, lab results, and medical imaging. The report does not argue for mimicking inefficient systems but instead emphasizes the critical importance of making data more "liquid" and associated with the individual receiving care rather than the organization generating the data on this care.
Reforming payment to align incentives with desired outcomes and processes known to impact outcomes, including decision support and process redesign
Defining a national health information exchange and knowledge management architecture – make sure critical history data, such as pharmacy, lab, and imaging data will flow across organizational boundaries. This definition is not the same as "certifying" health information exchanges as monolithic entities but instead focusing on ensuring reliable delivery of specific data types critical to care and incorporated into a range of current and future information technology projects. These functions will require some guarantee - but as functions and not as closed products.
Accelerating a nationwide e-prescribing network with decision support at the time and place of care. The report places more emphasis on "i-prescribing" and the use of medication histories and not merely connecting various prescribers and dispensers to enhance efficiency. The goal, the report argues, should be focused on enhanced patient care.
Utilizing pharmacy, lab, and imaging histories to improve quality at the point of care and increase reliable and valid reporting for quality and safety.

The second accelerator addresses the "bold steps" required for a patient-centered health care system as a foundation for care delivery. Among the immediate recommended actions are:

Granting individuals consistent, secure, and timely access to their personal health information and the ability to communicate securely with clinicians about it
Defining professional responsibilities and good stewardship policies and practices for health information workflow – define how health information is to be received, used, enhanced or processed, and passed along to others.
Refining policies with respect to health information privacy, confidentiality, and security breaches - assure patients and clinicians that health information is transmitted securely
Creating a voluntary authentication system where individuals can choose a unique personal identifier for care purposes – facilitate secure and convenient patient and clinician access to health information – facilitate health record matching

These recommendations should not be considered a carte blanche for the current policy direction but instead represent part of a growing movement towards immediate trials across a small and highly focused set of critical care needs where the standards exist and where clear attention can make enormous contributions.

Figure out roles and identities, and provide laboratory, prescription medication, and other key test information wherever it is needed. Do it now. Follow this with a broader approach as greater alignment between outcomes and reimubursement is achieved.

Frates: Health care could nab $100B payday

2009-01-06T13:34:00.000-08:00

In a January 6 posting on Politico.com entitled "Health care could nab $100B payday," Chris Frates outlines some current views on HIT spending.

follow this link to the Frates Politico.com story

Frates wrote that the current plan could "pump more than $100 billion into the health care sector, modernizing its delivery system and providing care to those who lost their health insurance along with their jobs."

$80 billion would go to Medicaid and perhaps safety net clinics.

An additional $20 billion would be a "down payment" on the $50 billion pledge to modernize the health IT infrastructure. Candidates would include: direct payments to practitioners as Medicare incentives, incentives for e-prescribing, and broadband infrastructure. It is possible some funds would "provide grants to states to help doctors, pharmacies and other Medicaid providers update their delivery methods."

Governor Patterson (NY) Economic Recovery Plan Presented to the President-Elect

2009-01-03T20:44:00.000-08:00

On December 29, Governor Patterson published a letter written to the President-Elect. He suggests that all state governments combined would benefit from a $500 billion stimulus package.

Follow this link to his press release and letter

$250 billion are for counter-cyclical stimuli including increases for: Federal Medical Assistance Percentages (FMAP); Unemployment Insurance and Worker Training Placement:;Food Stamps; Temporary Assistance for Needy Families (TANF) program, and child care.

$250 billion is required for infrastructure programs. He cites NY State as an example of projects that are "ready to go."

Patterson then delineates the "shovel ready" projects in NY State totalling over $11 billion. He stated that NY has $1.3 billion worth of "ready to go" health care information technology programs.

New York’s Needs: “Ready-to-Go” Infrastructure Projects & Cost
(Order changed by this writer; scroll down if you do not see the table immediately below this sentence.)

Quoting:

New York State alone has at least 1,922 infrastructure projects, totaling $11.7 billion that can be “ready-to-go” (i.e., federal funds can be obligated within 180 days). Of these “ready-to-go” projects, 481 are traditional infrastructure projects (i.e., transportation and water), totaling $5.0 billion. Using the broad definition of infrastructure that you have proposed, New York has an additional 1,231 “ready-to-go” projects for school modernization, affordable housing, state parks, rural broadband, and health information technology, totaling $5.3 billion. Finally, as I set forth in greater detail the following section, New York has at least 210 energy-related projects and programs totaling $1.4 billion that are “ready to go.” The economic recovery package must provide a flexible source of funds for these latter two broader categories of infrastructure projects.

Governance
Patterson makes a strong case for the State's current organizational structure. Quoting again:

New York is uniquely qualified to invest in health IT infrastructure thanks to the policy and technical blueprint established over the past 18 months using a public-private sector collaborative model. The blueprint includes a detailed set of information policies and standards governing health IT infrastructure, including privacy and security policies, which must be built up-front to support the technology, as well as a statewide governance process, managed by the New York e-Health Collaborative, to ensure implementation of and accountability for all current and future policies and standards.

Krugman on the role of state government

2008-12-30T07:27:00.000-08:00

A December 29, 2008 op-ed piece by the Nobel Laureate Paul Krugman drives home the dilemma to state government. Entitled "Fifty Herbert Hoovers," the article points out that a drastic contraction in state government spending will essentially neutralize stimulus provided by the federal government. (These budget reductions are often required for budget neutrality provisions included in some state constitutions; unlike the federal government, states cannot change the money supply by printing more and their only other recourse - bonds or taxes - are either unrealistic or self-defeating economically and politically)

Follow this link to Krugman's article (subscription may be required)

It is for this reason that the federal stimulus package may focus on states both as a conduit for funding and as instruments for coordinated action. (And I would add there are more than 50 "Hoovers" - let's not forget Puerto Rico and the cascading calamity in county and city government.)

Returning to Krugman, here are a few wonderful quotes:

No modern American president would repeat the fiscal mistake of 1932, in which the federal government tried to balance its budget in the face of a severe recession. The Obama administration will put deficit concerns on hold while it fights the economic crisis.

But even as Washington tries to rescue the economy, the nation will be reeling from the actions of 50 Herbert Hoovers — state governors who are slashing spending in a time of recession, often at the expense both of their most vulnerable constituents and of the nation’s economic future.

.....

Ted Strickland, the governor of Ohio, is pushing for federal aid to the states on three fronts: help for the neediest, in the form of funding for food stamps and Medicaid; federal funding of state- and local-level infrastructure projects; and federal aid to education. That sounds right — and if the numbers Mr. Strickland proposes are huge, so is the crisis.

And once the crisis is behind us, we should rethink the way we pay for key public services.

Krugman goes on to ask whether or not in the long-term health care, education, and infrastructure should be held captive by the ebb and tide of state financing. It seems to this writer that the federal contributions to Medicaid in particular argue for a stronger common basis for these programs across all states and territories. It's already a reality and proposed increases in FMAP make it only more so.

Acting CBO Director's Posting on the CBO Health Care Reports

2008-12-28T14:40:00.000-08:00

On December, 18, 2008, Acting Congressional Budget Office Director Robert A. Sunshine summarized the two CBO reports on health care.

Follow this link to the Acting Director's December Blog Listings

Commenting on the report entitled "Key Issues in Analyzing Major Health Insurance Proposals," Sunshine noted that there is no clear way out. Clearly, greater cost control and alignment of incentives are critical factors. IT is not a major cost-saving measure, according to CBO. The Acting Director's comments included the following (quoted verbatim as accessed December 27, 2008):

The rising costs of health care and health insurance pose a serious threat to the future fiscal condition of the United States. Under current policies, CBO projects that federal spending on Medicare and Medicaid will rise from about 4 percent of gross domestic product (GDP) in 2009 to nearly 6 percent in 2019 and 12 percent by 2050. Most of that increase will result from rising per capita costs, rather than from the aging of the population.

Without changes in policy, a substantial number of nonelderly people (those younger than 65) are likely to be without health insurance. CBO estimates that the average number of nonelderly people who are uninsured will rise from at least 45 million in 2009 to about 54 million in 2019.

Those problems cannot be solved without making major changes in the financing or provision of health insurance and health care. In considering such changes, policymakers face difficult trade-offs between the objectives of expanding insurance coverage and controlling both federal spending and total costs for health care.

By themselves, premium subsidies or mandates to obtain health insurance would not achieve universal coverage. Proposals could, however, achieve near-universal coverage using a combination of approaches. One option, for example, would be to establish an enforceable mandate for individuals to obtain insurance and provide subsidies for lower-income households to help them pay their required premiums. Another option, under a voluntary system, would be to provide subsidies that cover a very large share of the expected costs of insurance for every enrollee and establish a process to facilitate enrollment (as is done in Medicare). Other policies could achieve substantial reductions in the number of people who are uninsured at a lower budgetary cost.

Serious concerns exist about the efficiency of the health care system, but no simple solutions are available to reduce the level or control the growth of health care costs. Steps to restructure the insurance market and to encourage people to purchase less extensive coverage could reduce the use of treatments that provide minimal benefits, but enrollees would face higher cost sharing or tighter management of their care.

Other approaches—such as the wider adoption of health information technology or greater use of preventive medical care—could improve people’s health but would probably generate either modest reductions in the overall costs of health care or increases in such spending within a 10-year budgetary window.

In many cases, the current health care system does not give doctors, hospitals, and other providers of health care incentives to control costs. Significantly reducing the level or slowing the growth of health care spending would require substantial changes in those incentives.

AHA Position - December 8, 2008

2008-12-23T23:51:00.000-08:00

Some segments of their December 2008 report entitled "The Road to Economic Recovery: A proposal to support health care in America":

MEDICAID FMAP INCREASE

The demand for Medicaid services increases during a time of economic recession, requiring states to manage the increase in enrollment and funding pressures at a time when most of their budgets are stretched thin. Experts estimate that a one percentage point increase in unemployment increases enrollment in Medicaid and the State Children's Health Insurance Program (SCHIP) by one million lives. Thirty nine states have reported budget shortfalls for the current fiscal year or projected budget shortfalls for fiscal year 2010. The AHA supports a temporary Federal Medical Assistance Percentage (FMAP) increase that would allow states to use such funds to support their Medicaid programs and, through maintenance of effort criteria, states should be required to maintain their current levels eligibility and enrollment levels, benefit levels, and provider payment rates. Any FMAP increase should apply to DSH payments, with a corresponding increase in DSH allotments to accommodate the enhanced federal match. These reforms are critical because states have already targeted their Medicaid programs in a search for savings through provider payment freezes or reductions, as well as benefits and eligibility changes. Such cuts will further weaken the already tenuous foundation of the health care safety net, dramatically harming the ability of providers to continue serving our most vulnerable patients.

HEALTH INFORMATION TECHNOLOGY LOANS AND GRANT

An immediate investment in health care information and technology systems (IT) is critical. Many hospitals and health systems have been pioneers in harnessing information technology to improve patient care and high quality medicine. Sophisticated clinical information technology is critical to the health care infrastructure and a strong federal financing role today is necessary for the benefits of IT to be realized throughout the health care system. Special funding for hospitals and regional health information exchanges should be made available through the Agency for Healthcare Research and Quality or the Centers for Medicare and Medicaid Services (CMS) in American Hospital Association Page 3 of 9 December 2008 partnership with the Office of the National Coordinator for Health Information Technology (ONCHIT).

Loans and grants for hospitals. A program should be established to provide low- interest loans to hospitals and critical access hospitals (CAHs) for acquisition of certified, quality-enhancing, clinical health IT and its associated training and ongoing support. Grants - for essential, urban and rural safety net, and/or financially struggling hospitals - should be made for the acquisition of certified clinical information technology systems, training and ongoing support and maintenance of systems. Qualifying systems for both loans and grants would include currently certified electronic health record (EHR) systems and systems that provide medication administration or bar coding of medications, access to current medication lists, allergy lists, digital images, laboratory results or decision support tools.
Grants for health information exchange efforts. These grants should be provided to organizations whose principal mission is to establish a secure, health information exchange network in a specified geographic area that allows the secure electronic sharing of health information among health care providers and other authorized users in the provision of care.
Payment adjustments under Medicare for hospitals using certified, quality- enhancing, clinical IT. Hospitals currently using health information technology systems that improve patient safety or quality of care should receive a 1 percent increase in their Medicare inpatient and outpatient PPS payments. Qualifying systems would include certified EHR systems and systems that provide medication administration or bar coding of medications, access to current medication lists, allergy lists, electronic prescribing, digital images, laboratory results or decision support tools.

From the Wall Street Journal

2008-12-23T23:32:00.000-08:00

December 18:

The broad parameters of the package are known already. It will include a tax cut designed to pump $50 billion to $100 billion into the economy almost immediately; about $100 billion in aid to state governments, primarily to temporarily assume more of the cost of Medicaid, in hopes of staving off benefit cuts or tax increases; and funding in five main areas: traditional infrastructure, school construction, energy efficiency, broadband access and health-information technology.

December 24:

Vice President-elect Joe Biden released new details on the incoming administration's planned stimulus package, saying 85% of the three million jobs to be generated would be in the private sector and that no pet projects of lawmakers would be accepted.

President-elect Barack Obama has said the package -- estimated to cost between $675 billion and $775 billion -- will include a middle-class tax cut, large infusions of aid to cash-strapped state and local governments, and spending on bridges, roads, water projects, schools and energy programs.
Melody Barnes, director of the Obama Domestic Policy Council, said Tuesday that some of the funds would be used for preventive health care and health-insurance programs, to ensure that "those who are losing their employer-based health care are supported."

Messrs. Biden and Summers said the stimulus plan would have measures to track spending on the Internet and ensure funds are spent effectively.

Thomas Friedman

2008-12-23T23:04:00.000-08:00

Friedman's December 23, 2008 Op-Ed piece entitled "Time to Reboot America" summarizes the challenge ahead. Quoting:

That’s why we don’t just need a bailout. We need a reboot. We need a build out. We need a buildup. We need a national makeover. That is why the next few months are among the most important in U.S. history. Because of the financial crisis, Barack Obama has the bipartisan support to spend $1 trillion in stimulus. But we must make certain that every bailout dollar, which we’re borrowing from our kids’ future, is spent wisely.
It has to go into training teachers, educating scientists and engineers, paying for research and building the most productivity-enhancing infrastructure — without building white elephants. Generally, I’d like to see fewer government dollars shoveled out and more creative tax incentives to stimulate the private sector to catalyze new industries and new markets. If we allow this money to be spent on pork, it will be the end of us.

Senator Patrick Leahy's (Vt) Proposals for HIT and Broadband

2008-12-23T10:54:00.001-08:00

U.S. Senator Patrick Leahy (D-Vt.) has sent a letter to President-elect Obama outlining Leahy's priorities for an economic stimulus package as Congress starts to draft the legislation. In the letter, he makes the case for federal funding to states for health information technology initiatives. Enclosed are portions of a letter sent from the Senator to the President-elect.

Follow this link for the complete letter

Health Information Technology

You have expressed a desire to invest in a transformation of our nation's health care system through health information technology. I agree that this investment will have both short and long-range benefits to the health care of all Americans. Long-term cost cutting measures, such as the use of electronic medical records, can help stimulate the health care economy while providing important groundwork for a larger health care proposal in the near future. Federal funding to help states implement health information technology improvements will encourage needed modernization to health records to provide states the means to promote innovations in this area. Vermont has made important strides in advancing health information technology throughout the state to improve patient care and control costs. Vermont's program could be expanded quickly with additional federal funding, creating more jobs, and furthering improving patient outcomes.

Medicaid

In Vermont, the Medicaid shortfall for next year is estimated to be between $40 and $60 million. In a difficult economy where more and more Americans are losing their jobs and their employer-sponsored health coverage, coverage through public programs like Medicaid is more important than ever. Vermont's governor has laid out a number of options to reach our state's budget neutrality requirements including steps to reduce Medicaid eligibility. Thus, I strongly support a temporary increase to the federal share of the Medicaid program. An across-the-board increase to the federal medical assistance percentage (FMAP), rather than a tiered approach, is essential to ensuring continuing health coverage to some of the most vulnerable Americans

Broadband deployment

Even well into the onset of the Digital Age, the United States still faces a deep digital divide in broadband deployment, particularly in rural areas. This is due in large part to the failure of broadband providers to offer services to rural areas and to the lack of a strategic, national plan to make broadband access a universal service. Like you, I believe expanding broadband access to rural America is an essential part of any economic stimulus plan. Though the federal government has begun to make earnest investments in broadband expansion, primarily through programs at USDA Rural Development and modest investment at the Economic Development Administration 9EDA), we must exponentially expand these programs. USDA Rural Development's Community Connect program and Broadband Loan and Loan Guarantee program could both be used to drastically improve broadband availability if we provided program offices and UDA Rural Development state offices with additional funds and more flexibility. For instance, a $100 million fiber-to-the-home project in Vermont that could create hundreds of construction jobs, more than 100 immediate operations center jobs, and thousands of new business opportunities for Vermonters could start connecting customers this summer through the use of a $50 million USDA Rural Development broadband loan guarantee - an authorized program that has yet to be implemented. Additional state an municipal broadband deployment projects in Vermont that need construction funding would be able to start or continue construction this spring if we provided a one-time allocation to EDA with a focus on municipal and non-profit broadband expansion programs.