John Halamka describes Will Ross’s open-source approach to affordable Direct exchange at his Life as Healthcare CIO blog. Federal, state and local health departments are looking for lightweight Direct solutions and should explore this one. Thanks John!
While healthcare providers and public health departments continue to study how Stage 2 of the Electronic Health Record (EHR) Incentive Program, or “Meaningful Use,” will affect them beginning October 2013, the Health Information Technology Policy Committee has issued a Request for Comment (RFC) on proposals for Stage 3 and beyond that may shape the program after October 2015. Comments are due January 14, 2013. At least some of these proposals, shaped by comment, will re-appear in a Notice of Proposed Rule Making (and yet another round of public comment) next year.
The RFC unexpectedly pushed back a proposal for electronic case reporting of reportable conditions to an indefinite time AFTER Stage 3 (see below). Because the two Population and Public Health objectives targeted “after Stage 3” have been to focus of rapid and intensive work in the Public Health Reporting Initiative, they will likely merit further discussion as to timing.
Some items of public health interest for Stage 3 (by my own arbitrary criteria–you should read the RFC!) include:
- Adding the capability to record occupation & industry codes, sexual orientation and gender identity (optional fields) and disability status to EHR certification requirements (while not setting goals for provider capture of these elements)
- Using vital signs and lab results to support up-to-date problem lists (e.g., to use vital signs to signal potential hypertension on the problem list)
- RETIRING requirements to capture blood pressure, BMI and smoking status because recording is already at high levels (<80%, data source unstated). Progress will be tracked through hypertension and tobacco use quality measures instead.
- Increasing clinical decision support interventions from 5 to 15, including preventive services and chronic disease management, especially hypertension control and dosing of drugs for renal impairments.
- Change recording family history to recording high priority (unspecified) family history
- Educational materials made available in at least one non-English language based on which of the top-five non-English languages in US are spoken locally
- Transitions-of-care now specifically include referrals. Care summaries should include the identity of care team members like care coordinators, and EHR certification includes the ability to populate a referral form for specific referrals including smoking quit-lines.
- Notifying care coordinators (when appropriate) of significant healthcare events like emergency department visits or hospital admission or discharge.
- EHR importation and use of structured historical immunization data from immunization information systems (registries), and to receive, generate or access age-, gender-, and immunization-history-based immunization recommendations. The EHR certification criteria would requires the EHR to use standard rule sets and patient data to recommend immunization.
- Continuation without change to electronic laboratory reporting and syndromic surveillance reporting.
- Adding other mandated jurisdictional registries beyond cancer registries for which Eligible Professionals (and now Hospitals) may perform successful ongoing data submission to achieve a menu (optional) objective. In other words, cancer registries could be replaced by other registries in the menu objective for Eligible Professionals (and Eligible Hospitals would be offered a menu option for registry reporting for the first time).
- Adding a second menu option for standardized reporting to a second registry, which could include those from professional societies, public health jurisdictions or other aggregators (e.g. Accountable Care Organizations). It is a new requirement that such reporting use a national standard (“e.g., consolidated CDA”).
- Sending healthcare associated infection reports to the National Healthcare Safety Network (at least 10% of all reports sent from the certified EHR)
Two items of interest are pegged for “future stages” (i.e., after Stage 3). While it seems likely that HHS will continue to add future objectives and repairs to the program, the timing and nature of such activity is currently undefined.
- EHRs should determine when a case report of a reportable condition need be sent to a public health agency, and should send at least 10% of initial case reports electronically. [“Case report” means clinical information on a case for which a laboratory report of a reportable condition may or may not have been sent separately. NOTE that in earlier discussions by the HIT Policy Committee this objective was slated for Stage 3.]
- Reporting of adverse event (related to, e.g., vaccines, devices, EHRs, drugs or biologics) reports to FDA and/or CDC.
Dr. Thomas Frieden, Director of the Centers for Disease Control, can see satisfaction of his request that Stage 3 tackle improved clinical hypertension control, support for tobacco quit line referrals, and bidirectional communication with immunization information systems. Other voices, inside and outside CDC, have had additional goals, and many of these are reflected as well. Some of the key questions the public health (and larger Health IT) community must answer:
- Should at least some form of public health case reporting be pushed forward into Stage 3? Will the necessary message or document standard be ready in time, AND will a meaningful number of health departments be ready to receive it? [Look for a post on this topic shortly.] Is it necessary to have a national public health knowledge system that provides rules for public health reporting, or could jurisdictional requirements be manually programmed into EHRs? And who will drive to these answers and assure needed tools are created? [Disclosure: I served as a co-chair of the Public Health Reporting Initiative for a year until September, 2012.]
- Should cancer registries be demoted to just “one of” a variety of public health disease registries?
- If a standard format is created to report to disease registries, will public health (and non-public health) registries be able to convert in time?
- Will state health departments have adapted to receiving and managing CDA documents for Cancer Registries in Stage 2, and can they apply this to other use cases (possibly case reporting or additional disease registries) for Stage 3?
- And the perennial question: will health departments be drowning in data from Stage 2, or will they successfully harness the many new ongoing data streams into more effective and efficient case management and health surveillance systems?
Hard on the heels of my own departure from the US Centers for Disease Control and Prevention (CDC) on September 30 comes a clean sweep of high-level informatics leaders in the organization. Sources now confirm that James Buehler, MD the current Director of the Public Health Surveillance and Informatics Program Office (PHSIPO) will depart before year’s end. His supervisor, PHS Rear Admiral (ret.) Steven Thacker, a long-time advocate for cross-cutting integration, is also slated to leave his post as Director of the Office for Surveillance, Epidemiology and Laboratory Services (OSELS). These departures follow at least three years of marked funding reductions at CDC’s informatics core.
[Update 12/11/12: We’ve learned Dr. Buehler is departing for family reasons, and Dr. Thacker for health reasons. Friends and colleagues of Dr. Thacker can connect with him and his family here.]
Few signals indicate the future direction for informatics at the Agency. Acting leadership for OSELS will be placed in the hands of Denise Cardo, MD, director of the Division of Healthcare Quality Promotion, and Dan Jernigan MD, MPH of the National Center for Immunization and Respiratory Diseases (NCIRD) as her deputy. While Buehler and I were recruited from outside CDC, both of the new OSELS leads come from powerful National Centers in CDC’s Office of Infectious Disease. This may (but also may not) indicate a plan to redistribute the OSELS portfolio across the National Centers (sometimes called “Silos of Excellence”).
The timing for an apparent leadership vacuum and dwindling resources could not be worse. It comes in the middle of a massive one-time Federal investment of tens of billions of dollars in healthcare information technology and exchange. Standardization engendered by the “Meaningful Use” electronic health record incentive program could enable major progress in public health programs if two conditions are met. First, cash-strapped local and state public health agencies must make it a priority to migrate to new, more uniform standards and must have the resources to do so. Second, critical public health requirements for information exchange must be successfully negotiated with cost-averse healthcare providers and their information system vendors. Neither can be accomplished without dedicated leadership and resources. The need for a confident, skillful, flexible and funded approach to public health information exchange with healthcare providers has never been greater. We anxiously await the announcement of both new a new informatics vision and stable leadership at CDC.
I recently attended the 25th anniversary celebration for the Mectizan (ivermectin) Donation Program (http://www.mectizan.org/). Today the program is closing in on eliminating onchocerciasis, or river blindness, in several nations. President Jimmy Carter, former Merck CEO Roy Vagelos and former CDC director and Task Force for Global Health founder Bill Foege took the stage to recall how the program was born and succeeded out of a combination of luck and determination. Each admitted having no clear idea about how to realize the program at first, and each offered grains of wisdom learned since.
Dr. Vagelos recalled that the decision to give Mectizan away, as much and for as long as needed to combat onchocerciasis, was made for lack of an ethical alternative, though several were explored. Unexpectedly rapid regulatory approval and high expectations forced the executive decision even before the Merck board could be consulted. The decision had an unexpected long-term impact. Chemists, doctors, even factory workers flocked to Merck to work for the company with a clear moral compass. Merck did well by doing right.
President Carter said the program illustrates the oft-overlooked power of volunteers. The distribution of Mectizan is powered by local volunteers worldwide, including Lions Clubs who mobilize a small army of local business and community leaders in most nations touched by the disease.
Dr. Foege suggested that this program’s success, in contrast to many other public health campaigns, illustrates Sutton’s lesser known second law: “I get more done with a gentle voice and a revolver than with a gentle voice alone.”(1) An effective tool made the difference. “After people took Mectizan, some had the first itch-free day that they could ever remember,” Foege said. This rapid, obvious improvement in quality of life for some helped sell the drug’s benefits to all.
These lessons should give heart to informaticians who are rapidly prototyping, piloting and iterating real tools in the field, and those using volunteers (such as in open source development) to shape the work collectively. An application that “scratches the itch,” brings rapid uptake and success. Vaporous promises and endless planning likely have the opposite effect. We must not underestimate the power of the “revolver” in the hand over well-intentioned talk, nor the power of volunteers motivated by their communities’ needs.
Notes: (1) Paraphrased. I could not find attribution of this remark to Mr. Sutton, though he is quoted “You can’t rob a bank on charm and personality,” which carries the same message!
Pictured in the photograph L to R: Dr. William Foege, Dr. Roy Vagelos, President Jimmy Carter, moderator and Task Force for Global Health President/CEO Mark Rosenberg.
Additional information on the 25th anniversary event available at http://www.mectizan.org/news/mectizan-donation-program-celebrates-25-years-of-partnership-and-progress .
Keywords: public health informatics, Seth Foldy, health informatics, open source, Jimmy Carter, William Foege, Roy Vangelos