Meaningful Use Stage 3: An Urgent Checklist for Public Health

The clock is running for public health advocates to advise what should be included in Stage 3 of the Electronic Health Records (EHR) Incentive Program (“Meaningful Use” (MUse)).

January 14, 2013 is the deadline for comment on the Health IT Policy Committee’s recommendations for Stage 3.

  • A key issue is whether EHRs should be certified in Stage 3 to generate electronic public health reports using a new, standardized approach.   The Public Health Reporting Initiative is finalizing both a harmonized data element profile and a Clinical Document Architecture implementation guide in the next few weeks.*   These are based largely on the Cancer Registry reporting standard that appears in Stage 2 MUse rules and on implementations already in place for the National Healthcare Safety Network (NHSN) and recommended for Stage 3.  Adopting the PHRI approach need not require change to existing MUse reporting activities like electronic laboratory reporting, immunization registries or syndromic surveillance.  However, it provides a reusable, modular, and extensible methodology that could be leveraged by these and many other types of reporting (for example, communicable disease case reports, product safety reports, birth and death reports) into the future.
  • The public health (and health IT) communities should examine the PHRI documents to decide if they represent an achievable step toward more generic interoperability between EHR and public health surveillance systems.  If so, they will have to make their voices heard during the comment period, because MUse Stage 3 certification is NOT recommended by the HIT Policy Committee (rather, it is recommended for some future, unspecified time).
  • The Centers for Disease Control and Prevention (CDC), which funds much US public health surveillance, needs to decide and announce whether it will support pilot implementations, full-scale implementation, and health department migration to the new approach going forward.
  • The Office of the National Coordinator and CDC need to ensure that PHRI products  are harmonized with similar initiatives across the ONC Standards and Interoperability Framework, and curated and maintained over time.
  • Other important issues in the Stage 3 recommendations include EHR data capture of information like occupation and disability; whether NHSN hospital reporting should be included as a new objective; and whether additional public health registries should be offered as choices in the incentive program.
Unfortunately, these decisions are being made at a time of significant vacancies and uncertainty in the decision-making structure at CDC.   Representatives of local and state health departments, who are critical stakeholders in this process, will need to study, act and advise CDC, rather than depend on the agency.  But the CDC Meaningful Use program is sponsoring a half-day Virtual Conference on public health and Meaningful Use Tuesday, December 18 beginning at 12ET.   This should provide a good orientation to Stage 2 changes, and set a foundation for discussion of Stage 3.
Meanwhile, the urgent deadlines of MUse and ONC (sometimes labelled the “Office of No Christmas” for its December demands) loom.  Inaction over the holidays might lead to a lump of coal in the public health stocking for Stage 3.**
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* Disclosure: Author was a lead team member of the of the Public Health Reporting Initiative from October 2011-September 2012.
** References to Christmas are for humorous purposes only and do not imply an endorsement of any particular holiday or religion.  Happy holidays to all, whichever you celebrate.

The “X-Factor” for Health Information Exchange: Is competition toxic?

Early in the Wisconsin Health Information Exchange (WHIE) we realized a high likelihood of finding information for a local provider or patient was key to a successful business case.  (Techies call this “network dependency.”)  So I wasn’t surprised November 28 to hear market share penetration labeled the single item that best distinguishes sustainable from struggling HIEs by the HIE Learning Network of the National eHealth Collaborative (NeHC).  What is surprising is that HIE policy often disregards this vital factor.

At Technology Crossroads, Jeffrey Rose (ICG Group) and Delaware Health Information Network (DHIN) CFO Michael Sims presented factors identified by the Learning Network that distinguish profitable from unprofitable HIEs.  (Other factors in addition to high market share penetration are aggressive pricing and investment in product development.)  DHIN is verging on both 95% market penetration and long-term black-ink performance.  (For more on this and other Learning Network lessons, join the December 17 NeHC University webcast.)*  [Update: Dec 18: the Learning Network report has been published.]

Meanwhile, many HIEs around the country are struggling.  The eHealth Initiative’s 2012 HIE survey lists sustainability as the top obstacle, and found that over half are encountering competition from other HIEs.  They are also competing with HIT vendors providing exchange technologies directly to provider networks.

For example, the November 21 IHealthBeat reprinted a story from the Oct. 18 Tampa Tribune detailing how a public HIE serving hospitals is competing with a private HIE serving physicians.  Meanwhile, in several states, new HIE entities created by the Office of the National Coordinator (ONC) State HIE grant program compete with pre-existing regional efforts.  (Most early regional HIEs focused on medical marketplaces defined by referral patterns, not state lines.)  Adding to the confusion are statements from ONC leaders that put exchanges developed inside Accountable Care Organizations (ACOs) on the same footing as regional “all-provider” HIEs.  This fails to acknowledge that such private entities may aggressively compete, including taking information hostage.  A recent New York Times story details how increasing provider consolidation (neither citing ACOs nor excluding them) can block clinical communication with competing providers.

Perhaps, at least initially, competition is toxic for successful health information exchange.  In a 2007 eHealth Initiative report on HIE sustainability, we described social capital (resilient relationships among HIE stakeholders) as a key element for success.

An alternate scenario is that each electronic health record system will contain its own exchange capabilities (like the Direct “push” standard).  But this model still works best with a “central switchboard” managing directories, authentication, record locators, and other services that an HIE can provide.

It seems that HIE resembles mail service, electrification, telephony, highways and fire services, possibly requiring a period as publicly-regulated, public service monopolies.  Once the infrastructure is well established, competition can be introduced to accelerate innovation and price competition.   Today, however, regional HIEs are competing with Federally-funded state HIE designated entities, which are competing with for-profits and ACOs.  Meanwhile, market share is elusive, and network dependency can kill.

*Disclosure: I am currently on the NeHC University Advisory Board and a former NeHC board member.

Who Leads Informatics at CDC?

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.

 

Informatics, Global Health and Sutton’s Second Law

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.

Mectizan 25th Anniversary Event

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.

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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

Interface ATL Public Health Informatics Event

Interface ATL: join public health informatics colleagues for networking, sharing and fun.  Manuel’s Tavern, 602 N. Highland, Atlanta on Wednesday, November 14 6-9pm.  Free event, you pay food and drinks.

informaticians bioinformatics medical informatics Seth Foldy sethfoldy.com health.e.volution