ARRA summary

With a vision for change, and an advocacy for healthcare President Obama signed into law the American Recovery and Reinvestment Act of 2009 (ARRA). This authorizes more than 19$ billion dollars for Healthcare information technology. As this sets the stage much needed incentives for healthcare organization to shift gears to adopt Electronic Healthcare Records, but unfortunately has received significant skepticism from many physicians.

As part of this stimulus plan, there are four requirements: Certified EHR, Information Exchange, Meaningful Use, and Reporting on clinical quality measures.

“Certified EHR": It is believed that the CCHIT will be the certification method of choice. In a recent announcement made by CCHIT Chair Mark Leavitt, there will be three paths to certification for vendors and health organizations. Applications will adhere to one of the following: EHR Comprehensive EHR -C, Certified HER Module EHR-M, or Certified Site EHR -S. These certifications vary in requirements. For example, to become EHR-M or EHR-S certified, your system will be required to have patient-physician PHR communication capabilities as well as an ability to exchange data with a certified HIE (Health Information Exchange).

“Information Exchange: It is important to note that there has been a significant emphasis on data exchange in the certification process. The purpose is to reduce healthcare costs and medical errors by promoting care coordination. This means that for any services provided to a patient that would like there data to be shared across a community based HIE or National HIE, this information must be available to other participating health organizations with the appropriate access. This includes SSA, CMS and other federal or state entities.

The next requirement is “Meaningful Use”, while recently a document has been released with some outlines of the “Meaningful Use Matrix” from the HIT Policy Committee. Everyone is still awaiting a final definition of “Meaningful Use”. One thing to keep in mind regardless of the details of this requirement is that physicians may need to make few adjustments on how data is reported as well as recorded.

Finally, reporting on clinical quality measures is the last requirements in the ARRA. It is stated that the eligible professional must be able to submit clinical data in a form and manner specified by the Secretary, on such clinical quality measures and such other measures as selected by the Secretary.

Physicians and other health organization must thoroughly examine the ARRA in great details, and all the changing environments surrounding them. Many have already successfully adopted electronic prescription, computerized physician order entry CPOE, patients using online PHR and all the possible potential adjustments surrounding the insurance reform. Taking the right steps forward will require careful planning and assessment.

Meaningful use released

It is finally here. We now can review the initial details behind meaningful use. With the release of the matrix and Preamble we can have a good grasp on what would be needed from everyone to follow the ARRA requirements.

The matrix is very well organized. From looking at it, not only technical individuals can see exactly which standard/MDX queries to create, but also clinical staff will be able to identify what changes are needed in the data collection and work flow adjustments.

These measures would be completed in three different stages 2011, 2013, and 2015.

The matrix has the following headings:

• Health Outcomes Policy Priorities
• Care Goals
• 2011 Objectives Goal is to electronically capture in coded format and to report health information and to use that information to track key clinical conditions
• 2011 Measures
• 2013 Objectives Goal is to guide and support care processes and care coordination
• 2013 Measures
• 2015 Objectives Goal is to achieve and improve performance and support care processes and on key health system outcomes

I truly hope that while everyone is reading these requirements, vendors out there are starting to make adjustments and will enable their clients to easily report on these objectives. Every vendor who is "certified EHR" (to be defined soon) should begin to publish some of the queries and report files needed to the healthcare organizations. If not I will be more than happy to assist anyone with the appropriate database access permissions to accomplish the measures. ;) you will just need to ask!


Now, I will start connecting to few databases and see what queries I can start playing with!

Here is the matrix Click here, and the Preamble

Healthcare RFID 360

Tonight, as I was playing with a new little gadget (RFID Reader) that allows you to logon to any windows workstation on network using RFID cards. This little device believe it or not was less than 50 dollars to purchase, it comes with an API Application Programming interface for in house programmers to create integrate with, and can be deployed in about an hour. While I would really prefer to use this with SSO (Single Sign On), but I did not mind settling for something small, simple and that can fit into a small budget. So, I experimented for a while with “TouchaTag" that a coworker recommended to me. At first, I did not see many uses of this RFID Reader on my desk, but as I dug deeper and started to see the simplicity and yet the power of using RFID, and the great potential it offers in the medical environment.



In most recent years, we are seeing a lot more use of RFID in the healthcare market place. Much of our common knowledge of the uses of RFID are usually limited to Asset Tracking, Real Time Patient/Asset location systems, and Patient identification systems.
But one challenge we face when planning to adopt the RFID technology has been the costly price tag. While in many cases the high ROI justifies the jump, it is still a huge project for any hospital to undertake. Traditionally you are required to have special RFID readers all over the place, and also the need to purchase Passive/Active tags for your assets. Interestingly there has been many new advancement in technology in the past years that not only lower the cost of acquiring these solutions, but also eliminate the need of expensive RFID readers spread all over the place and the cost of their installation.

Just imagine that you can start using Real-Time Location System (RTLS) tomorrow by only purchasing the TAGs, doing a site survey, get the software needed to running your assets/patients and voila! With the use of CCX (CISCO Certified Extensions), you can actually use the CISCO AP (Access Points) as your “RFID Antenas” to locate your Wi-Fi tags. This model allows you not only to maintain your existing CISCO Wireless infrastructure (which keeps the Executive team and budgeting team happy), but also allows for greater flexibility with the use of the many APIs that the vendors offer.


But what I am really interested in discussing today is another subject that I found very interesting. We all know that the US is few years behind Europe and some Asian countries when it comes to cell phone technology. When you are walking in downtown Paris, you can put your cell phone close to a movie poster and get all the show times for that movie, or when you are in the subway you can pay for your ticket using your cell phone. So, how is that possible, and what technology is that using, but most importantly, can that technology be useful in the healthcare environment and worth adopting.

Well, most of the new cell phones that are manufactured and shipped to Europe and Asia have a chip that provides them with NFC (Near Field Communication) capability. Believe it or not, it is using RFID technology as well. There is a number of these phones that allow you to use Near Field Communication technology that has a short-range high frequency wireless communication technology which allows you to read an RFID tag directly from your phone. Why this is important you may ask??? Well, first starters, if the technology is available, then it is only fair for us to have access to it so we can apply it to resolve different business challenges.


What I found out was that in the Nederland’s they are using this technology very effectively. Basically the home health nurse can take her cell phone and she touches the (patient's) card with it, then identification information about the patient is submitted (over the network) to the phone; contact persons, medical data, care arrangement, are exchanged between the phone and medical application on the Home health servers. Now, some may argue that it would be easier to use a laptop, access all that information on it, and use Wi-fi or Wireless Broadband to communicate, but unfortunately with the economy and high costs of this type of infrastructure makes it a less attractive option and not an impressive ROI.



So this Mobile phone technology can be applied in a hospital environment. It will be less expensive that the typical RFID installation and you will no longer be required to use the smart phones that come equipped with the bulky RFID reader anymore. Plus this technology is a simple extension of the ISO/IEC 14443 proximity-card standard. This means that care providers can identify patients and even medication details (if we tag medications with tags).

Examples of other healthcare technology companies in Europe such as Dutch electronic-monitoring company Elmo ICT Solutions introduced a similar NFC product recently and it was called MobiCare-EasyID. It has sold about 1,500 NFC phones made by Samsung.


NFC technology in mobile phone handsets can also be used to open locked doors, or to download a URL or other information from a separate NFC device, such as an NFC tag embedded in a smart movie poster.


I would like to think of a scenario that I can be walking down the street and come in contact with a lost done, use my cell phone to check a dog's embedded RFID tag to see who he belongs to and contact his/her owner.

Cool toy of the month!!!! Watch your internet shows on your TV

Ok, it has been a while since i was able to watch anything that talks about technology on TV. I used to watch in the past TechTV, but that's long gone and been replaced. I settle now for reading/watching tech podcast during lunch at work, or before I start my day in the morning. The challange I kept finding was that I can never efficiently organize and view that information as entertainment. Ok, let me explain. In the evening instead of learning about Desktop virtulization or the latest micrtosoft developpement tools 2010, I am stuck surfing tv reality shows between commercial breaks from MSNBC and CNN. So, I finally made a decision to bring those useful shows to my TV. And that's when I discovered the D-Link 520/510. These are neat little devices that act as a Top Set where they connect to your wireless network and your tv, and allow you to bring your media library to your TV and control it using a remote control. Just imaging the following:
at 10:00 AM you receive an update from an RSS feed you signed up for, and it talks about the latest microsoft Surface SDK, and different showcases or uses in the medical field.
Now imagine that you are too busy to click on it and view it, because like all of us you have deadlines a boss breathing your neck. So, you are disapointed that you missed that opportunity to learn something new and cool.
Then you go home and realize that you have this little cool toy that actually keeps track of your favorite RSS feeds, and presents them to you directly on your TV. Well that toy or one of them is the D-Link 510/520.
You kick back on your couch or start on your tradmill, then press play and voila. You are now watch and learning about the exciting new Microsoft Surface and trying to think of ways you can get your boss to spend 15k on it to prove how cool it would be to use as part of your next EMR presentation.

PS: i am convinced that this technology one day very soon will be in the radiology departments as well as other specialties!!!

Can you exchange patient healthcare records

While many of us are exposed to the ARRA or stimulus, many healthcare groups are still wondering how this is all going to play out once all the requirements are defined. In a series of blogs I will be posting, I am going to discuss three different subjects with several scenarios of different practice types with different infrastructure and package.

The three subjects I am going to cover will be:

Interoperability
Meaningful use of a "certified EHR"
Certified Package

I will start by discussing the first one, and it is my favorite one. In the last few months, I have been very fortunate to participate with some very smart people. We worked together as part of the Technical & development Committee for NCHICA to create a draft that identifies our recommendations for a state wide/Community base Health Information Exchange Network.

Basically our goal was to identify the architecture of a NC HIE that would be able to participate a the national level and facilitate the exchange of health records amongst stakeholders such as (ER, Hospital providers, Physicians, State entities, SSA, and others..).

During that process I have learned tremendously from the team, and I could not help but try to envision how many of the providers I know would use and benefit from such a system.
So to help explain how a State HIE and its uses would look in the future, I have three practice scenarios to explain the implementation:

Practice 1:Dr. Smith with Practice SoloProv is a small provider practice with a single physician who is using a Basic EMR. This EMR called SoloEMR is a small vendor that is not planning on getting certified, and will not be enabling any interoperability in their software.

Practice 2:Dr. Jones with BusySpecPractice is a mid size busy specialist practice that feels that an EMR might slow them down, and elected to stick to paper charts but would like to participate at a state level HIE.

Practice 3: Dr. Ashton with Busy multiSpec which is a mid size busy multi specialty practice that has implemented recently a well known EMR that does support interoperability and also is planning on using the state HIE.

As for many of the patients of Practice 1 are becoming more aware of the advantages of having access to their PHR (Personal Health Records) they started requesting from Dr. Smith that they would really like to see their records on state HIE as well as receive updates under their (Google Health or Health Vault). This puts a lot of pressure on Dr. Smith as he realizes that he will need to do something before patients start looking at other providers that may have that edge or those capabilities. So, he approach the software vendor but with no luck. Then he decided to take a another approach. He came up with a plan to basically charge a patient a small fee to cover the cost of a staff member entering that data directly into the State HIE web portal. Not only the basic medication list, allergy and vitals, but also scanning sections of the paper chart to be uploaded. While the cost per patient becomes break even with what he is charging, he realizes that this is his only option unless he goes for an EMR package that has that functionality of Interoperability. This model allowed him to still maintain business as usual, but also allowed him to print/receive updates on his patients anytime their records are updated by another health provider. Unfortunately, the down side to this model is that the provider will be missing out on the stimulus money, but also on the advantages that an EHR offers. Anything from Drug interactions, to E&M coding, Rx History, Paperless office and much more.

Practice B, is a busy specialist practice. No time to waste typing on a tablet PC or laptop. They do everything on paper, and very comfortable with that method, and not looking into any change anytime soon. However, they realize that they would like to move the practice toward a EMR model and the next years, and would like to minimize the upfront costs as well as lowering the risk and change. With this group, it was a very simple yet powerful approach. They decided on using an EMR lite package that not only allowed them to access/request patient records from the Community/State HIE, but also perform electronic prescriptions as well as enter the basic clinical information electronically (Vitals, allergy, diagnosis, procedures, basic notes..) which was available for the Community/State HIE, and the rest of the medical record was still transcribed. This group was able to maintain the efficiency, be more informed before making decisions, and still provide the same amount of attention the patient deserves during the visit.
Now in my opinion this model above is a lot better than the first one. You have access to more information of the patient conditions (problem list, medication, allergies, vital and such), also the provide has visibility of the patient "CCD" or summary record provided by the HIE, but still does not provide a way for the practice to "measure quality or improvements". This is the part where the NQF will select our of their existing criteria which one will be utilized and implemented as part of "meaningful use".

With the last practice 3, recently implemented an EHR system across multiple departments. Each has all their patient records stored electronically. From the radiology department to the pediatrics. If you are a patient there, there one comprehensive electronic health record that contains all your data gathered from across the departments. So, you will have all your imaging stored as a standard DICOM, then you have all your lab data in HL7, and your overall summary of record as a CCD. Anytime any outside entity needs your record, the Community/State HIE sends a request and then receives a response with all your medical data from this group. The nice thing about this model, is that the providers did not have to do anything different to enable the interoperability here. Except of course paying for it (some vendors are planning on charging you for that functionality separate!!!!). In addition, this group will have as part of their participation in the Community / State HIE, any new patient or existing patient's PHR or LHR can be downloaded to a special tab in the EHR (Outside Records) to allow care providers to view patient's medical records from previous or other entities. Unfortunately this model is most likely the most costly for a practice, although it has tremendous advantages and will truly be the best case that the ONC and our administration would like to see, it is still the most challanging.

I am a firm believer that technology is going to help improve our healthcare system. The cost of it would be the variant here, but nevertheless, it is something that is needed. My mission while working with providers is to show the value technology can bring. Whether it is using EHR, or efaxing, virtualization or just simply securing their network to better protect patient information, it is important to show the many positive things that technology can bring to the table, it is just a matter of putting the RIGHT one to resolve the RIGHT problem. It does not always have to cost an arm and a leg either. I have seen enough successful open source products out there, that we don't have to continue to use cost as an excuse.

My favorite open source products:
Open Vista (VA EMR)
CONNECT (NHIN that allows for Health Information Exchange)
Mirth (Interface Engine for Labs, Demograhpics, DICOM CCD and many more.)
ClearCanves (My favorite .net PACS solution, and it is open source and as good as the 100k solution).

I will cover more of those open source solutions in another blog.

The health Provisions in the stimulus package and what it means to your practice

While I am trying to juggle between getting all my work done, and packing to prepare for our new office move, I had to find time during my non excising lunch and do a quick blog message.

Earlier this week president Obama signed the stimulus bill, so that meant that everything that is proposed for our healthcare is now law. But after spending two nights trying to read the healthcare section of the 1071-page American Recovery and Reinvestment Act, I still had a lot of questions to ask about what are we really getting, and how do the healthcare groups go about getting it. I even had more questions than the ones I started out with.

So, as I googled all my concerns and questions, I found articles that really put a negative spin on the new stimulus bill. I have read things about how the seniors in the US will face rationing, and how doctors will be influenced by the government. These articles could not be more wrong. It was important to really stay positive and make the best out of the assistance that healthcare has long needed to help the adoption of the technology that it most definitely needs. I found many of my answers in the following site Click Here.

The incentives proposed for the health professionals are payments of 15,000 to 18,000 dollars for the first year, 12,000 dollars for the second payment and on until the fifth and last payment of 2,000 dollars.

Things that will be potentially requested from health professionals in order to be eligible for the incentives:

• Submission of claims with appropriate coding (such as a code indicating that a patient encounter was documented using certified EHR technology) ---This reminds us on how we reported on PQRI.
• The use of Electronic Prescribing (e-Prescription, and this can be achieved with third party vendors, so you don’t have to change your EMR if it does not support it).
• The ability to exchange / forward your patient medical data to “data repository” defined by the Secretary ( RHIOs and hospitals have implemented these types of data warehouse and can store any of the following (which one they will request is the million dollar question):

Electronic Referrals and Consultation

Electronic Lab Orders/Results

Electronic Prescription

Electronic Imaging of patients

Electronic medical history

Radiology reports

Discharge reports

• Treatment plans
• An attestation
• A survey response

Since I am still reading the Healthcare section of the stimulus, I will continue on this blog in the next few weeks and describe some of the ways that small to mid practices can utilize to benefit from this.

Obama’s push for digital health records and what I think its flavors should be

While our new administration is doing the right thing by pushing for the modernization of our healthcare system, it is important to have a plan that will work and motivate everyone in the healthcare industry.
In my view the 5 year timeframe that our government is looking at will be very short to accomplish EHR implementation and standardization, especially in the small to mid size medical groups. In working with some of these types of offices in the last 10 years, I realized that many of them have complex workflows, and many encompass diverse delivery systems while many still suffer from the lack of proper infrastructure (Backups, server hardware requirements, scanners, efaxing,…etc.).
It is important to note that, in order to overcome the daily challenges that these groups are faced with (small IT Budgets, lack of HIT knowledge, and few uncooperative providers, high software costs), the new administration will have to create a road map that will impose some standards and also still be flexible by having different flavors of the modernization plan.
The package that should be offered will offer different options for different models as shown below:

Small Size Practices

• The offering of a complete web based solution (PMS/EMR) that will eliminate having to make large IT hardware/software investment, and still allow the practice to have EHR. Which package is needed would be a another blog subject).
• An option for the practice to use an EMR package that has been certified and approved by a Healthcare body.
• Educate the practices of the advantages of medical data sharing.
• Strong financial incentives in form of tax breaks or grants to offset the costs of time spent in training, and other requirements to get the new system going.
• Appoint at the state level a body that does nothing but consult with the practices and make sure they are seeing the benefits of such a system.

Mid Size Practices

• Work with these groups and allow them to keep using their current systems to maintain their patient medical records. Since these are the groups that have long implemented successfully many of the EMR packages that are offered.
• Provide financial incentives if they choose to migrate to a new EMR package.
• Provide financial / technical assistance to interface these systems to a central data repository. Similar efforts have been seen working with RHIOs where there is a substantial amount of resources needed to accomplish this.

Community health systems and hospitals

• I think we can all agree here that based on many of the recent statistics that still a larger number of hospitals are using electronic health records. So, the need here would be to centralize or allow for data sharing with the central data repository.

The only thing that I would add is that the effort should be shared amongst government and non government entities. Many health groups have successfully implemented some sort of central data repository where information is being exchanged and shared. The government role should be to enforce the standards, and offer reward to those who take the initiative to get on board.