Around the Corner – Chapter 2

Posted on March 13, 2012 by Feik

It has been some time since my last post. A lot has happened.

It is now 2012. HIMSS has come and gone. The NPRM for Meaningful Use Phase 2 has been published. All of these have been blogged about many times.

A lot has happened for me too. I have started a new chapter. I am now with the Office of the National Coordinator (ONC) for Health IT. I joined in early February and have been learning the ropes in a new organization. I am certainly no stranger to ONC having met with folks there since the early days (before they called it ONC).

I have always been a strong believer that ONC will have a very powerful role, working with the private sector, in shaping the future of efficiencies in healthcare in the US. I have spent the last couple of years on the industry side of that equation. Now I get to sit across the table, still focused on the same end goal.

My new role is to co-lead the Standards & Interoperability (S&I) Framework Initiatives within ONC. The S&I Framework had its first birthday in January and it is well underway with over 450 committed members who represent 350 organizations.

For those of you who have not heard of S&I – what is it?

The S&I Framework is one approach adopted by ONC’s Office of Standards & Interoperability to fulfill its charge of enabling harmonized interoperability specifications to support national health outcomes and healthcare priorities, including Meaningful Use and the ongoing efforts to create better care, better population health and cost reduction through delivery improvements. The S&I Framework creates a forum – enabled by integrated functions, processes, and tools – where healthcare stakeholders can focus on solving real-world interoperability challenges.

Basically our charge is to make it easier for healthcare stakeholders to achieve higher levels of interoperability and greater levels of health information exchange. In the process, we are also making it easier to achieve  Meaningful Use.

My personal goal is to continue to move these efforts forward as Arien Malec and Jitin Asnaani have before me. I hope to be back here frequently updating the community with insights along the way.

Feik

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A Busy Year for Direct

Posted on December 23, 2011 by Feik

While I don’t want to call the year done before it is time, it seems appropriate to summarize some of the progress on the Direct project and our efforts in 2011.

January 2011 – The first Direct transaction in production happens between Hennepin County Medical Center and the Minnesota Department of Health.

February 2011 – Dr. Blumenthal holds a Direct Project Briefing in DC with Aneesh Chopra, Farzad Mostashari, Todd Park and others to highlight Direct project success in less than 12 months since inception.

March 2011 – Ket Industry stakeholders commit to supporting Direct in their products. These vendors represent >80% of EHRs and most of the HIEs and HIE vendors.

June 2011 – Minnesota Department of Health Certifies ABILITY as Minnesota’s first HDI supporting Direct.

July – Rhode Island Regional Extension Center certifies four HISPs in the Rhode Island marketplace.

August – WISHIN names ABILITY as state-wide Direct Messaging provider.

September – The NwHIN power team reports to the HIT Standards committee. The progress of the Direct project was cited as an important advance.

October – It is becoming clearer how important DIrect could be in enabling efficient transitions of care.

November – ONC holds annual grantee meeting and highlights Direct massaging as a core HIE service.

December – The Delaware Health Information Network (DHIN) names ABILITY as Direct Messaging provider. This service was live in two weeks.

It is also worth noting that the DirectTrust.org group is working hard on a multi stakeholder, industry wide collaborative who’s goal is to “foster stability, interoperability, and sustainability of Direct implementations across the country. By offering education and guidance for security and trust best practices for Direct exchange, we will help form and maintain a national trust framework and trust community that supports secure health data exchange over the Internet.

December is not over, in fact the volume of inquiries, projects, RFPs, etc. are higher than ever. It has been a very good year already. Lots of seeds have been planted and watered.

I am looking forward to 2012.

Feik

 

 

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The ONC Grantee meeting (part two)

Posted on December 5, 2011 by Feik

There were a lot of very good presentations at the ONC Grantee meeting. Most of the presentations from the Thursday session can be viewed here. They are individually webcast so you can pick the ones that you want to watch. The day ended with a rousing presentation by Aneesh Chopra. It is always fun to see the infectious enthusiasm spread through the room when Aneesh talks.

On Friday there were a number of breakout sessions. Many of them educational. I particularly liked the Direct 201 session lead by Ross Martin, Greg Chittim and John Hall. It was designed to bring folks up-to-date with the current state of the Direct Project in various implementations across the country.

I really liked this slide since it quite simply sums up the utility of Direct.

NewImage

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The ONC Grantee meeting

Posted on November 21, 2011 by Feik

ABILITY was invited to attend the ONC Annual Grantee meeting last week. The Annual Meeting brought together the awardees of all of ONC’s programs created through the Health Information Technology for Economic and Clinical Health Act. This included HIEs, RECs, and Beacon and Sharp grant awardees.

We were asked to “highlight the practical application of interoperable health information exchange” and we participated in a Technology Showcase that included interoperability demonstrations by federal partners and private organizations, along with demonstrations of health IT innovations being developed through the Office of the Chief Scientist.

We demonstrated the exchange of CCD documents between a user with a DirectABILITY address and a patient account on Microsoft HealthVault. The combination is quite powerful.

We also demonstrated how easy it is for a doctor to help a physician colleague get a direct address through our lock-box feature. Any DirectABILITY user can send an email from their Direct account to a colleague who may or may not have a Direct Address. He/She would send a message their regular email account. DirectABILITY would check to see if it is Direct address. If it found the digital certificate via DNS it would deliver the message. If it did not find a valid Direct address it would embargo the original message and send a notification to the inbox of the intended colleague. They click on a link in the message and will be given a choice. Either they indicate an existing Direct address (that we could not find) or they fill out the information to sign up for a new address.

It is a great way to help your trading partners to sign up for a new address.

Attendees at the conference were pleased.

In my next post I’ll review other findings from the Annual Meeting.

Feik

 

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DirectTrust.org

Posted on November 15, 2011 by Feik

How do I know if the HISP that wants to sell me services is playing by the rules?

How do I know that their certificates are compliant, should I trust them?

There are lots of vendors saying that they are Direct compatible, but how do I know?

The specifications are clear, the rules are posted but we need someone to mind the store.

Enter DirectTrust.org. This is a group of HIEs, Vendors, and Direct supporters that are focussed on making Direct a success.

Things are moving, fast, and in the right direction.

I remain quite hopeful.

Feik



 

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Rules of the Road – Why? (Part two)

Posted on November 11, 2011 by Feik

Part two: Another reason for having a uniform process for evaluating HISPs is just plain economics.

I have some examples:

ABILITY Network is now very active in three specific markets (we have activities in all states but these three are noteworthy); Minnesota, Wisconsin and Rhode Island.

In Minnesota the state has handled access to the market statutorily. If you are going to exchange Meaningful Use (MU) transactions you need to be a State certified provider. This requires a lengthly (50 pages or so) application, a public hearing, a review period, etc. Not bad because it protects local providers from fly-by-night vendors, but expensive (for both the state and the vendor).

In Wisconsin you need to be either the state HISP (WISHIN) or a WISHIN Bridge certified provider (which gives you a local blessing). Without this, you can offer HISP services but the likelihood of WISHIN (or others) “trusting” your HISP is open at this point. Certainly not desirable.

In Rhode Island the REC has set up a “marketplace” where HISP vendors have to be vetted to be allowed to participate. Again the purpose is to protect the provider from those that attest to one thing, but provide another. Texas has a similar process. All good.

We are too early in the NwHIN federal process to be a part of their governance process – which is not finalized yet. So what is a provider, or a vendor, or a State to do.

Each state could develop its own process as MN, RI (etc. TX) and WI have done – expensive. Each vendor could pursue certification in each state – expensive. Each provider could evaluate each vendor from scratch – expensive.

There should be a better way.

Several months ago a group called Rules of the Road (ROTR), seeing that this day was coming, formed a committee to try to set a playing field that States, Vendors and Providers could trust. That is now morphing into the DirectTrust.org group.

Things are moving quickly and positively and I am very encouraged. There are very positive advantages to this approach.

Stay tuned.

Feik

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Rules of the Road – Why?

Posted on November 8, 2011 by Feik

Not all endpoints are created equal.

Some are federal, some are patients, and some are providers. Members of the Federal Health Architecure (SSA, CDC, etc.) tend to have set the bar higher in terms of Identity Verification and Certificates. Most require certificates that are FBCA (Federal Bridge Certification Authority) compliant. The challenge is that this rigor comes at a cost. Not just a cost in testing, but a cost in per user licensing. It also has significant workflow complexities that have the potential to stifle adoption.

Out of these concerns, and frankly a concern that the bar needs to be set high enough to ensure privacy a working group was formed. They quickly (in healthcare terms) decided that there were really three sets of constituents. The patients, providers and federal endpoints. This resulted in the quote below (from ROTR).

Three communities of interest within Direct have been identified: the Direct Federal Community; the Direct Ecosystem Community; and, the Direct Citizen Community.

Each have different needs requirements, adoption characteristics and value propositions. Charting a course that preserves those notions, protects those user groups and doesn’t stifle adoption are some of the guiding principals that launched the ROTR.

For those that want more detail, I think that this link is quite useful (from David Kibbe).

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Rules of the Road -> DirectTrust

Posted on November 7, 2011 by Feik

Shortly after the first Direct pilot project went live in January, a group of dedicated Direct volunteers started discussing “How are we going to manage this in the wild?”

At some point ONC will finish rule making and introduce governance for NwHIN. In all likelihood this will include Exchange (Connect) and Direct. This will certainly regulate how Direct can be used to exchange with Federal agencies (i.e. VA, DOD, CMS, SSA, CDC). It will also likely involve use policies consistent with the FBCA (Federal Bridge Certification Authority) and certification with an federally endorsed body (ala CCHITT for EHRs).

In the meantime, the opportunities for Direct abound. While the standards for the protocol are detailed and done; how one implements, the processes for generating digital certificates, the processes of establishing trust, and how a HISP knows how to work with another HISP are still open issues.

Shortly after the the first Direct transaction this group of dedicated Direct volunteers, formed a group called Rules of the Road (ROTR). A sort of users guide for how to operationalize (is that a word?) Direct.

The next couple of posts, I plan to review where things were when the ROTR started, how they progressed, where they have landed (at least for now – DirectTrust).

Feik

 

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Transitions of Care

Posted on October 21, 2011 by Feik

Today the HIT Standards Committee reviewed results from the Privacy and Security Workgroup, listened to a thoughtful presentation by Doug Fridsma on the current status of work from the S&I Framework meetings and received an update on the use of Metadata in clinical exchange (aimed at increasing the efficacy of the exchange.)

In post, I plan to comment on the second presentation, the part of the S&I Framework meetings that focussed on the Transitions of Care Initiative. The purpose of this work (as stated by Doug) is:

The Transitions of Care (ToC) Initiative is focused on improving the electronic exchange of core clinical information among providers, patients, and other authorized entities in support of Meaningful Use and IOM-identified needs for improvement in the quality of care.

One of the hot buttons in health care today is the transition from one care setting to another. For example, the discharge of a patient from an acute setting to a skilled nursing facility. Making sure that this transition is as effective as possible has the potential to make the delivery of care more efficient and cost effective.

One of the ways to help is to make sure that the relevant clinical documentation is available to the receiving organization. This is true whether the receiving organization is a SNF, a primary care physician (PCP) or a specialist.

There are two somewhat diverging approaches. One could send everything they know about the patient. This would place a lot of burden on the receiving system to be able to represent ALL different kinds of data. In addition it would require a patients specialist or PCP to wade through reams of data that were not relevant to that treatment episode. Alternatively, one could send only the common information to the receiving doctor that are relevant to all care settings and the specifics that are important to that specialist.

The notion in the ToC initiative is to create “Templated CDAs” that contained relevant information but not all information.

TOC

This is an attempt to bridge the gap between the simplicity of a CCR and the flexibility and power of the CDA.

Can we create building blocks that become templates for clinical exchange. It has significant promise and the discussion was lively. This is an effort worth watching as it has significant potential to create new levels of interoperability with high utility.

Feik

 

 

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Rule Making

Posted on October 17, 2011 by Feik

It is interesting, at least to me, how much goes into the rule making process.

Let me digress for just a moment. In February 2009, Congress passed the American Recovery and Reinvestment Act (ARRA). Contained in ARRA is the Health Information Technology for Economic and Clinical Health Act (HITECH Act). HITECH contains incentives related to health care information technology and contains specific incentives designed to accelerate the adoption of electronic health record (EHR) systems among providers. These incentives were designed to be available to providers that adopted EHRs and put them to “Meaningful Use”.

Knowing that was not going to happen overnight, a framework was created that contains an escalating set of criteria that could be used to certify meaningful use. Three stages were adopted. Stage one has been in place for a while now, stage two is being defined. It is that process “being defined” that I wanted to write about.

The HITECH Act created in statue two Federal Advisory Committees, the HIT Policy Committee and the HIT Standards Committee. These groups advise the Office of the National Coordinator (ONC) and help them submit the details that become the rules that dictate Meaningful Use reimbursements.

On Friday, I attended the virtual meeting of the Privacy and Security Workgroup (one of six workgroups) of the HIT Standards Committee. This workgroup has sixteen members that represent payers, providers, IPAs, consumer groups, and standards bodies. This is not atypical, the Policy Committee has eleven subcommittees. In total, they represent about 250 volunteers to help create the details. I think that this is worth noting. Lest one think that big government is taking over, the facts show that this is involvement from you and I (and our counterparts), driving the process.

I find it noteworthy that these seventeen different committees usually meet monthly, and often have have homework in between sessions. Not including the homework, that is over 6,000 hours of volunteer labor helping to put guidance in place that ONC can use in creating the NPRMs (notice of proposed rule making) for meaningful use stage two.

In the meeting I attended, there was significant attention paid to:

  • the notion that rules needs to be measurable (can we quantify this)
  • the intent of a guidance (what to we really want to accomplish with this)
  • the possibility that there could be unintended consequences (unnecessary complexities for vendors implementing rules)
  • the difference between perfect and good enough (but not less than good enough)

It was impressive. I have confidence that the set of guidelines, and the resultant rules for stage two, will be balanced and help propel us towards more meaningful exchanges in healh care.

Feik

 

 


 

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