EHR Product Management

It has become politically incorrect to refer to EHRs as products. Instead, EHRs are now “technologies” as evident in all ONC and CMS published rules and regulations. This subtle change in terminology was intended to encourage, yes you guessed it, Innovation. It was supposed to signal an open market for alternatives to existing EHR products in the form of modular approaches, open platforms, mobile applications and web-based software-as-a-service. Naturally, the industry is obliging and all efforts now are geared towards creating stuff that runs on iPads, preferably “cloud” based and with minimal utility. The new stuff looks very cool and promises to become even cooler, so what’s the problem?

The problem is that these new things do not solve any problems. Traditional product innovation concentrated on identifying problems, designing solutions and then selecting technologies that were capable of enabling those solutions. New technologies were usually born out of the necessity to solve a burning problem and those with enough applicability to larger markets became blockbusters. Every frying-pan today sports technology first invented in the process of creating refrigerants and later used for nuclear destruction (Teflon). Every large enterprise embarking on cost cutting, new markets acquisition, or general improvements, should know all too well that selecting a “cool” technology first, and then attempting to find a good use for it, is recipe for failure. As a former good friend of mine used to say, “There are three types of companies: engineering driven, sales driven and successful”. Successful companies are market driven – they look for those needs and problems that people are willing to pay to have resolved. Very successful companies create their own new markets by creating new needs that people didn’t even know they had. Sometimes, during this process, new technologies are invented for the purpose of creating products that solve people’s problems. Customers usually buy products and services. Rarely, if ever, do they buy “technology”. Moreover, technology should be transparent to the user and really good technology should feel like magic.

Back to EHRs, we are now trying to convince physicians and hospitals to buy cutting edge EHR technology, some of which has not been invented just yet. We are asking them to buy open platforms, clouds, information networks and more recently search-engine optimized data architecture. And when they drag their feet in utter confusion, we label them Luddites and technophobes. Furthermore, those supposedly concentrating on the “next generation” of health care computer tools are designing them in deference to the same cutting edge technology requirements with almost no consideration for business process. And when the business model gets in the way of the chosen technology, then the business model must go. This is why you always find criticism of our “fragmented” mom-and-pop health care system and vilification of the fee-for-service model in most health care technology reports. We have moved from the pre-HITECH sales driven approach to EMR (with an M), to an engineering driven effort to increase EHR technology adoption. I would like to suggest a third option: the market driven Product Management route.

Forget about EHR and databases and servers and networks. What problems do physicians and hospitals face today? This of course is a huge question and the answer will vary based on many factors. Hospitals are different than individual physicians; large hospitals are nothing like small rural ones; physicians’ problems vary with specialty, practice location, practice type and time of day. But why start with providers? If this is a National discussion, shouldn’t we primarily consider what Government and consumers need? Unless you are aiming at selling something to the U.S. Government, or to individual patients, my answer would be a resounding, and unpopular, No. Of course, providers’ problems will be inextricably tied to constraints placed upon them by both Government and their own customers, but the paying customer for our imaginary Product is the provider, and as all other industries that we so eagerly want to copy, already know: The Customer is King.

At this point, you would go out and talk to your customers, potential customers and non-customers. Most existing provider surveys are asking people about barriers to EHR adoption and why providers would be interested in paying for an EHR. This is not a very “innovation fostering” approach. Considering the large spectrum of customers we are exploring here, if you asked an open-ended question about pressing problems, you would most often elicit two general responses: inadequacy of reimbursement and a perpetual desire to provide better care. These two overarching requirements translate into different things for different market segments. The reimbursement issue, for example, can be looked at in two ways. How do I get more money from payers? How do I cut my costs down so I decrease overhead and increase profit? Providing better care is an even larger subject and more controversial too. For a primary care doc, this could translate into a desire for more time with each patient. For a hospital, it could mean reducing complications. For both these examples, the computer would be required to actively do something that either consumes time now, or something that is so time consuming that it is not done at all. Writing for The Health Care Blog, Dr. Steve Sanders describes a very simple vision of how computers, integrated into operations, could reduce falls in hospitals by triggering well defined sequences of human actions. This is how computers are used in manufacturing and supply chain operations.

Identifying business problems and suggesting adequate solutions requires careful examination of workflows, identification of commonalities and opportunities and constraints posed by conflicting requirements and external factors. Then, and only then, comes the time to select, or build, technologies capable of supporting your customer’s business goals. In 2006, a computer scientist thought that putting medical records on mobile phones would be pretty cool. In 2009, Eric Schmidt had the same thought, this time involving a motorcycle trip to Mongolia. In 2011, someone else had a similar epiphany. It’s not catching on. Although, the concept is very cool, it is only incrementally cooler than flinging “Angry Birds” on your cell phone and nobody has been able to locate a market segment willing to pay for implementing this concept because “pay it forward” is not a viable business strategy.

How about National strategies? After all, introduction of computers into the health care system is now a centralized Federal enterprise. On the surface, Government’s goals are very similar to providers’ goals: cutting costs and improving care by measuring outcomes, with the added lofty goal of conducting research. There is, however, a “slight” problem here because Government’s costs translate into providers’ revenue and you will be hard pressed to find a paying customer interested in software that will decrease revenues. As to measuring outcomes, just imagine trying to sell people software tools that would allow the IRS to better and more intimately measure their tax liabilities. Not much of a market there. As to research, while everybody probably agrees that clinical research is worthwhile, very few businesses, in any industry, would volunteer funds and effort to advance national research initiatives with no immediate and tangible ROI to the business itself.

We have reached a fork in the road. Either EHRs are built and sold according to free market rules, with some Government oversight and regulation, or they become regulatory, Government mandated and Government designed tools, required to be purchased and used in prescribed ways as a condition of licensure to provide health care in this country. The latter option, which seems to be where we are headed, will add another painful customer problem in need of solving: minimizing Government intrusion. For savvy HIT Product Managers, it is time to formally design a solution and begin the search for the best technology to minimize the pain created by, the yet to be agreed upon, Government technology. HIT is now a self sustaining enterprise.

Comment on the PCAST Report

The public comment period for the PCAST report is now closed. Since those comments are public anyway, I thought I'd post here what I submitted to ONC (with minor formatting changes to fit the blog).

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This comment is not in response to the specific questions posed by ONC, which seem to presume a certain validity of the PCAST report. This comment is respectfully raising several basic questions, which in my opinion, the PCAST reports either did not address or circumvented. With this in mind, you may choose to continue reading, or not.

I would like to start by clarifying that I am now, and always have been, a strong proponent and supporter of appropriate computerization of medical records, HIT in general and the resulting opportunities for expanded clinical research. For the purpose of full disclosure, I have no financial or any other, interests in any HIT vendor.

1. Where does clinical data reside today?

• Providers - As we all know, there are massive amounts of paper based medical records residing within the walls of providers of all shapes and types. In addition to paper based records, there is a significant (and growing) amount of medical records maintained in electronic format by mostly large providers, but smaller ones as well. The vast majority of these records are created and stored in document format (scanned, dictated, typed, annotated, handwritten, transcribed, etc.). A small portion of this data is stored in structured format, mostly if not all, in relational databases. The most common discrete data elements are demographics, insurance details, diagnoses (ICD-9), procedures (CPT), vitals, and here and there lab results, immunizations, medications, some histories and relatively rarely, findings.
• Payers (including public ones) – Payer databases dwarf provider databases by orders of magnitude. Payer databases include demographic information collected whenever people enroll in a particular plan, which includes everything providers have and probably much more. Payer databases include every data element (structured) in an X12-837 EDI claim transaction, i.e. diagnoses (ICD-9), procedures (CPT) – including labs, imaging, immunizations, visits, treatments, hospitalizations, etc., places of service, durable medical equipment, extended care, home care, and through PBMs, all medications filled at pharmacies and billed to insurance. Payers do not have test results and imaging studies results.
• Laboratories and Imaging Centers – Everything payers lack is stored in the equally large databases of testing facilities and for most Lab results, the data is stored in structured format. According to the FTC, the two leading national reference labs (LabCorp and Quest) control approximately 89% of the market [1], which means that 89% percent of discrete lab results are maintained in structured format by two centralized authorities. Radiology and imaging studies are infinitely less centralized, although highly computerized as well.

2. How should clinical data be collected for clinical research?

• I don’t think anybody will disagree that it is much easier to extract data from a few centralized databases than it is to extract it from tens of thousands of smaller and diverse ones. The set of data elements contained in the union of payers, laboratories, radiology and imaging centers databases is lacking very little that can be provided from mining provider generated clinical data. As an aside, I would like to clarify that, contrary to common mythology, there should be no distinction between payers “billing codes” and provider maintained codified “problem lists”. If there is a discrepancy, it is either due to incompetency or plain fraud. Provider databases may contain longitudinal vital signs and perhaps more up to date allergies, smoking and drinking status. So why is the research effort concentrated on providers EHRs which, under best circumstances, are practically mirrors of already aggregated and analytics ready repositories?
• With very few exceptions, population level research data need not be available in real time and need not be extracted in milliseconds. While web crawling enabled technologies and infrastructures are very appealing, the cost of retrofitting every data repository with the means to bypass a Service Oriented Architecture (SOA) seems a bit unjustified and the benefits seem unclear to me in view of the multitude of algorithms continuously executing in payer databases with obvious benefits to that industry. As an additional note, I believe the report severely underestimates the costs to the industry to migrate to a web-based, data-element centric architecture, which will involve major changes to all payer, laboratory, pharmacy, clearinghouse, intermediaries, HIE, CDS, drug database providers, etc., in addition to the obvious impact on providers and their EHRs.

3. Does a browser based, research oriented infrastructure benefit health and health care?

• There is no question in my mind that a “universal language” for health care information exchange is necessary. Languages are composed of syntax and semantics.
• Syntax - There has been increasing agreement in the U.S. and other countries as well, that HL 7 v3, which is XML based, is capable of providing a universal syntax for data exchange either through messaging or through exchange of “documents”. Both messages and documents are based on extensible structures, with the added benefit that CDA is compatible with the needs of those who do not own and cannot process individual data elements. Those needs will be around for a very long time. Additionally, the CDA automatically provides context for all data elements it contains. One may argue that metadata tags can contain all contextual information required to recreate the CDA, in which case the question is why disaggregate the document in the first place? For illustration purposes, let’s assume that an MRI order is represented by a metadata tagged element. For a given physician, treating a given patient, seeing that an MRI was ordered sometime in the past is rather meaningless without the context of a progress note containing diagnoses, subjective and objective findings and perhaps other diagnostic tests. However, I can easily see a “measurement” being created from the proposed atomic data elements, to calculate all the MRIs ordered by Dr. X in a certain period of time. Dr. X would probably be rewarded or wrist-slapped if he ordered less-than/more-than the “norm”. Without the proper context this measurement would, of course, be meaningless. Obtaining the proper context would pretty much require the assembly of the CDA and application of appropriate logic to the query. This is a bit more complex than what a web-crawler is required to do.
• Semantics – Here too I believe the report underestimates the complexities involved in using multiple vocabularies, translated at the edges by some type of “middleware”. If you ever clicked on the “Translate this page” link in Google, or used an online translator to obtain a nice Latin quote, you should know that using arguments like “my middleware speaks more vocabularies than yours”[2 slide 6] cannot be taken seriously by anybody with any exposure to UMLS and SNOMED-CT.
• I have no doubt that creating a health care ecosystem based on atomic data elements is conducive to a plethora of research activities. Perhaps even clinical research. I am not certain though, that such activities will either improve health or reduce cost of health care. If you happened to read Dr. Gawande’s latest article[3], you should realize that health care is best AND most cost effectively delivered one patient at a time with very high-touch methodologies. Patient-centric was never meant to be interpreted as data-centric. Yes, computerized records can help tremendously, but I could not identify a single use case in the report that requires atomic data elements, or even benefits incrementally from such strategy.
• Both physicians and patients need to exchange meaningful information. I cannot identify with certainty one optimal way for such exchange. The Direct Project looks to me as very promising. However, if I may be allowed one more illustration, medical records are very similar to books, mostly collections of short stories. Patients and their primary care providers may want to have a copy of the entire book. Other providers may want a chapter or two, or even just an abstract, but nobody has any use for just words or sentences being moved across the wire. Most books do have an index, but that index serves as a pointer to contextual information. There can be no understanding without the context. If I say that my book contains an index to “death panels” which appears 50 times in the book, you still have no idea if this is a liberal book, a Tea Party manifesto, a history book about ancient tribunals, a critique of the NHS, or Mr. Boehner’s latest interview. Yes, we do know how to efficiently crawl around the web and aggregate billions of indexed locations with no particular context in mind, but just because we have a hammer…..

4. What is Government’s proper role in technology?
This is not about Meaningful Use, incentives, vision for a better future, or any lofty goals. This is about capriciously and arbitrarily influencing industries and markets.

• I do understand how technology serves manufacturing, retail and financial industries exceedingly well, but there is a reason why health care did not take the same path. As I wrote elsewhere, medicine is very different than other “industries” in that it lacks 100% repeatable processes. For example, the entire process of manufacturing, packaging, ordering, delivering, stocking and selling a box of Fruit Loops is exactly the same for every single Fruit Loops box. Automation of such process is easy. Unfortunately, people are not very similar to Fruit Loops boxes, and paradoxically, the lack of appeal and utility of current EHRs is in large part due to EHR designers thinking about Fruit Loops instead of the many ways in which people express pain and suffering. The legal industry is even less computerized than health care for the same exact reason. I do understand the frustration of technical folks and research oriented scholars with the slow adoption of HIT by physicians, but the answer is not to decree exactly how medicine should be practiced, and how it should be paid for, just so that it accommodates existing technologies, no matter how cutting edge their inventors seem to think those are.
• I am familiar with the various theories of innovation, disruptive innovation, fostering innovation, stifling innovation and all other derivatives of what has become a meaningless term. I don’t see how Government’s role extends to arbitrarily deciding that some products are “legacy” and others, yet to be invented are not, and to creating a “vibrant market of innovators”. “Vibrant market” should suffice. Is Government engaged in similar efforts in other “industries”, whether those are technically advanced or not? Yes, there is a host of incumbent technology vendors in HIT, and yes, they are well entrenched and getting more so as adoption rates are increasing, and yes, their products are well positioned for improvement. Has the Government decided that these vendors are unable to be “innovative”? Has anybody done a bit of “longitudinal” research on how products have changed in the last few years? I do understand there is significant private capital on the sidelines, waiting impatiently to enter the “market” [2 slide 3], but is it proper for the U.S. Government to “pave the way” by imposing new regulations on the industry, which may or may not be appropriate, just so that room is made for those who could not enter, or gain enough share of the market on merit alone? Is this what we now consider innovation?
• We will probably be better served if Government, or CMS, just defined what the outputs and inputs should be, what the rewards and penalties are, and let physicians, hospitals, HIT and the rest of the industry figure out how best to deliver. You would probably see some serious and true innovation right there.

Thank you for reading what has ballooned to 5 times what I intended it to be.

[1] http://www.ftc.gov/opa/2010/12/labcorp.shtm
[2] http://healthit.hhs.gov/portal/server.pt/gateway/PTARGS_0_0_8069_3354_21743_43/http%3B/wci-pubcontent/publish/onc/public_communities/_content/files/brieftooncworkgroup20110114.pdf
[3] http://www.newyorker.com/online/blogs/newsdesk/2011/01/atul-gawande-super-utilizers.html

That Which We Call a Rose

What’s in a name? Sometimes nothing much. Sometimes a shift in paradigm.

The Medical Record in its current format was created over a century ago by Dr. Henry Stanley Plummer at the Mayo Clinic. When in the course of human events the Medical Record began migrating from paper folders to computer files, the Institute Of Medicine naturally named the new invention Computer-based Patient Record System (CPRS). The Medical Records Institute chose the term Electronic Patient Record (EPR). Somewhere along the line the “patient” got dropped from the concept and the software used to compose and store medical records became known as Electronic Medical Record and the name EMR stuck.

As the EMR software evolved and started exhibiting rudimentary information exchange abilities and some semblance of “intelligence”, it was felt that a name change was in order. To differentiate the newer and smarter software from the original EMR, the term Electronic Health Record (EHR) was introduced and is now enthusiastically supported by the Federal Government. The term EHR is used in acts of Congress, rule makings from CMS and ONC and Presidential speeches. Since EMR has been around for quite some time, most industry veterans, as well as most doctors, are a bit confused about the new terminology. Is it EMR or is it EHR? Is it just semantics? Would an EMR by any other name smell as sweet (bitter)?

In a recent ONC blog, Peter Garrett and Joshua Seidman argue that there is a significant difference between EMR and EHR. The former is just “a digital version of the paper charts” and “not much better than a paper record”, while the latter is “designed to be accessed by all people involved in the patients care”, including patients, and generally “represents the ability to easily share medical information among stakeholders and to have a patient’s information follow him or her through the various modalities of care engaged by that individual”. This dramatic difference stems from replacing the word “Medical”, which implies disease, with the word “Health” which is “the general condition of the body”. Note that the word “Patient” is still absent. However, Health is supposedly from cradle to grave, while Medical is episodic in nature. Since, no matter what you call it, clinicians are the primary users of this software, would we say that doctors provide Medical Care or Health Care?

When we say that cost of Health Care is sky-rocketing, we don’t usually include costs for clean air, clean water, car seatbelts and gym memberships, and although we all know that an apple a day keeps the doctor away, the cost of apples is not included in our Health Care expenditures. To be sure, Medicine, “the science and art dealing with the maintenance of health and the prevention, alleviation, or cure of disease”, does include costs for direct prevention of specific diseases (immunizations) and efforts for early diagnosis of others (screenings). Historically, doctors, nurses and their less formally educated predecessors have been tending to the very sick. It is with this goal in mind that Dr. Plummer’s collaborative Medical record was created, and it is for this purpose that the American Academy of Pediatrics advocated for a Medical home for sick children, and it is Medical care for the sick which the EMR attempted to facilitate, one patient at a time. The EHR represents quite a different philosophy and places new and expanded responsibilities on the Medical profession.

The EHR is intended to serve the healthy as well as the sick, and the President’s vision is that every American should have one, whether that particular American is healthy or not. The ONC vision, shared by many innovators in the field, is that “EHRs focus on the total health of the patient—going beyond standard clinical data collected in the provider’s office and inclusive of a broader view on a patient’s care”. That broader view will presumably include lifestyle habits, diet and exercise and everything one may wish to record which pertains to one’s general health status. If and when a person becomes ill and is transformed into a patient, the various clinicians and care providers will contribute their documentation to the EHR, and since EHRs are easily shareable, all Medical care will be coordinated through the EHR and collaboration will flourish, as it should. This sounds almost exactly the same as what a Personal Health Record (PHR) is supposed to be. Is an EHR really a PHR?

No. EHRs include one feature that is not possible in a PHR: the ability to aggregate individual patients into populations. When physicians write introspectively about their work, you usually find stories about this or that particular patient, pondering whether they did too much for the 90-year-old Alzheimer’s victim, or too little for the misdiagnosed 40-year-old ovarian cancer patient. They talk about emotions, or lack thereof, about small victories and exasperatingly “non-compliant” middle aged executives who should know better. Each story has a patient with a name, physical details and most often character description. For those inclined to self-assessment, the day-in and day-out tally of these personal episodes is the decisive yardstick. When people recommend a doctor to a friend, they usually talk about “nobody could figure out what was wrong with Katie; he took one look at her and knew right away” or “you can get in today or tomorrow and she is so nice and patient ; always takes my phone calls and you know I can be a pain (giggle)” or “when Adam had that knee problem, he fixed it like magic and he did surgery on cousin Joe’s shoulder; as good as new, and I think he takes care of the Cardinals too; he is definitely the best in town”.

This unscientific, anecdotal method of both performing and assessing one’s work will be replaced by the broader view of EHR enabled population indicators and considerations. Instead of dealing with Mr. Wilson’s gout and Mrs. Wilson’s incontinence, you are now the keeper of the Health of Populations. The EHR can tell you that half of your under 40 patients are obese and doing absolutely nothing about it. You, or your team, will need to intervene because an ounce of prevention today will lead to healthier lives for this population, and lower costs for society. While managing Mrs. Wilson’s neuropathy is important (especially to Mrs. Wilson), having your population of 300 diabetics controlled within acceptable cost effective parameters will become the main focus of your practice. EHRs will provide you with the intelligence (information) to manage your numbers and with ongoing measurements to assess your performance against goals, and EHRs will continuously collect data for ground-breaking research and more effective recommendations.

EHRs, as imperfect, ineffective and downright primitive, as they are today may be our first glimpse of a future where curing or treating disease is largely a thing of the past. If populations are proactively managed and everybody gets their shots and recommended genetic therapy, or whatever they will come up with next, Medical care will be limited to trauma and exotic ailments that have not been researched just yet. While our generation will not be crossing the River into the Promised Land of perpetual Health, it is up to us to manage this transition so human dignity is preserved and collateral damage is minimized in the process of industrializing medicine, a process which starts with changing the M in EMR to the H in EHR.

Failure is Not an Option

2010 is drawing to an end amongst a flurry of activities in the Health IT field. In a few short days 2011, the year of the Meaningful Use, will be upon us and the stimulus clocks will start ticking furiously. In addition to the yearlong visionary activities from ONC, December 2010 brought us two landmark opinions on the future of medical informatics. The first report, from the President’s Council of Advisors on Science and Technology (PCAST), recommended the creation of a brand new extensible universal health language, along with accelerated and increased government spending on Health IT. Exact dollar amounts were not specified. The second report from the Institute of Medicine (IOM) is a preliminary summary of a three-part workshop conducted by the Roundtable on Value & Science-Driven Health Care with support from ONC, and titled “Digital Infrastructure for the Learning Health System: The Foundation for Continuous Improvement in Health and Health Care”. The IOM report, which incorporates the PCAST recommendations by reference, is breath taking in its vision of an Ultra-Large-System (ULS) consisting of a smart health grid spanning the globe, collecting and exchanging clinical (and non-clinical) data in real-time. Similar to PCAST, the IOM report focuses on the massive research opportunities inherent in such global infrastructure, and like the PCAST report, the IOM summary makes no attempt to estimate costs.

Make no mistake, the IOM vision of a Global Health Grid is equal in magnitude to John Kennedy’s quest for “landing a man on the moon and returning him safely to the earth” and may prove to be infinitely more beneficial to humanity than the Apollo missions were. However, right now, Houston, we’ve had a problem here:

1. The nation spent upwards of $2.5 trillion on medical services this year
2. Over 58 million Americans are poor enough to qualify for Medicaid 
3. Over 46 million Americans are old enough to qualify for Medicare 
4. Another 50 million residents are without any health insurance
5. The unemployment rate is at 9.8% with an additional 7.2% underemployed
6. This year’s federal deficit is over $1.3 trillion and the national debt is at $13.9 trillion

In all fairness, the recent Federal investments in Health IT were spurred by the HITECH Act, which was a part of the ARRA, a recession stimulus bill aimed at injecting money into an ailing economy and creating jobs, while improving national infrastructure. It was not explicitly intended to reduce health care costs or improve access and affordability (that came later with PPACA). Perhaps adding an EHR to every doctor’s office was viewed as the first step towards building the Learning Health System. However, somewhere along the road to fame EHRs were magically endowed with powers to provide patients “with improved quality and safety, more efficient care and better outcomes”. Perhaps these claims came from EHR vendors’ glossy marketing collateral, or perhaps it was just wishful thinking, or perhaps this was a forward looking statement for the fully operational grid of a Learning Health System, or maybe this is just incorrect use of terminology. Health IT is much more than EHRs and Health IT can indeed help improve efficiency, i.e. cut costs, in several ways.

Administrative Simplifications

Section 1104 of the PPACA contains a roadmap for administrative simplifications “to reduce the clerical burden on patients, health care providers, and health plans”. Eligibility transactions must be standardized and deployed by 2012, electronic payments by 2014 and claims, certifications and authorizations by 2016. Physicians spend about 14% of revenue on billing and insurance related functions, while hospitals spend 7% - 11% and health plans spend around 8%, not to mention the aggravation involved. Why do we have to wait 6 years before this particularly wasteful activity is completely addressed? If there is a place where health care can learn from other industries, this is the one. Both the banking and retail industries have solved this problem many years ago. It is trivial to imagine swiping a magnetic card at the doctor’s office to verify eligibility, obtain authorization, and exact dollar amounts for patient responsibility, while initiating a real time payment transaction from insurer to provider. The complexities of a thousand different plans can be easily accommodated by computer algorithms and the technology is available in every supermarket and every gas station. For all those joining Congress in 2011 with the intent of altering PPACA, could we alter Section 1104 and shorten the timeline by a few years?

Fraud

The National Health Care Anti-Fraud Association estimates the costs of health care fraud to be 3% to 10% of expenditures. Despite all the publicity, credit card fraud is estimated to cost 7 cents per each $100 in transactions, or 0.07%, with issue resolution times estimated at 21 hours. This is yet another lesson health care can learn from the financial industry. Granted, purchase patterns in health care are different than the market at large, so the anti-fraud algorithms will need to be tweaked and specialized. Computers are very good at this and from watching the President’s bi-partisan meeting on health care reform last year, I thought this is one area where everybody agrees that something needs to be done. There is nothing tangible in PPACA regarding the use of Health IT for fraud reduction.

Duplication of Tests

If you prescribe electronically through Surescripts, you can see a patient’s medications list courtesy of the PBM. PBMs and insurers know exactly what medications they paid for. They also know exactly what procedures, tests and visits they paid for, and who performed them. Would it be a huge stretch of imagination to envision a display of the last 6 months of tests paid by the insurer every time you attempt to order a test? No, insurers don’t have the results, but if you saw that the patient had an MRI last week, would you order another one today? Or would you call the facility for a copy? When you prescribe electronically, the PBM insists on showing you the formulary and drug price for the individual patient. Why not show you prices for the tests you are about to order, and help you and the patient choose lower priced facilities, just like they steer folks to prescribe generics? This has nothing to do with clinical decision support or changing the way medicine is practiced. These are examples of very simple, common-sense, immediate solutions for reigning in costs without disturbing quality of care.

The Global Learning Health System presents a compelling vision. I wish that the President would commission the necessary budget estimations, go before Congress and in a JFK style oration request appropriations for defeating Cancer (or some other scary thing), appropriations which will include funding for the Learning Health System global grid. It is possible that if such Learning Health System existed today, or could be quickly deployed, it would provide solutions for most health care problems we currently have. However, it is pretty clear that such a system will take many years and many billions of dollars to build. In the meantime we have an immediate problem, which requires an immediate solution with immediately available tools, and no, failure is still not an option.

Health IT and the Carob Tree

At a certain point in time, somewhere in America, someone stated that people should all have lifetime, complete medical records. Sounds reasonable and I presume nobody ever asked, “Why?” As time goes by and health care services in America are approaching an unsustainable 18% GDP, the mythical lifetime record is quickly becoming panacea to the obvious problem health care has become. Americans accustomed to thinking about their health care as “the best in the world” are now being instructed that American health care is fraught with errors, needless deaths, unsafe treatments, uninformed physicians, unsanitary hospitals and basically stuck in the stone age of technology. And all this while sucking inordinate amounts of cash from simple-minded folks who have “no skin in the game” and thus completely oblivious to being robbed, bankrupted, maimed and killed by greedy health care providers and industry financiers. Don’t know about anybody else, but I am positively terrified... mortified... petrified... stupefied... by this.

Enter the aforementioned lifetime health record, a.k.a. “EHR for every American by 2014”.  EHR in this context denotes collections of information or data, not a software product. Instead of overstuffed manila folders and oversized yellow envelopes, each one of us will have a complete electronic dossier, stored somewhere TBD later, chock full of every lab result and imaging study we ever had, all blood pressure, weight, height, temperature, etc. ever taken, all pre-op, post-op, consultation and progress notes ever written, all diagnoses and medications, all cuts and bruises, all chief complaints and histories and all treatment plans that we followed and even those that we did not. When our EHR is ready for use, doctors will be making fewer errors, order fewer unnecessary tests, make more informed decisions, prescribe safer treatments and charge less money for more thorough work. Well, maybe the last one is a bit of a stretch….

Problem #1: Do we really need a comprehensive lifetime health record? Here and there, particularly for small children with chronic conditions, such record will be clinically meaningful. For the vast majority of Americans, a lifetime EHR may be a cute thing to have but not really a necessity. One may need records for recent years if managing chronic disease or battling a potentially fatal diagnosis, but for everybody else, including the exotic case of someone ending up in the ER unconscious, buck naked and all alone, the most you will need is a brief summary of vital information. So if we don’t need our pre-school growth charts and we don’t need an itemized litany of every URI we ever had, every story we told our doctor and every “RRR, normal S1, S2 and without murmur, gallop, or rub” ever recorded, what is it that we do need? I guess a reasonably healthy 40-year-old could derive some joy from perusing his comprehensive lifetime record – “Look honey, that awful cold I had in the winter of 87’ when we went skiing for the first time was really pneumonia. No wonder I broke my leg the next day… It’s all here. Isn’t this great?”  When the same 40-year-old goes to see his new family doc the next day for persistent “heartburn”, his 87’ adventure would be largely irrelevant, and if he ends up unconscious and naked at the ED that night, they may be interested in his recent “heartburn”, but still have no use for information on his hapless skiing vacation 23 years ago.

As Dr. David Kibbe aptly observed, what we, or our health care providers need, very much depends on the context. Defining a relevant superset of information should of course be left to practicing physicians, but if I had to define such superset, I would go with immunizations, problem list and medications (current, with option to view historical), allergies, a couple of years of lab results and imaging studies (longer for certain studies), standard major medical and family histories and for chronic or serious conditions, the last few physician notes. Interestingly enough, these data elements are already being captured in structured and codified manner by most currently available technologies. If money were no object, I don’t see a downside to cataloging and retaining every tiny piece of information, provided that it can be contextually filtered for different circumstances. But judging by the billions of dollars being spent on HIT, money is a very big object indeed and either way, those who care for unconscious, naked people presenting at the ED in the middle of the night, should not be expected to peruse lifetime records.

Problem #2: How do we get access to either comprehensive or contextually appropriate information? As we all know, our “fragmented” health care system is nothing but a collection of data “silos” maintained mainly on paper under lock and key by greedy providers, no doubt purposely so in order to maintain a competitive advantage in a brutal health care market where an overabundance of physicians are fiercely competing for an ever dwindling number of patients . Or maybe not…. Perhaps traffic of clinical information has been severely hampered by that one antiquated oath physicians still take which commands doctors to keep patient information downright secret. Either way, since in most instances people are treated by multiple providers, medical information must be shared between providers and certainly must be available to patients electronically (faxing, copying and phone calls are so uncool). Unfortunately, we don’t have a national healthcare system where all providers are employed by one entity, conform to one set of policies, use one technology platform and clinical data is easily shared. We do, however, have a few “look alike” entities such as Kaiser and the VA. Why not do away with the remaining “fragments” and consolidate our health care in a handful (a single one would be too Socialist) of fully integrated systems? It would certainly simplify things for HIT grand-designers and programmers.

The financial system, our beacon of informatics wisdom, has resolved this pesky problem long ago, as evident in the world-spanning network of ATMs, where card carrying customers with unique identifiers can exchange several bytes of information with their remote financial institution. For those desiring comprehensive financial records, there is Yodlee and Mint, which will aggregate all your financial accounts in one cloud based dashboard free of charge (any takers?). Strangely enough this hallmark interoperability accomplishment did not require federal funding, government committees or a compulsory “universal financial language” (arithmetic seldom does). One can never be certain, but it is possible that financial IT experts were less obsessed with fostering/stifling innovation and more concerned with providing pragmatic solutions to real problems without requiring that banks change the way “financial services are delivered” or that smaller banks cease to exist in order to simplify software programming.

Problem #3: Should we plant a carob tree? Legend has it that carob trees require 70 years to reach maturity and bear fruit (more like 7 really), thus planting a carob tree is a selfless act to benefit posterity. There is a remarkable disconnect between the voice of physicians who treat twenty, thirty patients every day, one patient at a time, and physicians in the academia and those in “leadership” roles who routinely converse about population health, bio-surveillance and clinical research. Doctors who make a living by touching patients today, not tomorrow and not after Meaningful Use Stage 5 has been achieved, usually find that an EHR has very little to contribute to the quality of care they deliver to the one patient in front of them. Health IT is promising them a paperless future, devoid of software and hardware both, where every metadata tagged digital piece of information about their patient is “a click of a button” away. Health care delivery will become well informed, efficient and flawless to the point that the patient may not even need to be “seen” in order to be treated. Magically frightening? No; just futuristic technology which may come to fruition in, say, 70 years. Perhaps EHRs are our carob trees.

Moral: If you insist on planting nothing but carob trees, you will starve to death and there will be no one left to enjoy the fruits of the carob tree.

Thoughts on the PCAST Report

The President’s Council of Advisors on Science and Technology (PCAST) released a report this month ambitiously titled “REALIZING THE FULL POTENTIAL OF HEALTH INFORMATION TECHNOLOGY TO IMPROVE HEALTHCARE FOR AMERICANS: THE PATH FORWARD”, complete with current state of HIT analysis and authoritative recommendations to ONC, CMS and HHS on how to proceed going forward. Initially, I skimmed through the 90 pages of the report and very much liked what I saw. PCAST is recommending a federated model for health information, with medical records stored where they are created and a comprehensive view aggregated on the fly on an as-needed basis by authorized users, including patients and their families. PCAST is urging ONC to significantly accelerate efforts in this direction.  Perfect. And then I took a deeper dive into the details of the report, and disappointingly came across a series of misconceptions and questionable assumptions surrounding what is basically a very good, albeit expensive, strategy.

The State of Affairs

The classic opening to all HIT reports seems to be the obligatory comparison to “other industries”: “Information technology, along with associated managerial and organizational changes, has brought substantial productivity gains to manufacturing, retailing, and many other industries. Healthcare is poised to make a similar transition, but some basic changes in approach are needed to realize the potential of healthcare IT”. While this is true, we should also recognize that medicine is very different than other “industries” in that it lacks 100% repeatable processes. For example, the entire process of manufacturing, packaging, ordering, delivering, stocking and selling a box of Fruit Loops is exactly the same for every single Fruit Loops box. Automation of such process is easy. Unfortunately, people are not very similar to Fruit Loops boxes, and paradoxically, the lack of appeal and utility of current EHRs is in large part due to EHR designers thinking about Fruit Loops instead of the many ways in which people express Severity or Location.

The PCAST report continues with the common mantra regarding our “fragmented” health care system and the fee-for-service model which is preventing the availability of complete health information at the point of care and the advantages of larger health systems which, unlike small practices, “have an incentive to provide care efficiently and reduce duplication or extraneous services when possible”. They must be referring to Integrated Delivery Systems (IDN), since large hospitals and multi-specialty groups have many incentives, but reducing extraneous services is not one of them and if there is an entity which lives or dies by achieving efficiency, it is the solo or small practice operating on abysmal margins. Either way, we need technology recommendations for an existing health care system, not so much for some utopian system were payers and providers cheerfully align their interests with patients and tax payers in general.

Legacy and Condensed Water Vapors

Unsurprisingly the overarching thread in the report is describing current EHR systems as “legacy” systems, which will eventually become obsolete and make room for “innovative” technologies delivered via the Clouds. I can see how using centrally deployed and managed applications (not really a new concept) can be easier and more cost effective for most providers, but does the software have to reside in a vendor datacenter in order to qualify for a “no more software” stamp of approval? Would the many Epic installations accessed remotely by physicians qualify as Clouds? Or must they be deployed in an Epic owned datacenter, and be natively browser based, in order for the software to mysteriously vanish? Or perhaps Epic is too large and thus too heavy to ascend to the clouds? Epic, the fastest selling EHR system in the country, is a “legacy” product built on the 1960s MUMPS programming language, and so is VistA, the Veterans Affairs (VA) EMR, which seems to be a physicians’ all-time favorite. Perhaps the European Space Agency knows something we don’t, since they are taking MUMPS straight through the clouds and all the way up into outer space to map the Milky Way Galaxy.

After affixing the “legacy” label on the EHR industry incumbents, the PCAST report repeatedly emphasizes the government’s role in creating a “vibrant market of innovators”, particularly the “disruptive” type, citing the example of ARRA incentives leading to “substantial innovation and competition” and “more affordable systems and improved products”. This is pure fantasy. Some of the smaller, previously most affordable, EHRs have been forced to double their prices in order to comply with regulations. Most of the larger (legacy?) products have maintained their pre-ARRA pricing, or increased them. And then there are the literally all cloud, and no software to speak of, vendors, who preyed on physicians before ARRA and are continuing to do so after. It seems that Apple and its iTunes App Store has created the illusion that any kid with a completed “Programming for Dummies” curriculum can whip up a useful clinical decision support application in a couple of weeks, sell it on the App Store for $0.99 and help us all get healthy, if we would only give him access to mountains of personal medical records.

Privacy or Lack Thereof

The beauty of the PCAST recommended solution for health information exchange (details below) is that privacy preferences are built into each data element. Anyone attempting to access personal health information would be required to authenticate and validate that the patient’s privacy policy allows access to the requested data element. Moreover, all data will be encrypted both at rest and in transit between users, thus barring all intermediaries from reading or storing any personal information. Rock solid plan; that is until you run into this statement: “It seems likely that the modifications to HIPAA enacted in Subtitle D of the HITECH Act—in particular those that require covered entities to track all disclosures to associates—will further stifle innovation in the health IT field while offering little additional real-world privacy protection”. The PCAST authors seem to dislike the idea of tracking disclosures of personal health information.  Somehow, uninhibited disclosure (or outright wholesale) of patients’ private information to “associates” is a necessary condition for “innovation”. Makes you wonder what exactly is meant by “innovation”.

The Grand Solution

Let me say this again. I love the distributed data concept at the heart of PCAST’s recommendations. No big databases in the sky here. All the pieces of one’s medical record are housed by the institution that created each piece. When someone needs access to a record, or part of a record, an authorized query is issued (think Google search) and the requested information is located and aggregated across multiple data stores and displayed on the requestor’s computer screen (think Google again). The mechanism to achieve such wondrous task is by and large the same one Google uses, with added layers of security and privacy. These tools are dubbed "data element access services (DEAS)" which are nothing more than customized search engines for health information, maintained and operated by large health systems or purposefully built entities. As is the case with Google search, medical records will need to be indexed if the DEAS are going to find them. For this purpose, PCAST suggests “a universal extensible language for the exchange of health information based on “metadata-tagged data elements””. In plain English, medical records will be broken into atomic data elements, each having attached information describing the element (patient identifiers, what it is, when recorded, how, by whom, etc.) and most importantly who can access it (patient directed privacy rules). The search engines will presumably use these metadata tags to locate actual data elements, without ever needing to read the data itself, and return the results to the querying user. Of course, there are more questions than answers at this point, and some interesting discussions too, but the general concept is sound and very innovative.

Beware the Legacy Giants

While PCAST was deliberating and formulating its recommendations, at least one “legacy” EHR vendor was implementing the solution. During its user conference in October, Cerner unveiled “Chart Search”, which is a semantic search engine using Natural Language Processing (NLP) and a specific ontology to allow users to intelligently search a patient’s chart. As in PCAST’s recommendations, Cerner is indexing all medical records and is storing the indices in its own datacenter (cloud). The use of NLP and clinical terminologies, such as SNOMED, allows Cerner to perform contextual searches by concepts (searching for beta-blocker will return all occurrences of Atenolol, Metoprolol, etc.) and rank the most clinically pertinent results on top. You can view a very brief presentation of this feature, shown by my favorite family doc, Dr. Karl Kochendorfer, here. The Cerner semantic search is different than PCAST’s recommended solution in many ways and of course, right now it is limited to Cerner charts in one physical location, but it is real and currently used by actual physicians. Looks like those old “legacy” giants are still packing some punch after all.

In summary, PCAST’s basic concept of where HIT should be headed is very appealing and properly ambitious. The serious considerations given to privacy, security and patient preferences are refreshing, but in order to support the fascinating research agenda proposed in the report, government will at some point need to step in and curb the enthusiasm of Cloud owners, severely curtailing the commerce of medical records. I would have preferred that PCAST refrained from the fashionable and rather baseless assumptions on how innovation occurs and the equally worn-out subtle advocacy for unproven changes to our health care delivery system. Other than that, very interesting report.

Full disclosure: I have no financial interests in Epic, Cerner or any other EHR vendor

Selecting an EHR for the Patient Centered Medical Home

The conceptual definition of a Patient Centered Medical Home (PCMH) speaks of a physician directed medical practice, oriented to the whole person, where patients have enhanced access to a personal physician and care is coordinated and integrated focusing on quality and safety, nothing more and nothing less, other than appropriate payment to physicians for all activities.

Since concepts are rarely enough, the National Committee for Quality Assurance (NCQA) took it upon itself to provide concrete requirements and formal certification for medical practices desirous of being recognized as Patient Centered Medical Homes. The NCQA PCMH definition consists of nine Standards used to score the practice. This is NCQA’s attempt at translating the original PCMH concept into measurable activities and here is where Health Information Technologies (HIT) and EHR in particular, are formally associated with the PCMH concept. Conspicuously absent from the NCQA standard are the “personal physician” and unless you consider the assessment of language barriers sufficient, so is the “whole person orientation". Most NCQA PCMH elements are geared towards data collection, data analysis, tracking and reporting. Theoretically, you could earn NCQA PCMH designation without an EHR, but the amount of typing, writing, filing and calculating would easily consume your entire day. If you are serious about PCMH designation, you will need an EHR. But which one should you get? Are some technologies better than others for PCMH purposes?

Unfortunately, no one is trying to answer these questions and perhaps this is one of the reasons for the initial mixed results observed in PCMH implementations. The HITECH Act put in motion a monumental rush towards Meaningful Use and associated financial incentives. The Patient Protection and Affordable Care Act (ACA) is initiating another rush, this time towards new payment models and PCMH seems to be at the heart of all innovations. So what should we do first, buy HIT and become Meaningful Users, or transform our practices into an NCQA PCMH? Some would say, let’s do both and others, mostly primary care physicians in small private practice, would say, let’s do neither. In reality, Meaningful Use trumps PCMH right now, since it has hard due-dates and specific dollar amounts associated with it. Moreover, the pervasive opinion amongst PCMH consultants (yes, they have those already) is to get the HIT part over with, before engaging in the complex PCMH "culture transformation". And this is yet another recipe for failure, driven by tactical instant gratification needs and inability to take the time necessary for formulating long term strategies.

Suppose you decide to build a tree-house for your kids. Since you’re a doctor, not a carpenter, what do you do next? You could go on the Internet and figure out what tools and materials you need, measure the big old oak tree in the backyard, talk to the neighbor that just built one and make a list of stuff you would need to buy for the project. Or you could just get in the car and rush to Home Depot because they have a holiday sale on hammers & nails and buy a truckload of random tools and lumber. If you pick the latter route, chances are most of what you bought will be rotting in your garage and the kids will be playing in the neighbor’s tree-house. Similarly, if you want to build a PCMH and randomly purchase some EHR tool just because the Government is giving out rebates and vendors have fire sales, chances are your PCMH will never take off successfully. Below is a list of NCQA PCMH standards and things you need to consider when shopping for an EHR with the goal of eventually obtaining NCQA PCMH recognition (items marked with ** are mandatory).

Standard 1: Access and Communication

1. Has written standards for patient access and patient communication** - An EHR won’t help you write the standards, but it will help you implement them. You should have a scheduler that enables you to easily set aside times for open schedule, allows creation of global scheduling templates and gives you the ability to define your own appointment types, including web visits and email encounters. The EHR should also have the ability to create encounter notes without an appointment and/or a physical office visit.
2. Uses data to show it meets its standards for patient access and communication** - The EHR should have built-in capabilities to report on aggregate schedules and be able to account for email communications and web visits in one comprehensive report.

Standard 2: Patient Tracking and Registry Functions

1. Uses data system for basic patient information (mostly non-clinical data) – Any good Practice Management System will do here.
2. Has clinical data system with clinical data in searchable data fields – This is your Registry. Querying the Registry should be flexible and allow multiple parameters (e.g. all diabetics taking drug A, but not drug B, with A1c in a certain range, who also have a Dx of HTN and have not been seen in 6 months), but should not require that you have a degree in applied mathematics to use it. The quality of registries in EHRs varies wildly. Make sure the reports look clear, that all columns are sortable and that the reports are actionable (i.e. clicking on a data element will allow you to do something about it right then and there, instead of having to print the report out and search for each patient).
3. Uses the clinical data system – If you have that nice Registry, you would probably use it. For this element and the next two, the Registry should be able to report on itself (i.e. how many queries were run in a certain time period – an audit log is not sufficient).
4. Uses paper or electronic-based charting tools to organize clinical information** - Same as above.
5. Uses data to identify important diagnoses and conditions in practice** - Same as above.
6. Generates lists of patients and reminds patients and clinicians of services needed (population management) – With a good and actionable Registry, sending reminders out to patients should be easy, but you need to verify that the functionality to send bulk reminders (by email, phone or mail merge) is there and it defaults to recorded patient preferences for communications.

Standard 3: Care Management

1. Adopts and implements evidence-based guidelines for three conditions ** - The EHR should come with built in clinical decision support from a reputable source, such as USPSTF and this should be updated by the vendor on a regular basis. It should also come with clinical documentation templates, care plans and order sets preconfigured based on equally reputable guidelines. Be sure to ask about it and verify that it is actually as the vendor claims it to be.
2. Generates reminders about preventive services for clinicians – The Registry should be able to be queried automatically in scheduled batch mode for all patients and it should also allow customized configuration to display overdue services when a chart is accessed (you don’t want pop-ups here – a gentle, but bold, reminder on the page itself should suffice).
3. Uses non-physician staff to manage patient care – Every decent EHR will allow you to do this, but it would be nice if the EHR recorded the user who enters data into the various portions of the chart (not just an audit log, but visible indication that nurse A took the vitals).
4. Conducts care management, including care plans, assessing progress, addressing barriers – The EHR should come with preconfigured, evidence-based and fully customizable care plans. It should also have a place to enter goals and subsequently calculate adherence to those goals. This is where you want the longitudinal display, particularly useful for chronic disease management.
5. Coordinates care//follow-up for patients who receive care in inpatient and outpatient facilities – This will probably be done by phone & fax for a while longer, but your EHR should have capabilities to interface with hospitals and other providers. Some of the larger vendors have the ability to exchange information within networks of their own customers, and all vendors will eventually have to play nice. I know this is not a popular view, but for interoperability with multiple complex sources, the bigger the vendor, the more capabilities it has.

Standard 4: Patient Self-Management Support

1. Assesses language preference and other communication barriers – All the EHR has to have is a place for you to document language, translator and health literacy status. It would be best if these were structured data fields, because sooner or later, they will require you to report on these things.
2. Actively supports patient self-management** - In addition to your goal oriented care plans and registries, you should have a quality Patient Portal where you can make all this information, along with education materials, available to the patient and his/her family. While most EHRs have Patient Portals now, you need to make sure that they are not just a web page for patients to pay bills and request refills. Whether your patients will use the Portal, or not, is a completely different question.

Standard 5: Electronic Prescribing

1. Uses electronic system to write prescriptions – An EHR certified to work with Surescripts is necessary for Meaningful Use. Here you just need to make sure that the EHR is not just certified by ONC, but also appears on Surescripts’ website and this feature is operational (not all are).
2. Has electronic prescription writer with safety checks – This is also a Meaningful Use requirement, but it won’t hurt to find out if the EHR uses a reputable source for drug and allergy alerts, such as First Data Bank, Medispan or Multum.
3. Has electronic prescription writer with cost checks – Again, check the Surescripts website to make sure that the EHR is certified for Formulary checks (not just sending prescriptions electronically).

Standard 6: Test Tracking

1. Tracks tests and identifies abnormal results systematically** - A nice dashboard, with sortable columns and color coded abnormal indicators should be standard in any EHR you are considering. This should also be actionable with respect to being able to sign-off and inform patients and staff on further actions right from the dashboard.
2. Uses electronic systems to order and retrieve tests and flag duplicate tests – This is the dreaded CPOE. Note that it requires additional intelligence in checking to see if the tests you are about to order are duplicative. This is not a simple task and very few ambulatory EHRs have this feature. Choose with care and beware the endless stream of possible alerts.

Standard 7: Referral Tracking

1. Tracks referrals using paper-based or electronic system** - Many EHRs will allow you to fax referrals from the application. Some will allow electronic transmission to providers using the same EHR or will have interfaces to hospital systems for transition of care. The upcoming Direct Project standards may facilitate this functionality. You should inquire about the EHR vendor’s plans, and capabilities to support implementation of emerging standards at short notice.

Standard 8: Performance Reporting and Improvement

1. Measures clinical and/or service performance by physician or across the practice** - If you have that nice Registry discussed above, you should be able to run any reports you want by physician, by date, by patient group, by practice, by specialty, by insurer, etc.
2. Survey of patients’ care experience – Although, you could do this on paper at check-out, this should be an option on your Patient Portal, which will allow you to measure and report results.
3. Reports performance across the practice or by physician ** - Same as element A above, only now you have to share those reports with others.
4. Sets goals and takes action to improve performance – Not much an EHR can do here, but the Registry should be able to provide reports substantiating improved performance.
5. Produces reports using standardized measures – Not sure why the repetition on reporting, but Meaningful Use has a host of required measures as well. Make sure your EHR can actually deliver on all 44 measures, plus whatever else you may want to measure. Some certified EHRs only have capability to deliver the minimum 6 NQF measures allowing you no freedom to choose what you want to measure, or report on. This too is part of the Registry.
6. Transmits reports with standardized measures electronically to external entities – Several EHRs have Registries that are certified by CMS to submit quality measures electronically. The standard for reporting will be changing soon, and as with interoperability in general, you need to be convinced that your EHR vendor has the resources and ability to roll with the punches.

Standard 9: Advanced Electronic Communications

1. Availability of Interactive Website – This is your Patient Portal, which needs to allow patients to input requests, data and generally communicate with the practice.
2. Electronic Patient Identification – This could mean a user name and password (or something more exotic, if you choose) for your patients to access the portal or it could refer to a unique patient identifier in the EHR. Either way, this is not an issue.
3. Electronic Care Management Support – Everything you do every day will satisfy this element, if it is done in an EHR.

To summarize this litany of standards, if you have any interest in NCQA PCMH recognition, the main functionalities to look for in an EHR, in addition to ease of use and affordable pricing, are a comprehensive Registry with excellent reporting abilities, a flexible Patient Portal, quality clinical content from reputable sources and vendor ability to sustain new standards and regulations, particularly those related to health information exchange. If you want to provide your patients with a compassionate and caring medical home, where they feel safe and well cared for, you will need a different set of “tools”, but perhaps technology can help a little.