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American Health Information Community

By Leslie Collins,2014-03-26 16:07
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A presentation on the AMIA paper entitled Toward a National Framework for the Secondary Use of Health Ken Waldbillig (for Mark Lewis) EMC Corporation

    American Health Information Community

    Electronic Health Records Workgroup

    Summary of the Web Conference Held

    Tuesday, November 7, 2006

    (11th Web Conference of This Workgroup)

PURPOSE OF MEETING

Charges for the Electronic Health Record Workgroup (EHR WG)

    ; Broad Charge: Make recommendations to the Community on ways to achieve

    widespread adoption of certified electronic health records (EHRs), minimizing gaps in

    adoption among providers.

    ; Specific Charge: Make recommendations to the Community so that within one year,

    standardized, widely available, and secure solutions for accessing current and historical

    laboratory results and interpretations are deployed for clinical care by authorized parties.

     thThe primary objectives of the 11 Web conference of the EHR WG meeting, chaired by Jon

    Perlin and Lillee Gelinas, were the following:

    1. Receive an update from the Office of the National Coordinator for Health Information

    Technology (ONC) staff with respect to the EHR WG’s May 2006 Recommendation 3.0

    related to the EHR WG’s specific charge.

    2. Identify what additional information the EHR WG might need to develop

    recommendations in five critical domains pertaining to the Workgroup’s broad charge: (1)

    privacy and security, (2) legal/regulatory, (3) state of the technology, (4) organizational,

    and (5) financial.

INTRODUCTORY REMARKS

    Dr. Perlin reported that he had recently attended a meeting sponsored by the Commonwealth Fund in Washington, DC, at which they presented an analysis of some of the leading countries' implementations in health records. There was wide agreement that EHR systems could be implemented in an interoperable way in a reasonable amount of time. Some presenters from European countries indicated that they already had identified a task list for getting to interoperable EHRs. Ms. Gelinas suggested that the EHR WG, when thinking about how to advance its broad charge, might broaden its focus to include countries other than the United States, in addition to considering practices at the Cleveland Clinic and the Department of Veterans Affairs (VA).

    Staff Action Item #1: The ONC staff will consider the possibility of arranging

    a presentation to the EHR WG on the implementation of EHR systems in

    Europe, as well as on the EHR systems at the Cleveland Clinic and the VA.

AHIC Electronic Health Records Workgroup 11-7-06 Meeting Summary 1

    Karen Bell reported that ONC is rethinking its figures for baseline adoption of EHRs in physician offices, because a new report, Health Information Technology in the United States:

    The Information Base for Progress, suggests that the penetration rate varies, depending in part on how an EHR is defined. Dr. Perlin and Ms. Gelinas recommended that EHR WG members look at the new report (available at http://www.rwjf.org/newsroom/newsreleasesdetail.jsp?id=10439).

    They also recommended that although the pre-publication report was presented to the workgroup, Dr. Blumenthal and/or his coauthors be invited again to review the findings with the EHR WG.

    Staff Action Item #2: The ONC staff will invite the authors of the new report

    Health Information Technology in the United States: The Information Base

     to make a presentation to the EHR WG on that report’s findings for Progress

    about EHR penetration rates in physicians’ offices.

KEY TOPICS

1. Update on ONC’s Progress with Respect to Recommendation 3.0 Related to the

    Workgroup’s Specific Charge Jodi Daniel, ONC

    Ms. Daniel reported that the ONC staff had been working with staff at the Centers for Medicare & Medicaid Services (CMS) and legal experts to comply with the EHR WG’s May 2006

    Recommendation 3.0 to the Secretary of Health and Human Services (HHS) pertaining to the Workgroup’s specific charge:

    Recommendation 3.0: By September 30, 2006, ONC should review the possible models

    for the exchange of historical lab information and determine which would require the

    Clinical Laboratory Improvements Amendments of 1988 (CLIA) and/or Health Insurance

    Portability and Accountability Act guidance, regulatory change, and/or statute change.

    She explained that CLIA was passed to ensure accurate reliable and timely testing regarding the location of the test and covers all phases of the testing process from specimen handling and analysis and to result reporting. To facilitate the identification of issues pertaining to CLIA that require CMS guidance, regulatory change, and/or statute change, ONC and CMS staff members and legal experts have identified the following three potential models for the exchange of historical lab information:

    ; Model #1: A laboratory sends test results in paper or electronic form directly to the

    ordering health care provider.

    ; Model #2: A laboratory sends test results to the ordering health care provider via an

    intermediary (e.g., a vendor or regional health information organization).

    ; Model #3: A laboratory sends test results to a health care provider who is treating a

    patient but did not order the tests.

    Model #2 illustrates issues related to CLIA regulations requiring laboratories to return test results to the authorized individual or the individual who is responsible for using those test results (42 CFR 493.129f): Can the test results can be returned via an intermediary? What if lab data do not get to the provider? Model #3 illustrates issues related to CLIA regulations that define an authorized individual as “an individual authorized under State law to order tests or receive test results, or both” (42 CFR 493.2). Some State laws authorize only the ordering physician or

    his/her designee to receive test results, thereby limiting labs’ ability to share lab test results with AHIC Electronic Health Records Workgroup 11-7-06 Meeting Summary 2

    other health care providers. Model #3 also raises issues related to who is “responsible for using the test result.” Would it be possible to have lab results be made available to any treating provider?

    Ms. Daniel reported that ONC had just signed a contract with the National Governors Association’s Center for Best Practices to create a State alliance for e-health that will review State laws that might preclude sharing of lab data with physicians involved in a patient’s treatment with a view toward changing those laws. In addition, ONC is working with CMS to see whether any action steps can be taken to overcome barriers to the widespread adoption of EHRs posed by CLIA regulations. Any regulatory changes would go through the full notification and comment process in the Federal Register not via the American Health Information Community.

2. Gap Analysis Based on Review of a Document Summarizing Testimony to the EHR

    WG Pertaining to the EHR WG’s Broad Charge Dr. Bell, ONC

    Dr. Bell distributed a document summarizing testimony to the EHR WG over the last several months related to five domains of the EHR WG’s broad charge. She asked EHR WG members to

    think about what recommendations the EHR WG might make related to its broad charge and to indicate whether they wanted additional presentations on any topic related to that charge.

    Using the ONC document distributed by Dr. Bell, EHR WG members discussed the need for additional information related to five domains of the EHR WG’s broad charge: (1) privacy and

    security, (2) legal/regulatory, (3) state of the technology, (4) cultural/organizational, and (5) financial.

Gaps in information about privacy and security. Jon Houston expressed concern that the new

    Workgroup on Confidentiality, Privacy, and Security has been focusing almost entirely on “identity proofing,” and he underscored the importance of having a broad range of privacy recommendations related to the National Health Information Network (NHIN). Other Workgroup members agreed with this point. Dr. Bell suggested that the EHR WG take another look at the National Committee and Vital Statistics’ (NCVHS) June 2006 report on privacy and

    confidentiality to the HHS Secretary (available at http://www.ncvhs.hhs.gov/060622lt.htm), and

    possibly consider the NCVHS recommendations as the basis for its own recommendations to the new Workgroup.

    Staff Action Item #3: The ONC staff will recirculate the June 2006 NCVHS

    letter and report with recommendations to ensure privacy and confidentiality

    in the NHIN to the EHR WG so that the EHR WG can consider them in making

    recommendations to the Workgroup on Confidentiality, Privacy, and Security.

    Dr. Houston noted that many people are concerned about a “land grab” of their personal health data for purposes other than their own treatment. His comment led to an extended discussion of the need for more information on issues related to secondary uses of personal health data. A number of people made suggestions for presentations to the EHR WG related to the secondary uses of personal health information. Dr. Houston, noting that one of the topics addressed by the NCVHS report is secondary uses of personal health information, recommended inviting the Chair of the NCVHS Subcommittee on Privacy and Confidentiality, Mark Rothstein, to give a presentation to the EHR WG on this topic. Mr. Isenstein indicated that the American Medical

    AHIC Electronic Health Records Workgroup 11-7-06 Meeting Summary 3

    Informatics Association (AMIA) has developed a white paper on developing a framework for the secondary uses of health data and recommended that the EHR WG take a look at that. Mike Kappel stated that the Markle Foundation and Connecting for Health have done a lot of work in the area of privacy and security in a networked health care environment and have begun working on secondary uses of personal health care data. He recommended that the EHR WG hear a presentation on this work. Dr. Bell suggested the possibility of hearing from Indiana about how it is dealing with privacy issues and CLIA in a regional health network.

    Staff Action Item #4: The ONC staff will consult with members of the EHR WG

    about which of the following presentations pertaining to the privacy and

    security domain of the EHR WG’s broad charge they would like to have at the

    January 2006 meeting:

    ; A presentation on secondary uses of personal health data by Mark

    Rothstein, Chair of the NCVHS Subcommittee on Privacy and

    Confidentiality

    ; A presentation on the AMIA paper entitled Toward a National

    Framework for the Secondary Use of Health Data

    ; A presentation on the Markel Foundation’s work pertaining to privacy

    and security issues in an NHIN, including its more recent work on

    secondary uses of personal health data

    ; A presentation from Indiana about how it is dealing with privacy issues

    and CLIA in a regional health network.

Gaps in information pertaining to legal/regulatory issues. Several EHR WG members

    indicated that a presentation on physicians’ malpractice concerns related to the use of an EHR or managing large amounts of data would be valuable. Lieutenant Colonel Bart Harmon said that he had heard attorneys say that there the rules requiring physicians to exercise due diligence may not be that different just because information is available electronically, and he would like to hear someone validate that. Dr. Houston recommended inviting a lawyer with an ethics background.

    Staff Action Item #5: The ONC staff will arrange for a lawyer or lawyers to

    give a presentation to the EHR WG about malpractice and ethics issues

    related to EHRs that the Workgroup should consider when making

    recommendations to the HHS Secretary about achieving the widespread

    adoption of EHRs among providers.

Gaps in information related to the state of the technology. EHR WG members agreed that the

    private sector should be the focal point of this document. It was also agreed that the ONC staff would solicit Blackford Middleton’s input on whether additional presentations pertaining to the

    state-of-the-technology domain was needed.

    Staff Action Item #6: The ONC staff will get Dr. Middleton’s input on whether

    additional information related to the state of the technology in the private

    sector is needed for the EHR WG to consider when making recommendations

    to the HHS Secretary about achieving the widespread adoption of EHRs

    among providers.

AHIC Electronic Health Records Workgroup 11-7-06 Meeting Summary 4

Gaps in information related to cultural/organizational issues. Dr. Bell, noting that several

    presenters have indicated that it is hard to get physicians to adopt EHRs without a lot of support and tools to change their workflow, asked whether someone from the Agency for Healthcare Research and Quality (AHRQ) could give a presentation on how to support workflow changes related to EHRs in physicians’ offices. Dr. Clancy said that someone from AHRQ definitely

    could do this.

    Staff Action Item #7: The ONC staff and Dr. Clancy will arrange for a

    presentation to the EHR WG on AHRQ’s work on supporting workflow

    changes related to EHRs in physicians’ offices.

    Connie Laubenthal indicated that the American College of Physicians also was doing something related to workflow changes in physicians’ office and that she could check to see whether Michael Barr might be able to give a presentation on that.

    Staff Action Item #8: The ONC staff and Ms. Laubenthal will check to see

    whether it is possible for Dr. Barr to give a presentation to the EHR WG on the

    American College of Physicians’ work related to supporting workflow changes

    related to EHRs in physicians’ offices.

Gaps in information related to financial issues (“the business case”). Ms. Gelinas

    recommended putting in parentheses “the business case” when talking about the financial domain, to make it clear that this is what is meant here. Colonel Harmon noted that some physicians believe that pay-for-performance means “withhold money if you don’t do what we

    want you to do. He suggested that the EHR WG consider how to structure payment to provide physicians with incentives to share in the gain. Dr. Perlin said that in some communities (e.g., Boston), providers and payers have structured payments to make the financial case for EHRs viable for physicians. EHR WG members agreed that it would be useful for the EHR WG to learn about what has been done in Boston.

    Staff Action Item #9: The ONC staff and Jim Sorace will check with Dr.

    Middleton about arranging for a presentation to the EHR WG on the project in

    Boston where payers and providers structured payment to make the business

    case for EHRs more viable for physicians.

    EHR WG members also agreed that they would like to get more information about on electronic prescribing (“e-prescribing) and approaches payers are using to support it. Dr. Perlin and Robert Smith added that e-prescribing might be a catalyst for broader adoption of health information technology.

    Staff Action Item #10: The ONC staff will arrange for a presentation to the

    EHR WG on e-prescribing and approaches payers are using to support it.

    Dr. Perlin and Ms. Gelinas thanked EHR WG members, the ONC staff, and others for their participation and robust discussion. Dr. Perlin said the next task will be to translate the analysis into recommendations to make EHRs more available to Americans in 8 years. The next meeting AHIC Electronic Health Records Workgroup 11-7-06 Meeting Summary 5

    of the EHR WG will be in January 2007, but the precise date has not been set. The ONC staff

    will send the calendar out as soon as possible.

    Staff Action Item #11: The ONC staff will send the calendar of the EHR WG’s upcoming meetings to EHR WG members as soon as possible.

    SUMMARY OF ACTION ITEMS

    Staff Action Item #1: The ONC staff will consider the possibility of arranging a presentation to the EHR WG on the implementation of EHR systems in Europe, as well as on the EHR systems at the Cleveland Clinic and the VA.

    Staff Action Item #2: The ONC staff will invite the authors of the new report Health Information Technology in the United States: The Information Base

     to make a presentation to the EHR WG on that report’s findings for Progress

    about EHR penetration rates in physicians’ offices.

    Staff Action Item #3: The ONC staff will recirculate the June 2006 NCVHS letter and report with recommendations to ensure privacy and confidentiality in the NHIN to the EHR WG so that the EHR WG can consider them in making recommendations to the Workgroup on Confidentiality, Privacy, and Security.

    Staff Action Item #4: The ONC staff will consult with members of the EHR WG about which of the following presentations pertaining to the privacy and security domain of the EHR WG’s broad charge they would like to have at the

    January 2006 meeting:

    ; A presentation on secondary uses of personal health data by Mark

    Rothstein, Chair of the NCVHS Subcommittee on Privacy and

    Confidentiality

    ; A presentation on the AMIA paper entitled Toward a National

    Framework for the Secondary Use of Health Data

    ; A presentation on the Markel Foundation’s work pertaining to privacy

    and security issues in an NHIN, including its more recent work on

    secondary uses of personal health data

    ; A presentation from Indiana about how it is dealing with privacy issues

    and CLIA in a regional health network.

    Staff Action Item #5: The ONC staff will arrange for a lawyer or lawyers to give a presentation to the EHR WG about malpractice and ethics issues related to EHRs that the Workgroup should consider when making recommendations to the HHS Secretary about achieving the widespread adoption of EHRs among providers.

    Staff Action Item #6: The ONC staff will get Dr. Middleton’s input on whether additional information related to the state of the technology in the private sector is needed for the EHR WG to consider when making recommendations

    AHIC Electronic Health Records Workgroup 11-7-06 Meeting Summary 6

    to the HHS Secretary about achieving the widespread adoption of EHRs among providers.

    Staff Action Item #7: The ONC staff and Dr. Clancy will arrange for a presentation to the EHR WG on AHRQ’s work on supporting workflow changes related to EHRs in physicians’ offices.

    Staff Action Item #8: The ONC staff and Ms. Laubenthal will check to see whether it is possible for Dr. Barr to give a presentation to the EHR WG on the American College of Physicians’ work related to supporting workflow changes related to EHRs in physicians’ offices.

    Staff Action Item #9: The ONC staff and Dr. Sorace will check with Dr. Middleton about arranging for a presentation to the EHR WG on the project in Boston where payers and providers structured payment to make the business case for EHRs more viable for physicians.

    Staff Action Item #10: The ONC staff will arrange for a presentation to the EHR WG on e-prescribing and approaches payers are using to support it.

    Staff Action Item #11: The ONC staff will send the calendar of the EHR WG’s upcoming meetings to EHR WG members as soon as possible.

    AHIC Electronic Health Records Workgroup 11-7-06 Meeting Summary 7

    Electronic Health Records Workgroup

    Members and Designees Participating in the Web Conference

    November 7, 2006

Co-chairs

    Jonathan B. Perlin HCA Inc.

    Lillee Smith Gelinas VHA, Inc.

ONC/OHITA Director

    Karen Bell HHS/ONC

Members

    Jason DuBois (for Alan Mertz) American Clinical Laboratory Association

    Connie Laubenthal (for Dr. John Tooker) American College of Physicians Howard Isenstein (for Chip Kahn) American Federation of Hospitals Daniel Morreale (for George Lynn) American Hospital Association Jim Sorace (for Barry Straube) HHS/CMS

    Colonel Bart Harmon Department of Defense

    Robert Smith Department of Veterans Affairs

    Ken Waldbillig (for Mark Lewis) EMC Corporation

    Mike Kappel (for Pam Pure) McKesson Provider Technologies John Houston National Committee on Vital and Health Statistics,

     and UPMC

Disclaimer: The views expressed in written conference materials or publications and by speakers and

    moderators at HHS-sponsored conferences do not necessarily reflect the official policies of the HHS; nor

    does mention of trade names, commercial practices, or organizations imply endorsement by the U.S.

    Government.

AHIC Electronic Health Records Workgroup 11-7-06 Meeting Summary 8

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