Tag Archives: informatics

Getting ready for Stage 2 MU PH Reporting Requirements by the Meaningful Use Public Health Task Force

The Stage 2 Meaningful Use (MU) “Final Rules” published in the Federal Register on September 4, 2012, required local and state Public Health Agencies (PHAs) to ramp-up their MU capabilities and establish new processes to receive the relevant MU-compliant public health data from eligible providers, prior to the start of Stage 2 MU (10/01/2013 for EHs and 01/01/2014 for EPs). In Stage 2 MU, the capability to submit electronic data for immunizations is in the core or mandatory set for Eligible Professionals (EPs) and the capability to submit electronic data for immunizations, reportable laboratory results, and syndromic surveillance is in the core set for Eligible Hospitals (EHs). In addition, two new public health objectives for EPs have been added to the menu or options set – the capability to report cancer cases to a cancer registry and specific cases to a specialized registry (e.g., birth defects registries, chronic disease registries, traumatic injury registries). PHAs preparing for Stage 2 MU will require guidance to implement the new objectives and processes, such as:

  • Contributing their PHA’s MU capacity information to the proposed Centers for Medicare & Medicaid (CMS) centralized PHA capacity repository (declaration process),
  • Supporting providers (EPs and EHs) for registration of their intent to submit data for a MU objective,
  • On-boarding and accepting ongoing data submission from providers; and,
  • Providing an acknowledgement or a written communication (which may be in electronic format) from the PHA confirming a provider’s registration and achievement of ongoing submission.

The Centers for Disease Control & Prevention (CDC) has facilitated the establishment of the Stage 2 MU Public Health Reporting Requirements Task Force with representatives from the public health community; including: NACCHO, ASTHO, JPHIT, ISDS, CSTE, PHII, NAACCR, State PHAs, AIRA, ONC, CDC, and others. This task force is currently working to frame deliverables that will identify key concepts, task flows and guidance for PHAs to implement the Public Health objectives and associated new business processes required for Stage 2 MU. The task force has already provided recommendations and requirements to CMS for the establishment of the centralized PHA capacity repository which will provide EPs and EHs information on jurisdictional capacity to accept electronic data for Stage 2 MU public health objectives. The task force is developing guidance for PHAs to facilitate the registration of intent by providers, on-boarding and ongoing submission, and the ability to provide acknowledgements to providers. The task force is also developing guidance related to transport protocols for the electronic submission of meaningful use data to PHAs. The task force has created a specialized registry work group to provide guidance on how public health agencies can leverage the specialized registry meaningful use objective to obtain case information on mandated public health reporting information such as birth defects, traumatic injuries, hearing and vision and other public health surveillance information.

The consensus guidance and recommendations developed by this collaborative Public Health task force, currently scheduled to be available by April 2013, will be shared widely with state and local PHAs. PHAs across the nation will be able to adopt this guidance according to their jurisdictional needs to implement the new objectives and processes required for Stage 2 MU. For more information on this task force please visit http://www.phconnect.org/group/ph-reporting-task-force, and if interested in providing meaningful contributions to this work, please email meaningfuluse@cdc.gov

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Insights from Kansas Information Management and Exchange Workshop

Recently Vanessa Holley and I were asked to facilitate a workshop with local health departments (LHDs) in Kansas.  We were slated to discuss how to help LHDs make two decisions:

  • Do they need an electronic health record (EHR) system?
  • If/how should they connect to the health information exchange (HIE)?

Through the course of the discussions, it quickly became apparent that the decisions to have an EHR or connect to the HIE were only part of the story and in some ways were over emphasized because they are easier to conceptualize.  But the discussions began to broaden and clarify some of the issues.  As it turns out, I think we actually stumbled upon a pretty good road map for ePublic Health.

Let’s look closer at what I mean.

Before you can effectively take advantage of any technology or HIE option:

  • Step 1: develop the future vision for your LHD and clarify both what value and what services you plan to offer your community.  You first need to determine what services your LHD will be focused on in the new world of healthcare.  This is critical because if, for example, your health department is not going to continue to heavily invest in clinical services, then considering a practice management or EHR system may not be a good investment – despite current needs.  On the other hand if you plan to increase your case management and care coordination role in the community, you’ll want to be sure whatever system you purchase or build takes into account those requirements in order to best support your work.
  • Step 2: is to create or update your statewide collaborative Health Information Management Plan and planning body with a wide representation from LHD, state, and program personnel.  Even if this already exists, ensure that representatives are both well informed and doing a complete job of communicating out decisions that are made.  To begin this step you have to begin to coordinate at a heightened level with your state and neighboring LHDs.  In Kansas, they have had a great relationship with their state and a very active LHD association.  However, they still realized that they could benefit by making a more formal body that is charged with coordinating and collaboratively developing the Health Information Management Plan for public health.  This is different from the statewide HIT plan because it is much more than information technology and is solely focused on creating one public health voice for health departments throughout the state.  This is so critical because your partners need to hear a coordinated and unified voice for public health.  Also, most of the Meaningful Use solutions are designed and managed at the state level.  Therefore it is imperative that LHDs are collaborating with the state to understand how their information needs will be met and how these solutions will interact with their local systems.  There has been so much to keep up with in the fast pace of Meaningful Use that many states have not yet formalized this body and its charge.  However states that have recently created such a coordinating body, like Ohio, report huge successes in making decisions and dealing with unforeseen issues related to the changing world of ePublic Health (See CDC Charter Lite Template).
  • Step 3:  gain a clearer appreciation for your LHDs capabilities, needs, and desires. This can often involve an assessment of the systems you have, the needs that are met and the gaps that exist.  It might even be good for the aforementioned Health Information Planning group to survey LHDs and display results.  This will help LHDs identify peers they can work with and peers who can offer peer assistance or advice about vendors.  It is important that this not be done from a standpoint of competition or condemnation, but rather of bettering each health department.
  • Step 4: delineate the benefits of practice management and EHR systems. Though clinical operations and responsibilities for LHDs can vary wildly, most LHDs have some sort of specialty clinics that they run (examples include STD/HIV, TB, Maternal and Child Health, etc).  And though the state is often preparing systems to meet Meaningful Use requirements, LHDs must come up with their own solutions for meeting the demands of these clinics.  Complicating matters, LHDs often have cross over between local clinic information needs and programmatic reporting to state or federal partners.  In our discussions in KS, we discovered that even with smaller programmatic clinics there are good reasons to deploy one or both of these types of systems.  Especially since costs have decreased dramatically in the past 5 years.  Benefits include more efficient programmatic reporting, increasing overall clinic efficiency resulting in a higher volume of visits, increased recovery of costs and billing, decreased need for record space, etc.  Once you have determined that the benefits offered by these systems fit within your LHD vision, conduct a review of specific systems based on your unique requirements, and understand the costs and benefits you can expect, then you can make an informed decision as to which system you should deploy (see NACCHO’s All-Systems-Go tool).
  • Step 5:  know your requirements for exchange and assess/pursue your local HIE options to support those requirements. For this final step, our discussions in KS turned to the HIE options that exist in their state.  Since they have been a leader in Health Information Exchange and LHDs have been heavily involved, they have a couple of really nice options.  In their state, LHDs can get basic HIE services for free, which include direct secure messaging and access to a provider web portal.  And KS LHDs are finding really interesting ways to use these services – like using the web portal for case investigations and sending follow-up testing requests and outbreak summary reports to physicians using direct secure messaging.  The state health department is working to connect their reporting systems to LHDs through the HIE, but work remains to make local and state systems interoperate in this fashion.  It also came to light that there were other exchange requirements that the LHD had that aren’t a part of their “free” set of services, but have enough value that they will want to understand the costs/benefits and pursue those options.  For example, local clinic managers would like to perform clinical assessments on their clients and provide test results and other clinical notes to the referred provider or receive visit summary documents when the referred visit is complete.  Though there is still much work to do, what was clear was that in the not so distant future one could imagine LHDs in KS having an efficient and interoperable connection to the state and other community based systems through their HIE.  In order to have this sort of success, it is critical that your LHD get involved, stay involved, or increase involvement locally with your HIE options.  Be aware of what services your HIEs provide, how these services can benefit your LHDs vision for the future, and see if you can negotiate special rates for LHDs.

If LHDs earnestly and systematically pursue these five steps, I believe they will have a thriving and successful transition into becoming an efficient LHD of the ePublic Health future.  At NACCHO, we’re working with our ePublic Health workgroup to develop more detailed tools that will support LHDs who go through each of these steps – so stay tuned.  I want to give a special thanks to the Kansas Health Foundation, Kansas Association of Local Health Departments, and Kansas Department of Health and Environment for allowing me into their rapidly developing world of ePublic Health.

What is informatics, and why should I care? – Joseph Gibson, MPH, Ph.D.

From 2003 to 2006, I struggled to get a firm grasp on what people meant by “informatics”. Since understanding it, I have struggled to find a good way to explain its importance to my public health colleagues. But I think I finally have it.

Informatics skills are what you need to avoid wasting a lot of money, effort, and goodwill when implementing information systems.

Have you ever tried to implement software or some application, only to have it fail because it did not perform as you expected, it was not accepted by the end-users, it did not work with your other systems, or maintain it requires more resources than you could afford? That is a failure of informatics. Has some state or federal agency ever imposed technology or software upon you that captured the information they needed, but made your operations more difficult? That is the result of poor informatics. Does your agency has many program-specific applications that may work well for each program, but which are only sustained by one person’s special skills or which cannot exchange or consolidate information across your whole enterprise? Good informatics planning can lead to more robust, interoperable systems.

Effective use and management of information requires a combination of technology and work processes. Too often, we have viewed software solutions as the “silver bullets”; thinking that installing the right software will automatically improve our processes. But just as you need skill and strength to use a saw, you need training and content knowledge to make effective use of software. Informatics creates a bridge between technology and work processes, to assure good match. But it is not simple. Good informatics requires a significant resource investment in selecting and implementing solutions. Like most prevention, it is easy but risky to skip.

Important informatics skills include change management (not just IT change management, but culture and process change management as well), business analysis, stakeholder engagement, project management, requirements development, strategic thinking to place projects into a larger vision, building for inter-operability, translating between IT & business, system life cycle, Communications, ) A good informatician can speak the language of both IT staff and program staff, and should be a good communicator and group facilitator.

Informatics skills are not necessarily present in IT departments. A programmer may be very skilled in writing a program to do what he wants, but is rarely skilled in getting the thorough understanding of what users need. The database administrator may be very skilled in structuring a database to run very quickly, but usually does not understand the content well enough to create operational definitions that address what program managers want to know. And even if an IT department has good informatics skills, agency leadership often requires implementation timelines that short change the informatics-intensive phases of a project, like the homeowner who paints a room without first prepping the walls and trim.

Why should you try to get more informatics skills in your health department’s workforce? Why should you consider creating an informatics director position? Because, in the long run, it will save you money, effort, and will earn you goodwill, rather than reputation for having failed or hard to use systems that do not meet user needs. You will spend more time preparing for new systems, but less time fighting with those systems after they are implemented.

Read Dr. Gibson’s bio »

Focus your Vision for Success in Public Health Informatics

Often local health departments (LHDs) are stretched in multiple directions.  This is in large part due to the traditionally stove piped and programmatic funding of our organizations.

In our recent blog entry – A Vision For ePublic Health & Informatics – featuring Dr. David Ross Director of the Public Health Informatics Institute, LHDs are urged to have a visible and future vision for their informatics solutions.  While that is very important, there is so much happening that folks are often asking, “Where should I start?”  Well I believe you should attempt to find some focus.  It is important to have an overarching vision for informatics so, as Dr. Ross says in the video, you can “be prepared to use emerging technologies when they come”.  But I think once you have that broad vision, it is important to focus your resources on the project you will tackle right now.  Of course you must be flexible as new opportunities and challenges may come along, but you have to practice good project management and can’t be too distracted in your approach.

This takes a very high level of executive sponsorship.  You will have to devote personnel time, money, and may have to ration resources from other projects.  Start with getting leadership to ask the organization to really reflect on the question “What is our business? “Or “What do we want our business to be?”  With the competitive pressures of ACOs, FQHCs, HIEs, and other aspects of health care reform, it is more important than ever that local health departments know what our business is.  Healthcare partners should know when it comes to [Enter Your Health Department Name Here], organizations should contract with you to provide certain services.  These services could be things like Care Coordination, Home Health Visits, Specialty Care (HIV, STD, Dental, TB, Hepatitis, MCH), Primary Care for indigent populations, Surveillance, Environmental Health, Community Health Assessment, etc.

This understanding of your business will play a major part in defining where you should focus your informatics energy – but it isn’t everything.  You now have to account for other pressures like technical infrastructure, workforce, Meaningful Use Requirements, funding etc.  For example, do you have the right staff available for a project, can you receive Medicaid 90/10 funding through your state or Meaningful Use incentives, etc? And ask yourself, how long will this project take?  Set realistic timelines, while being cognizant of any time limitations on your funding.

So now you know what your business focus is, what stressors are constraining you, and what resources may be available.  You should be prepared to make an informed decision on where to focus your informatics efforts.  Like a laser you can develop a meaningful resource for your department that can enhance the work you do and improve efficiencies in your agency.  You can be a valued partner in the community and stake a claim on the work you do.  You can meet or exceed expectations and that will likely produce new resources for your health department in the future.

Let me give you an example.  Let’s say your overall vision for your health department involves creating a dashboard that provides real time information necessary for decision makers.  It may be unlikely that you are able to build this tool all at once to serve every information need of the department.  However, you do the assessment described above – survey your resources and environment to understand who is best suited to begin this project, which information is most needed right now, and which program may have some funding to support the project.  Though you will build the infrastructure of the system to easily accommodate future data source additions, you will have to decide where to focus first.  Let’s say you’ve decided to become a valued partner in the community by helping hospitals meet their IRS required community health assessments and you want the results of those assessments to be dynamically updated, near real time, and available to all pertinent decision makers in the health department, community, and hospitals.  The IRS requirement means your service is likely valuable and may support a line of funding from hospitals or other community partners.  You can now be focused on this project, get it accomplished in proper fashion – with Stakeholder participation and governance, project and risk management, and financing (see NACCHO’s tool – All Systems Go).  In 12 to 18 months you’ll have a success and then be ready to focus on the next part of your vision.

Be visionary, be organized, be realistic, be focused, and you’ll be successful.

Public Health Proposals from ONC’s HIT Policy Committee – October 2012

After Dr. Mostashari’s opening remarks, the HITPC meeting continued with hours of testimony.  Click Here to View October 3, 2012 HITPC Public Health Proposals for Stage 3.

Farzad Addresses ONC’s Health Information Technology Policy Committee (HITPC) Meeting 10-3-12

Dr. Farzad Mostashari, the National Coordinator for Health Information Technology, gave opening remarks at ONC’s Health Information Technology Policy Committee meeting.  He discussed some of the latest happenings since the last HITPC meeting.  This past interim, there were apparently several not so flattering commentaries in the newspapers.  He described it as 3 acts in a play.

Act 1:

There were some opinions that ONC is acting as a cheerleader.  A review of some cost benefit analysis was done on Meaningful Use incentives and said the data has not demonstrated any cost savings or real health benefit.  Further these opinions apparently went on to say that the Meaningful Use effort is misguided and a waste of money.  Another large criticism that came Dr. Mostashari’s way was that the government had not yet set any real standards for Health Information Exchange (HIE).

Dr. Mostashari responded by saying there were actually 31 cost studies done on this topic, and 27 out of 31 actually describe some cost benefit – not exactly the “rare exception” described.  In addition, Dr. Mostashari asked the question, “if we increase A1C measures for diabetics and save 2 amputations – is it worth it?”

What we’re seeing is that health information technology (HIT) is an infrastructure that once in place, you can do any number of studies and improvements.  The question isn’t if we need HIT infrastructure, but really the question is how do we do it and how do we maximize its use?

There are any number of stories of success, like the Minnesota diagnostic imaging scans that went electronic.  Before the electronic infrastructure, the decision to approve a scan was convoluted and took 10 min or more.  They asked the question, “could we use our electronic health record (EHR) for this approval process by coding the approval logic right into the system?”  Once they did, they saw a dramatic decrease in inappropriate and duplicate scans, and it took only 10 seconds for approval. 

As for the assertion that “there are no standards”, Dr. Mostashari pointed out that many use cases are now beginning to arrive at consensus standards precisely because of Meaningful Use.  It has taken some time, but stage 2 will show some really big changes in the near future.  He pointed out that many of the standards are cataloged at the Meaningful Use Stage 2 Standards-Hub.

Act 2:

A series of articles in several news papers around the country came out regarding billing.  They found that the decade before meaningful use (2000 – 2009), there was an association between higher severity codes and payments.  The implication was that this meaningful use government incentive program to encourage adoption of electronic health records may have had an unintended consequence of increasing both the number of requests and cost of severity codes.  Actually, Dr. Mostashari said, it is unclear if many things were simply under coded and now are captured or if there is a great deal of fraud.  It is also not clear what the final and total impact is on cost.  It is entirely possible that admission levels have improved despite these changes in coding.  More substantially, meaningful use was a conscious effort to move systems away from documentation and billing and toward patient centered care coordination and population health.  “If we continue to pay for documentation and more visits, that is exactly what we’ll get.”

Farzad mentioned that 76 percent of plans and medical homes expect to be in an Accountable Care Organization (ACO) pay model.  You simply can’t do a better job of measuring care without access to good information.

In addition, immutable health logs, a byproduct of meaningful use, help to enforce against fraud.  If care is documented that didn’t actually occur, then that is bad care and illegal and we take that very seriously. 

We also just heard about results of the open notes project (sponsored by RWJ).  Something like 99% of consumers and 100% of providers in the project want this practice of secure and full access to medical records for all appropriate parties to continue to be offered.  Again this sort of practice will go a long way to discover out and out fraud. 

With all of that said, it is incumbent upon us the HIT policy committee to take another look at documentation for medical purposes and offer guidelines and policies for what is good medical documentation.  We need to find out what would be good EHR functionality and what is just “over the line”.  Too much documentation just for higher billing codes, bypassing the audit log, or skipping record amendments where we can clarify should be considered in that discussion. 

Act 3:

There is real change beginning to occur on the ground.  But don’t expect this to be a one shot success.  It is and always has been a staged approach.  The first stage is collecting structured data.  The second stage is thinking about population health and data sharing.  The third stage is really getting to the meaningful use of electronic medical records.  One commenter said, “let’s be patient here, you can’t ask a two year old to do six year old tricks.”

The largest ever study of diabetes is underway through electronic EHR data and initial findings indicate remarkable improvement in patient care.  We owe it to practitioners and vendors to set ambitious goals, provide guidance, and maybe even a little bit of cheerleading.