Thank you for the updates. FWIW, I was part of the team that supported CMS’s review and analysis of public comments on the draft Meaningful Use rules, as well as responding to their requests for recommendations on the final rules for qualifying for incentives payments, so quite familiar with that process.

Interesting times indeed.

I am much more interested in your observations, reflections, and predictions on how well your concerns are being heard and acted on inside the Beltway.

Cheers!

Reed D. Gelzer, MD, MPH, CHCC
Advocates for Documentation Integrity and Compliance
Wallingford, CT

After this preliminary discussion, I posted the testimony document that I pre-submitted here:
http://e-patients.net/archives/2010/02/testimony-submitted-to-the-adoptioncertification-workgroup-for-its-feb-25-meeting.html

Under “Government 2.0″ transparency, complete meeting resources and transcripts are posted online. Here’s the archive of that meeting, including audio, everyone’s testimony documents, and transcripts of the actual discussions.

After the meeting there was email discussion among those who testified. I posted here about that later.

All of that was under the Adoption/Certification Workgroup, which looks at what the rules will be for providers to qualify for the incentive money.

You may be interested in a subsequent hearing of the Meaningful Use workgroup, which is writing the regulations on what qualifies as meaningful use. The April 20 hearing was on “What is the role of patient-generated data in meaningful use?”

I posted my testimony, linking to an earlier discussion here:
http://e-patients.net/archives/2010/04/testimony-submitted-to-the-meaningful-use-workgroup-for-its-april-20-meeting.html

Here’s the archive of that meeting, including audio, everyone’s testimony documents, and full text transcripts of the meeting. Regina Holliday’s testimony was especially compelling.

Thanks again for prompting this update.

Reed D. Gelzer, MD, MPH, CHCC
Advocates for Documentation Integrity and Compliance
Wallingford, CT

Here is why this is especially pertinent. The ONC’s own commissioned 2005 report on EHRs and fraud showed that EHRs would initially worsen the trustworthiness of health care information, and that this would be reflected in increased health care fraud. The follow-on report to the ONC, commissioned to provide recommendations to forestall or mitigate such damage, was delivered June 2007 and provided a list of key EHR functions to improve simple records validity assurance. That report has been buried. Those few that, by individual effort, made it into EHR Certification recommendations thru CCHIT were stripped out in 2008 and 2009 (I know because I served on the CCHIT Compliance workgroup, which now doesn’t even exist). The then-ONC, Dr. Kolodner, met with the 2007 report workgroup in January 2007 and, among other topics, had a lengthy interchange about the fact that neither HITSP (driving EHR interop) nor CCHIT (driving EHR certification) had basic business record validity and integrity record on their requirements list. Dr. Kolodner promised he would make it so and never did. Repeated inquiries to the ONC on this point have gone unanswered.

So, in a nutshell, this is a long way of saying that at the present time, EHRs are not even required to meet the same requirements that a record must uphold in all other business domains. If we do not expect health care’s primary source record to achieve the level of trustworthiness that your common everyday storefront retail store must uphold, why do we expect that these same non-standardized, minimally certified systems will necessarily improve patient safety, security, care effectiveness, etc.?

What is needed at this point is nothing more sophisticated that to point out to any and every entity looking at EHRs that they should:
1. Make sure the system is capable of supporting that organization’s policies and procedures for accurate, reliable medical records. (Sadly, even Certified EHRs exist that can’t pass this simple test, for example, is the indicated author of the record actually accurate.)
2. Make sure the system is trained and supported in a manner that aligns with the organization’s medical records policies and procedures.

A little due diligence by EHR purchasers would go a long way. A little emphasis on information integrity by the largest purchaser of health care services (i.e. HHS) would go a long way.

Lastly, every patient of a practice with an EHR should regularly request a printed or electronic version of their clinical record. The errors, omissions, over-documentation, and wrong author/provider events will stir some useful “feedback” as well.

The most important thing in my opinion is to quit giving the public the implicit message that some overarching “we” knows how this all should work. This is a matter of national urgency and critical importance for the future of the country, and reasonable expectations should be nurtured, as well as everyone’s engagement on behalf of national interest and, more importantly, the benefit of every person in the US.

Best of luck in your remarks this Thursday.

Reed D. Gelzer
Wallingford, CT

(Former member HL7 EHR-S Standards workgroup on Records Management and Evidentiary Support
Former member of CCHIT Ambulatory Cert. WG, Privacy and Compliance Expert Panel, and Privacy and Compliance WG, Former Member of AHIMA/RTI Study and EHRs and Data Qualty/Anti-Fraud.
Co-Author: How to Evaluate Electronic Health Records Systems.)

The joint problem of financing a system with terribly misaligned incentives will have to be addressed. My hope is that ONCHIT does not make true reform more difficult by increasing the amount of our health infrastructure that is designed to support the old, bad way. Right now, a revolution in healthcare would required mostly financial restructuring — many hospitals would have to pass through bankruptcy as financial incentives get realigned to correlate high pay with successful outcomes. If health information — and the workflows for health information — also have to be scrapped and re-built to achieve this, we will be that much less likely to see true reform and more likely to see gradualism without disruption.

I’m amazed that none of us has yet come up with other suggestions. Difficult questions!

Take a step back. Who is buying these EHR systems and why? For the most part, it’s either small private practices or it’s large hospitals. Small private practices cannot afford the super-tailored solutions. Hospitals are not looking for a solution which improves outcomes, enables patient-driven medicine, or are even easy to use. Your average hospital will put out an RFP for an electronic medical record system with the primary success metric being “will it increase our income and accuracy of our insurance billings.” That’s it. Most EHRs are primarily designed to facilitate and document BILLING OF MEDICARE and other patient insurance carriers. And for the most part, they do this very well…

Like all technologies, electronic health records have huge potential to be beneficial to patients, but also have potential to be the source of unintended consequences. Our Workgroup is holding public hearings with a goal of understanding the circumstances under which Patient Safety problems occur in EHR systems and, also, determining the best approach to insure that these IT systems do no harm to patients. For this hearing on Feb. 25, the Workgroup members will be listening with an open mind to many viewpoints. We asked Dave to participate to represent a patient (consumer) viewpoint.

In accordance with the transparency rules established by the Obama administration, all Workgroup hearings and discussions are open to the public. The schedule of all HIT events can be found at:

http://healthit.hhs.gov/portal/server.pt?open=512&objID=1269&&PageID=16497&mode=2&in_hi_userid=11113&cached=true

You are invited to listen to the Workgroup’s meetings and to participate in our work. Your comments and advice will influence our recommendations.

Paul Egerman