CMS and ONC Issue Rules on Proposing a Definition of Meaningful Use and Setting Standards for EHR Incentive Program

Yesterday the Centers for Medicare & Medicare Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) issued two regulations laying the foundation for improving quality, efficiency and safety through meaningful use of certified electronic health record (EHR) technology.

The two regulations are part of the implementation of the EHR incentive programs for physicians and hospitals enacted under the HITECH provisions of the American Recovery and Reinvestment Act of 2009 (ARRA). CMS issued a proposed rule outlining the proposed provisions governing the EHR incentive programs, including defining the central concept of “meaningful use” of EHR technology. ONC issued an interim final regulation setting forth the initial standards, implementation specifications, and certification criteria for EHR technology.

For more details see the following CMS Press Release. Also, CMS has issued Fact Sheets on the proposed regulations:

• CMS Proposes Requirements for the Electronic Health Records (EHR) Medicaid Incentive Payment Program
  
• CMS Proposed Requirements for the Electronic Health Records (EHR) Medicare Incentive Program
  
• CMS Proposes Definition of Meaningful Use of Certified Electronic Health Records (EHR) Technology

Below are links to complete copies of the rules. Once they are published in the Federal Register I will update with the specific Fed Reg details. Some light reading for the New Year!

Medicare and Medicaid Programs; Electronic Health Record Incentive Program
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Proposed rule.
SUMMARY: This proposed rule would implement the provisions of the American Recovery and Reinvestment Act of 2009 (ARRA) (Pub. L. 111-5) that provide incentive payments to eligible professionals (EPs) and eligible hospitals participating in Medicare and Medicaid programs that adopt and meaningfully use certified electronic health record (EHR) technology. The proposed rule would specify the-- initial criteria an EP and eligible hospital must meet in order to qualify for the incentive payment; calculation of the incentive payment amounts; payment adjustments under Medicare for covered professional services and inpatient hospital services provided by EPs and eligible hospitals failing to meaningfully use certified EHR technology; and other program participation requirements. Also, as required by ARRA the Office of the National Coordinator for Health Information Technology (ONC) will be issuing a closely related interim final rule that specifies the Secretary’s adoption of an initial set of standards, implementation, specifications, and certification criteria for electronic health records. ONC will also be issuing a notice of proposed rulemaking on the process for organizations to conduct the certification of EHR technology.

Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology
AGENCY: Office of the National Coordinator for Health Information Technology,
Department of Health and Human Services.
ACTION: Interim final rule.
SUMMARY: The Department of Health and Human Services (HHS) is issuing this interim final rule with a request for comments to adopt an initial set of standards, implementation specifications, and certification criteria, as required by section 3004(b)(1) of the Public Health Service Act. This interim final rule represents the first step in an incremental approach to adopting standards, implementation specifications, and certification criteria to enhance the interoperability, functionality, utility, and security of health information technology and to support its meaningful use. The certification criteria adopted in this initial set establish the capabilities and related standards that certified electronic health record (EHR) technology will need to include in order to, at a minimum, support the achievement of the proposed meaningful use Stage 1 (beginning in 2011) by eligible professionals and eligible hospitals under the Medicare and Medicaid EHR Incentive Programs.

Tweet By Hospital Employee: What information is considered PHI?

Interesting Tweet HIPAA Breach story coming out of Mississippi involving Governor Haley Barbour. The incident involved a response to Governor Barbour's tweet by a University Medical Center employee.

Ves Dimov, M.D. at Clinical Cases and Images Blog posts about the story - Single tweet by hospital employee to Mississippi Governor allegedly violates HIPAA, forces her to resign.

The incident will provide a good case study for health privacy lawyers who regularly consider the question of what information is and is not protected health information (PHI) under 45 CFR 160.103. PHI is defined under HIPAA as:

The Privacy Rule protects all "individually identifiable health information" held or transmitted by a covered entity or its business associate, in any form or media, whether electronic, paper, or oral. The Privacy Rule calls this information "protected health information (PHI)."

“Individually identifiable health information” is information, including demographic data, that relates to:

• the individual’s past, present or future physical or mental health or condition,
• the provision of health care to the individual, or
• the past, present, or future payment for the provision of health care to the individual,

and that identifies the individual or for which there is a reasonable basis to believe it can be used to identify the individual. Individually identifiable health information includes many common identifiers (e.g., name, address, birth date, Social Security Number).

Thanks for the tip @RLBates and @EdBennett.

Lorman Medical Records Law Seminar: March 18, 2010

On March 18, 2010 I will be speaking on Medical Records Law at a seminar in Charleston, West Virginia. The seminar is sponsored by Lorman Educational Services. Joining me for the day long seminar will be three very knowledgeable health care colleagues:

• Michael T. Harmon, MPA, CIPP/G, Compliance Specialist for the West Virginia Mutual Insurance Company, a Medical Professional Liability Insurance Company
• Sallie H. Milam, J.D., CIPP/G, Executive Director of the West Virginia Health Information Network and Chief Privacy Officer for the West Virginia State Government
• James W. Thomas, Esq., Manager of the Charleston, West Virginia Business Law Department of Jackson Kelly PLLC whose practice focuses primarily upon health care matters of a business, regulatory and operational nature
  

Additional information about the seminar and how to register can be found at Lorman Educational Services. Following is the full seminar agenda:

8:30 am – 9:00 am			Registration
9:00 am – 9:15 am			Overview
9:15 am – 10:30 am			HIPAA Compliance: Reality and Perspective
			— Michael T. Harmon, MPA, CIPP/G
			Overview Enforcement Complaints Case Examples Summary of HITECH Changes
10:30 am – 10:45 am			Break
10:45 am – 12:00 pm			HITECH Financial Incentives for Implementation of HIT
			— James W. Thomas, Esq.
			Qualifying an Electronic Health Record System Available Financial Incentives
12:00 pm – 1:00 pm			Lunch (On Your Own)
1:00 pm – 2:00 pm			Health Information Exchange in West Virginia: Impact on Patient Records
			— Sallie H. Milam, J.D., CIPP/G
2:00 pm – 2:15 pm			Break
2:15 pm – 3:30 pm			Consumer Driven Health Care: HITECH, Health 2.0, Social Media and Personal Health Records
			— Robert L. Coffield, Esq.
			HITECH Breach Notification Requirements Impact of Health 2.0 and Social Media Technology on the Future of Health Care Development and Adoption of Personal Health Records Discuss the Legal Implications of Emerging Technology
3:30 pm – 4:30 pm			Panel Discussion
			— Robert L. Coffield, Esq., Michael T. Harmon, MPA, CIPP/G, Sallie H. Milam, J.D., CIPP/G and James W. Thomas, Esq.

West Virginia State Bar and Office of Disciplinary Counsel News

The West Virginia State Bar announced today that the Office of Disciplinary Counsel has a new website. Also, the West Virginia State Bar has redesigned its website design..

The new Office of Disciplinary Counsel website contains information about the disciplinary complaint process the function of the Lawyer Disciplinary Board, the Rules of professional Conduct and the disciplinary complaint process. The website also has links to all Legal Ethics Opinions issued by the Lawyer Disciplinary Board and recent disciplinary decisions issued by the Supreme Court of Appeals of West Virginia.

Also, the West Virginia State Bar announces that the West Virginia Supreme Court of Appeal has entered order with a proposed amendment to Rule 8, Rules for Admission Pro Hac Vice. The proposed amendment increases the fee pad to the West Virginia State Bar for each individual applicant for pro hac vice admission from $250 to $350. Public comment on the proposed rule is being received through January 25, 2010.
A copy of the proposed order:

Request for Comments on Proposed Amendment to Rule 8.0 Admission pro hac vice, of the West Virginia Rules of Admission to the Practice of Law

UPDATE (3/16/10):

The West Virginia State Bar's Unlawful Practice of Law Committee released Advisory Opinion 10-001, relating to questions from attorneys regarding its interpretation of Rule 8 of the West Virginia Rules of Admission to the Practice of Law, relating to admissions pro hac vice.

Advisory Opinion 10-001 addresses the following issues:

1. Whether the requirement in Rule 8 of of admission pro hac vice extends to matters in which no action, suit or proceeding is pending;

2. To what extent is the responsible local attorney required to participate in proceedings involving the attorney admitted pro hac vice;

3. Whether presiding judicial officers can "excuse" local counsel form participation or "waive" the requirement of participating; and

4. What limitations exist for attorneys seeking to be admitted pro hac vice, particularly their ability to be admitted on a frequent basis, or in multiple or consolidated actions.

Drug and Device Law: Herrmann's Farewell Post

Farewell and congratulations go out to fellow health law blogger, Mark Herrmann, (formerly) co-author of the Drug and Device Law Blog and author of The Curmudgeon's Guide to Practicing Law.

In Mark's Farewell Post he announced that he is leaving Jones Day after 20 years to become the VP and Chief Counsel - Litigation at Aon Corporation. Fellow co-author, James Beck, has this to say (Long Live the Blog) about Mark's departure. He also announces 3 new lawyers joining the blogging team to replace Mark. Wow! 3 lawyers to replace 1. What a complement.

Although not much of my practice focuses on drug and device work, I have been a periodic reader since the early years of blogging. Why? Because I've always loved the tone of their posts - informal, practical and lighthearted. Great to see Beck link to a post that I remember reading (and liking) about why big firms don't blog well. Great advice for any law blogger.

Thanks to the Likelihood of Confusion post that tipped me on Mark's departure.

Thanks Esse Diem: The Best Blogs You're Not Reading Yet

A quick thanks to Elizabeth Damewood-Gaucher author of the Esse Diem Blog for including the Health Care Law Blog on her short list of The Best Blogs You're Not Reading Yet.

I would agree with her list and glad that am a regular reader of 4 out of the 5. All produce great content and cover distinct niche areas. For example, the Rainmaking Blog focuses on the business of law and tells you where to wear you nametag. Lee Kraus' Learning and Technology is the place I first learn about new technology tools that I can use - he is always thinking on the edge of the practical use of technology. Professional Studio 365 focuses on bridging the gap between college and the workforce for those just starting their career. I don't follow the Bad Leader Blog, but what a great name. You've got to love the lead in line, "what we can learn from bad leaders . . ."

"Thanks You" Elizabeth for including us on your list.

Blawg Review #242: The Age of Illumination

These days I don't always get around to religiously reading Blawg Review every week - but I'm glad I took the time to read Ron Coleman's Blawg Review #242 hosted at Likelihood of Confusion.

In the past I often submitted blog posts to the editor - but have gotten out of the habit. Ron's post reminded me of the importance of keeping this blogging carnival tradition alive. I'm glad that Blawg Review has survived the onslaught of the 140 character micro-blawg post (aka legal tweet).

Blawg Review #242 is an eloquent Chanukah edition containing an insightful look at the whys of blogging (especially for those of us who have been doing this for years). Ron provides a glimpse at the current state of law blogging and what the future may hold. He leaves us with this wonderful thought.

"It's the Age of Illumination. A light in every window. A blawg for every shingle. Photons and pixels souring across the either, generating, light yes! Fluorescent, halogen, you name it; sparkling, illuminating all . . . Generating light . . but no heat."

As past host of Blawg Review (Edition #97) and Grand Rounds (Grand Rounds 3.5) I understand the time and effort put into digesting and creatively weaving together the posts from the week. Incredible job Ron - thanks for giving me the pleasure of reading your post.

Florida Judicial Ethics Advisory Opinion on Social Media: Accept or Deny? Deny

The Florida Judicial Ethics Advisory Committee issued JEAC Opinion 2009-20 on November 19, 2009, indicating that judges may not add lawyers who may appear before the judge as "friends" on a social networking site, nor may judges permit such lawyers to add the judges as their "friend".

However, the Committee did not entirely ban judges from using social media tools. Judges may post comments and other materials on their social media pages as long as the materials do not otherwise violate the Code of Judicial Ethics.

So, if you are a Florida judge using Facebook the answer to invitations to connect from lawyer colleagues must be "deny." Interesting decision that may have significant impact in the legal community as it relates to the use of social media tools by litigation lawyers.

For more analysis and thoughts on the topic check out the NYT article, For Judges on Facebook, Friendship Has Limits. Additional coverage and posts via the Mike Frisch at Legal Professional Blog, Ashby Jones of WSJ Legal Blog and Dan Macsai of Fast Company. Thanks to Denise Howell for the tweet tip about the recently issued opinion.

This is not the first look by judicial ethics committees at the evolving role of social media relationships between lawyers and judges. As reported by the ABA Journal back in June, a North Carolina judge was publicly reprimanded by the North Carolina Judicial Standards Committee for "friending" a lawyer in a pending case.

Following are the specific questions/answers the Florida Committee addressed in the Opinion.

Q: Whether a judge may post comments and other material on the judge's page on a social networking site, if the publication of such material does not otherwise violate the Code of Judicial Conduct. ANSWER: Yes.
Whether a judge may add lawyers who may appear before the judge as "friends" on a social networking site, and permit such lawyers to add the judge as their "friend." ANSWER: No.
Q: Whether a committee of responsible persons, which is conducting an election campaign on behalf of a judge's candidacy, may post material on the committee's page on a social networking site, if the publication of the material does not otherwise violate the Code of Judicial Conduct. ANSWER: Yes.
Q: Whether a committee of responsible persons, which is conducting an election campaign on behalf of a judge's candidacy, may establish a social networking page which has an option for persons, including lawyers who may appear before the judge, to list themselves as "fans" or supporters of the judge's candidacy, so long as the judge or committee does not control who is permitted to list himself or herself as a supporter. ANSWER: Yes.

UPDATE (12/14/09): Over the weekend Ernie Swenson tweeted (via @LALegalEthics) about a South Carolina Advisory Opinion (Opinion No. 17-2009) issued in October 2009 looking at the propriety of a magistrate judge being a member of a social networking site such as Facebook.

The facts presented to the Advisory Committed on Standards of Judicial Conduct by the magistrate judge were:

A magistrate judge has inquired as to the propriety of being a member of Facebook, a social networking site. The Magistrate is friends with several law enforcement officers and employees of the Magistrate’s office. The Magistrate is concerned about the possibility of an appearance of impropriety since the list of Facebook subscribers is vast.

The South Carolina Advisory Committee reached a less restrictive conclusion than the Florida Judicial Ethics Advisory Committee discussed above. The Committee reasoned that a judge "shall act at all times in a manner that promotes public confidence in the integrity and impartiality of the judiciary." The Committee continued by stating that "complete separation of a judge from extra-judicial activities is neither possible nor wise" and that a judge should nto become isolated from the community. The Committee found that allowing a magistrate to be a member of a social networking site allows the community to see how the judge commicates and gives the community a better understanding of the judge.

The Committee's conclusion was the following:
A judge may be a member of Facebook and be friends with law enforcement officers and employees of the Magistrate as long as they do not discuss anything related to the judge’s position as magistrate.

Bob Ambrogi at Legal Blog Watch provides additional analysis and comparison of the South Carolina and Florida opinions. Bob points out a distinction between the two rulings in that one deals with the friending of "attorneys" by judges while the other deals with friending of "non-lawyers" (law enforcement officials and courtroom employees) by judges. He concludes by making this point:

The key difference between the two opinions is in who a judge may friend without calling into question the judge's impartiality and integrity. A judge who friends courtroom employees provides no cause for concern, South Carolina says, but a judge who friends courtroom advocates does, Florida finds.

HIPAA: Michigan Supreme Court Examing Preemption, Confidentiality and Ex Parte Interview of Treating Physicians in Medical Liability Litigation

The AMANews reports that the Michigan Supreme Court is examining whether the Health Insurance Portability and Accountability Act of 1996 (HIPAA) preempts state law to allow a defendant physician in a medical liability case to interview the plaintiff/patient's other treating physicians.

The history and docket information on the case before the Michigan Supreme Court, Andrea L. Holman v. Mark Rasak, SCt Case Number 137993, can be found via search here. Oral arguments were held on November 3, 2009. The Michigan Supreme Court provides a background summary of the case along with links to the briefs filed by the parties, including Amicus Curiae Briefs filed by the Michigan Association for Justice, Michigan Defense Trial Counsel, Michigan Health and Hospital Association, Michigan State Medical Society and ProAssurance Casualty Company and American Physicians Assurance Corporation.

The case involves a defendant physician who sought to interview the treating physicians, but the plaintiff/patient refused to waive her confidentiality rights under HIPAA. Plaintiff signed a HIPAA Authorization releasing the medical records but refused to provide a release for "oral communications." Defendant physician then sought a protective order to permit the ex parte interviews of the treating physicians but the circuit court denied the motion.

The circuit court concluded that the HIPAA provisions relative to the protective order only pertain to documentary evidence and that HIPAA does not authorize ex parte oral interviews.

On appeal the State of Michigan Court of Appeals in Andrea L. Holman v. Mark Rasak, D.O. ruling on November 18, 2008, reversed the circuit court's order denying the defendant physician's motion for a protective order to allow him to conduct ex parte interviews with the plaintiff/patient's treating physicians. The court held that HIPAA supersedes Michigan law to the extent that its protections and requirements are more stringent than those provided by stat law. The court held that the defendants may conduct an ex parte oral interview if a qualified protective order, consistent with 45 CFR 164.512(e)(1), is first put in place.

This will be an interesting ruling to watch. Stay tuned!

WVHCA Report: $1.1B Cost Saving from Adoption of HIT

iHealthBeat reports on the release of a new report prepared by CCRC Actuaries for the West Virginia Health Care Authority.

The full report is available via the West Virginians for Affordable Health Care website and is titled, Health Care Financing in the State of West Virginia: An analysis and Projection of the Current System and Potential Transformations, August 2009.

According to the articles, the report indicates that the adoption of health information technology (HIT) and implementation of centralized medical care through medical home concepts could save West Virginia's health care system more than $1.1B in 2014. The estimates in the report used insurance claims data from more that 800,000 West Virginia residents, including data from Medicaid and Mountain State Blue Cross Blue Shield.

More details in the AP article by Tom Breen from the Charleston Gazette and Washington Post, Report: Health strategy could save W.Va. $1B.

The Washington Post article indicates:

. . . In the case of electronic prescriptions, the report estimates an overall savings of $164 million in 2014, including nearly $51 million in savings to private insurers and $42 million in savings to policyholders. . .

. . . The report estimates that a statewide rollout of medical homes would cost about $45 million up front and incur ongoing costs of about $368 million . . .

. . . Estimates suggest that about nine in 10 health care offices still keep everything in paper. As the new report says, up front costs for physicians run from $25,000 to $45,000 and have annual costs thereafter of between $2,000 and $9,000, steep amounts for small practices . . .

UPDATE: Thanks to a reader comment - you can now read the full report. The report is titled, Health Care Financing in the State of West Virginia: An analysis and Projection of the Current System and Potential Transformations, August 2009.

Following is the Executive Summary of the report which contains some very interesting statistics on the state of health care in West Virginia.


Executive Summary

• A cohort model was developed to simulate health care eligibility, utilization and insurance availability of the projected 1,828,538 West Virginians in 2009.
• The model utilizes 8,640 cohorts to represent current insured status, health care utilization, age, gender, and household income.
• The projected average age in 2009 is 40.2 years.
  
• West Virginia is projected to have a population of 1,806,545 in 2019 and the average age is projected to increase to 42.2 years.
• The number of commercially insureds is 757,884 in 2009.
• The number of non-Medicare PEIA insureds is 175,324 in 2009.
• The number of non-dual eligible Medicaid insureds is 321,113 in 2009.
• The number of dual eligible Medicaid/Medicare insureds is 57,118 in 2009.
• The number of Medicare eligible PEIA insureds is 37,784 in 2009.
• The number of other Medicare insureds is 168,571 in 2009.
• The number of West Virginia CHIP insureds is 24,480 in 2009.
• The number of uninsured West Virginians is 286,264 in 2009.
• Health care costs can be defined as charges or as allowed charges. In terms of allowed charges, projected West Virginia expenditures total $13.1 billion in 2009.
• Allowed charges are projected to grow to $24.4 billion in 2019.
• In 2009, the uninsured population is projected to incur $3.2 billion in allowed charges, resulting in bad debt and charity care of almost $900 million.
• Initiative I, Adult Medicaid Expansion, is projected to cost the State of West Virginia $56.8 million and the Federal Government $162.0 million in 2014, while overall health care expenditures will decrease $611.5 million. Low income residents see the majority of the savings, spending $591.5 million less on health care.
• Initiative II, Adult Medicaid Expansion Combined with an Insurance Mandate for Employers and Individuals, is projected to cost the State of West Virginia $56.8 million in higher Medicaid expenditures and $1,004.3 million in insurance premium subsidy. The initiative will cost the Federal Government $162.0 million in 2014, while overall health care expenditures will decrease $2,176.0 million. Low income residents see the majority of the savings, spending $2,212.8 million less on health care.
• Initiative III, Adult Medicaid Expansion combined with an Insurance Mandate for Individuals, is projected to cost the State of West Virginia $56.8 million, $983.4 million in insurance premium subsidy. The initiative will cost the Federal Government $162.0 million in 2014, while overall health care expenditures will decrease $1,634.7 million. Low income residents see the majority of the savings, spending $1,656.2 million less on health care.
• Initiative IV, Medical Home, is projected to save the State of West Virginia $57.3 million in claim expenditures and the Federal Government $199.3 million in 2014, and overall health care expenditures will decrease $642.6 million. Low income residents and insurance companies see the majority of the savings, spending $170.6 million and $173.2 million less on health care, respectively. This initiative requires $45 million of initial costs and a total of $368.2 million of ongoing physician reimbursement per year.
• Initiative V, e-Prescribing, is projected to save the State of West Virginia $16.0 million in claim expenditures and the Federal Government $53.8 million in 2014, and overall health care expenditures will decrease $164.0 million. Low income residents and insurance companies see the majority of the savings, spending $41.9 million and $45.6 million less on health care, respectively. The cost of implementing e-prescribing has not been projected.
• Initiative VI, Electronic Medical Records, is projected to save the State of West Virginia $28.3 million and the Federal Government $98.5 million in 2014, and overall health care expenditures will decrease $317.6 million. Low hncome residents and insurance companies see the majority of the savings, spending $84.3 million and $85.6 million less on health care, respectively. This initiative requires around $25,000 to $45,000 of initial costs and an annual cost of $3,000 to $9,000 per provider. However, these cost estimates appear to be declining over time.
  

FTC Exploring Privacy: Rountable Series

Over the next couple of months the Federal Trade Commission (FTC) will be hosting the Exploring Privacy: A Roundtable Services.

The roundtable discussions are day-long public roundtable discussions to explore the privacy challenges posed by the vast array of 21st century technology and business practices that collect and use consumer data.

The FTC indicates that the "roundtable discussions will cover topics including social networking, cloud computing, online behavioral advertising, mobile marketing, and the collection and use of information by retailers, data brokers, third-party applications, and other diverse businesses. The goal of the roundtables is to determine how best to protect consumer privacy while supporting beneficial uses of the information and technological innovation."

More information can be obtained on the FTC's Exploring Privacy website, including the dates and locations of the upcoming roundtable events in Berkeley, CA and Washington, DC, submitted public comments and other information.

The first roundtable was held this week in Washington, DC. Details of the event are available on the website including two interesting charts -- Data flow chart (personal data ecosystem) and Data flow charts (medical, social networking, mobile, behavioral advertising, and retail loyalty card).

Chief Data Rights Officer

I love the creative and mind opening nature of Twitter tweets. Simple 140 character thoughts, questions, queries, etc.

As a lawyer who deals with pages, reams, volumes, boxes, rooms of written information on a daily basis I'm often amazed (and pleased) by the depth of concepts that can be expressed through 140 characters.

Example from today, @SusannahFox's tweet:

@SusannahFox What if, instead of a chief #privacy officer, ONC changed the conversation and appointed a chief data rights officer?

Susannah gets my "tweet of the day" award.

2009 Engage With Grace Thanksgiving Weekend Blog Rally

Last year Paul Levy, Matthew Holt and Alexandra Drane asked me to participate in the Engage With Grace Thanksgiving Blog Rally. My post last year describes the Engage with Grace project and tells my personal story of why end of life care is important for all of us to discuss with our family and loved ones.

Along with my friends and health blogging colleagues, Paul, Matthew, Alexandra, Adam Bosworth, Christian Sinclair, Drew Rosielle, e-Patient Dave deBronkart, Jessica Lipnack, Ted Eytan and many others - we ask that you to take time to talk to your loved ones over this holiday weekend about these important end of life questions and carry out your wishes by executing a living will and medical power of attorney.

How else can you participate in the Engage With Grace Thanksgiving Blog Rally?

If you are a blogger, spread the word about the project by adding your own post about Engage With Grace. You can use the text below (download a ready-made html version here) or tell your own story of the importance of communicating your end of life wishes. We suggest you post it starting on Tuesday, November 24 and leave it up over the entire holiday weekend.

Second, you can donate your Facebook and/or Twitter status to the rally. Post a link to your post and post a status update. You can create your own status update or use the following universal update (use the following hashtag #EWG so that we can track the rally:

Pssssst - Engage with Grace at www.engagewithgrace. Join the Blog Rally. Pass it on. #EWG

Following is the 2009 Engage With Grace Thanksgiving Weekend Blog Rally blog post:

Some Conversations Are Easier Than Others

Last Thanksgiving weekend, many of us bloggers participated in the first documented “blog rally” to promote Engage With Grace – a movement aimed at having all of us understand and communicate our end-of-life wishes.

It was a great success, with over 100 bloggers in the healthcare space and beyond participating and spreading the word. Plus, it was timed to coincide with a weekend when most of us are with the very people with whom we should be having these tough conversations – our closest friends and family.

Our original mission – to get more and more people talking about their end of life wishes – hasn’t changed. But it’s been quite a year – so we thought this holiday, we’d try something different.

A bit of levity.

At the heart of Engage With Grace are five questions designed to get the conversation started. We’ve included them at the end of this post. They’re not easy questions, but they are important.

To help ease us into these tough questions, and in the spirit of the season, we thought we’d start with five parallel questions that ARE pretty easy to answer:



Silly? Maybe. But it underscores how having a template like this – just five questions in plain, simple language – can deflate some of the complexity, formality and even misnomers that have sometimes surrounded the end-of-life discussion.

So with that, we’ve included the five questions from Engage With Grace below. Think about them, document them, share them.

Over the past year there’s been a lot of discussion around end of life. And we’ve been fortunate to hear a lot of the more uplifting stories, as folks have used these five questions to initiate the conversation.

One man shared how surprised he was to learn that his wife’s preferences were not what he expected. Befitting this holiday, The One Slide now stands sentry on their fridge.

Wishing you and yours a holiday that’s fulfilling in all the right ways.



(To learn more please go to www.engagewithgrace.org. This post was written by Alexandra Drane and the Engage With Grace team. )

WVHIN Releases RFP for West Virginia Health Information Exchange

Today the West Virginia Health Information Network released a Request for Proposal (RFP) for a statewide Health Information Exchange. More information, including the deadlines, bidder worksheets and a full copy of the RFP are available on the WVHIN website.

Following are sections from the RFP that provide a general overview of the proposed West Virginia Health Information Exchange and a general scope of the RFP:

The West Virginia Health Information Network (WVHIN) is soliciting proposals to provide a statewide Health Information Exchange (HIE) infrastructure platform for physicians, hospitals, other health care organizations, and consumers. The purpose of this Request for Proposal (RFP) is to obtain vendor services and expertise in support of the WVHIN. Details on the scope of work, requirements and deliverables are contained in this RFP. WVHIN reserves the right to use the results of this RFP to obtain services for additional and related work should the need arise throughout the course of this project . . .

. . . According to the eHealth Initiative’s Sixth Annual Survey of Health Information Exchange 2009, there are almost 200 self‐reported HIE initiatives across the country with a substantially increased number of organizations that reported being operational. The impetus for HIEs has increased as a result of the passage of the American Recovery and Reinvestment Act (ARRA) of 2009 and specifically key provisions from the Health Information Technology for Economic and Clinical Health (HITECH) Act. These provisions called for the Office of the National Coordinator (ONC) to create a program to engage in collaborative agreements with states or “qualified” state‐designated non‐profit, multistakeholder partnerships to “conduct activities to facilitate and expand the electronic movement and use of health information among organizations according to nationally recognized standards.” . . .

. . . There are 1.8 million people in the very rural state of West Virginia with a high level of elderly and low‐income people in many of the rural areas. With a geographically dispersed population, access to and coordination of care is a critical issue. To serve this rural population, there is a relatively high number of hospitals with less than 100 beds and a high level of clinics serving the underserved making access and care coordination both difficult and essential. Based on the population profile and the number of small providers, a strong case was made for the need for a statewide HIE, which will help providers overcome communication and geographic barriers to access and coordination of care.

The WVHIN was established in July 2006 by the West Virginia Legislature at the request of the Governor. The WVHIN is a sub‐agency under the West Virginia Health Care Authority. The intent of the legislation was for the WVHIN “to promote the design, implementation, operation and maintenance of a fully interoperable statewide network to facilitate public and private use of health care information in the state”. With this authority, the WVHIN established a multi‐stakeholder board and has been working with stakeholders to develop and implement a state‐level HIE. . .

. . . With this mandate, the WVHIN established a vision to enable “high quality, patient centered care facilitated by health information technology”. The WVHIN mission is as follows: “The West Virginia Health Information Network provides the health care community a trusted, integrated and seamless electronic structure enabling medical data exchange necessary for high quality, patient‐centered care.” Guiding principles have been established around collaboration, facilitation of patient‐centric care, enabled participation by all providers, quality improvement, patient participation, privacy and security, and sustainability.

The WVHIN, along with health systems, physicians, other providers, payers, and consumers, has a unique opportunity to establish a state‐level HIE infrastructure that helps communities and regions share data across organizations. The WVHIN is well positioned to provide a cost‐effective HIE infrastructure that benefits from economies of scale while enabling communities to develop their own unique solutions. As a convener and collaborator, the WVHIN will build bridges between health care stakeholders to launch and fund HIEs. It will help communities address complex issues such as setting standards for interoperable data exchange, addressing liability, setting policies for privacy and security, and exchanging data across state lines. It will collaborate with other health information technology (HIT) and HIE initiatives such as the Regional Extension Center (REC) to be initiated, public health, Medicaid, and others, to leverage collective resources. WVHIN activities are being pursued within the parameters of the West Virginia Statewide Health Information Technology Strategic Plan. WVHIN is one of several participating entities that jointly developed the strategic plan.

ONC: Health IT Buzz

The Office of the National Coordinator for Health Information Technology (ONC) has launched a second blog called the Health IT Buzz Blog.

Just a few weeks ago ONC announced the new Federal Advisory Committee Blog (FACA Blog).

The initial post by Dr. David Blumenthal, MD, MPP, National Coordinator for Health Information Technology, talks about the importance of using technology to continue the conversation on Health IT and create a forum for engagement.

Dr. Blumenthal's post goes on to state:

We intend to address a wide and diverse range of timely topics relevant to the “why’s and how’s” of efforts to support the secure and seamless exchange of electronic health information. We will discuss our ongoing work to protect patient privacy, secure information, and implement standards. We’ll also be using the blog to provide additional information regarding our new grant programs. And the conversation wouldn’t be complete without discussing the meaningful use rulemaking and incentive programs, clarifying our vision and addressing key challenges.

We want to hear from citizens, patients, health professionals, managers, policymakers, technology enthusiasts and technology skeptics. We can’t succeed unless we understand the wishes and concerns of the many constituencies we serve. So join us.

Tip to @ahier who pointed out the new ONC Blog.

AHLA: EHR, HIE and PHR Legal Liability Task Force

Today I participated in the first call of the American Health Lawyers Association's Task Force on Electronic Health Records and Legal Liability.

The task force will focus its efforts on the legal liabilities associated with Electronic Health Records (EHR), Health Information Exchanges (HIE) and Personal Health Records (PHR).

The group is being led by Jud DeLoss and Kathy Kenyon, both members of AHLA. There was a wealth of health lawyer experience and expertise on the initial conference call. I'm looking forward to helping out on the effort and learning lots from the the task force members on this project.

To follow up on Jud's blog post, we would welcome any input that others have on the legal liability issues.

A 1930 Medical Record

I was recently in my hometown of New Martinsville visiting my dad, a retired family physician. When I arrived he had waiting for me a copy of one of my grandfather's medical records from the 1930s. My grandfather, Dr. Albert Coffield, practiced rural medicine in Wetzel County, West Virginia from 1911 until his death in 1936.

My dad told me the following story about the medical record.

My dad was a doctor who practiced out of his house on Coffield Ridge in Wetzel County. After my dad died in 1936 our mother sold the household furnishing and his office equipment. I was 12 years old when he died and my older brother was a first year student at West Virginia University. Since my mother wasn't employed she decided to move us to Morgantown where the University was so that my older brother could continue his college education. As a way to continue the family income she rented rooms to college students - many who came to the University from Wetzel County.

Included in the sale of the household and office furnishing was a wooden credenza with metal alphabetized slides. Behind some of the slides were some old medical records that were left in the credenza.

Thirty years later a lady who was a patient of mine brought the wooden credenza to me and told me that she had bought the credenza at the auction of my family's household items in 1936. She told me that she thought I would appreciate having it.

Here are photos of the medical record of a patient from 1934. The medical record format is simple yet complete. It contains all the important demographic and clinical information - including the patient statement, habits, family history, past history, physician examination and diagnosis. On the back is additional space for notes and a drawing of the internal organs that I suspect was meant to be used with the patient for education and instruction. It even has a built in billing record section that even the change:healthcare crowd would love.

What can these photos tell us about the current health care reform debate. Compare these photos of a medical record from 1934 to those that cost .73 cents today. Could today's physician and his or her patient get "meaningful use" out of this record?

A close up of the billing section for the change:healthcare gang.

Visualizing HR 3962: Affordable Health Care for America Act

Below is a visual of the top 500 words used in HR 3962: Affordable Health Care for America Act. Since most people (including many of our representatives in Washington) haven't read all 1,990 pages of the Health Care Reform Bill, I thought a visual aid might be helpful.

I had been thinking of creating the word cloud of the Bill since it was introduced on October 29, 2009, however, yesterday a couple of tweets by Vince Kuraitis caught my eye and I finally got around to creating the HR 3962 Wordle Cloud this morning. Vince's tweets looked into the word count of a couple of key words in the Bill. His tweets:

• @VinceKuraitis "medical home" referenced 67 times in latest House #healthreform leg
• @VinceKuraitis "pilot program" referenced 106 times in latest #healthreform leg -- lots of experimentation

In creating the cloud I was able to look at the use of some other words in the Bill. Here is what I found:

• Privacy referenced 28 times
• Insurance referenced 552 times
• Physician referenced 182 times
• Hospital referenced 330 times
• Consumer referenced 36 times
• Consumer-directed referenced 1 time
• Consumer-oriented referenced 1 time

Click graphic for larger/clearer version. Thanks to Wordle (www.wordle.net) for the cloud.

Federal Advisory Committee Blog (FACA Blog)

The Office of the National Coordinator for Health Information Technology (ONCHIT) has launched a new blog called the Federal Advisory Committee Blog (FACA Blog).

The initial post by Judy Sparrow discusses that the FACA Blog will be uses in a spirit of transparency and collaboration to help open a broader dialogue on the issues before the Health IT Standards Committee and the Health IT Policy Committee. The post also provides some background on the role that Federal Advisory Groups play under the Federal Advisory Committee Act.

The second post by Aneesh Chopra, Federal Chief Technology Officer, spells out the planned process for an open conversation that will take place over the next couple of weeks with various committee members blogging about a variety of topics (Proposed Standards, Interoperability, Vocabularies, Privacy, Security, Quality, Implementation Cases Studies).

The FACA Blog allows individuals to share public comments on each post and has an RSS feed. Great to see ONCHIT using a blog platform to quickly and efficiently distribute information about the ongoing work being done by the committees to further the health information technology efforts under HITECH.

West Virginia H1N1 (Swine) Flu Resource Center

The West Virginia Department of Health and Human Resources (DHHR) unveiled a website for sharing information and updates specific to West Virginia about the H1N1 Flu also known as Swine Flu. The website has information for prevention, schools, businesses, parents and providers.

The new West Virginia H1N1 (Swine) Flu Resource Center can be found at www.wvflu.org. The website also has includes a link to the federal Flu.Gov website with national information.

Please spread the word about the new website (but don't spread the flu).

HIPAA Enforcement Meets HITECH: HIPAA Administrative Simplification: Enforcement Rule

On October 30, 2009, the Secretary of the Department of Health and Human Services (HHS) issued the HIPAA Administrative Simplification: Enforcement Interim Final Rule, 45 CFR Part 160 (74 Federal Register 56123, October 30, 2009).

This new rule was developed and adopted by HHS to conform the enforcement regulations under HIPAA to the revisions made to HIPAA under the Health Information Technology for Economic and Clinical Health Act (HITECH), which was part of the American Recovery and Reinvestment Act of 2009 (ARRA).

The rule amends the HIPAA enforcement regulations to include the imposition of tiered ranges for civil money penalty amounts based upon an increasing culpability associated with the violation. A full chart of the violation categories and related amounts can be found in the rule.

The interim final rule is effective on November 30, 2009. Comments on the rule can be made prior to December 29, 2009.

Congressional Members Concerned About HHS Inclusion of "Harm Standard" In Breach Notification Rule

Members of the U.S. House of Representative submitted an October 1, 2009 letter of concern to Secretary Sebelius and the Department of Health and Human Services (HHS) concerning inclusion of a "harm standard" in the recently released(August 24, 2009) Interim Final Rule - Breach Notification for Unsecured Protected Health Information (45 CFR Part 160 and 164) 74 Fed. Reg. 42740.

HHS in developing the Interim Final Rule interpreted the term "compromises" as meaning that a threshold substantial harm standard should be included when determining whether a breach of data has occurred. However, the Members indicate in their letter that they considered whether a "harm standard" should be a part of the legislation and decided not to include such a standard. The letter urges HHS to revise and repeal the harm standard provisions included in the Interim Final Rule.

The letter was submitted by Rep. Henry Waxman, Rep. Charles Rangel, Rep. John Dingell, Rep. Frank Pallone, Jr., Rep. Pete Stark and Rep. Joe Barton.

Tip to Alan Goldberg, health care attorney and American Health Lawyer Association HIT Listserve Moderator, who posted a copy of the letter.

ARRA - HITECH: Health Care Information Breach Notification Regulations Now In Effect

Have you had a health data security breach? Do you know what a health data breach is? Are you required to notify individuals impacted by the breach? Do you have to notify federal agencies of such breach?

Read on for more information regarding the Office for Civil Right (OCR) and Federal Trade Commission (FTC) regulations requiring health care providers and other health data business vendors to assess and in some cases notify and report health information data breaches under the new federal law created by ARRA-HITECH.

The new regulations went into effect on September 23, 2009 and September 24, 2009, respectively, with a full compliance date of February 22, 2010. Health care providers covered under HIPAA and third party users of health information, including personal health record (PHR) companies and vendors, PHR related entities, health 2.0 companies and other third party health data service providers, should examine the regulations and understand the impact on their business.

The regulations require entities to develop internal compliance processes to act upon and advise individuals of data breaches that pose a significant risk of financial, reputational or other harm to the affected individual. The OCR regulations apply mainly to covered entities and business associates under HIPAA and the FTC regulations apply mainly to PHR vendors and PHR related entities. The regulations define a "breach" and set forth the time frames and scope of notification required. The regulations require the tracking and reporting of such data breaches to OCR and FTC. Also, OCR has published separate guidance specifying the technology and methods that will render health information unusable, unreadable and undecipherable as defined under ARRA-HITECH.

OCR has provided a summary of the breach notification rule on its website. OCR has also published instructions for reporting breaches to the HHS Secretary. The instructions include details for reporting "Breaches Affecting 500 or More Individuals" and "Breaches Affecting Fewer than 500 Individuals." OCR will also maintain a list of reported breaches that impact 500 or more individuals. The FTC also has a section on its website providing information on its health breach notification rule.

Below are links to the full regulation text:

• OCR Interim Final Rule - Breach Notification for Unsecured Protected Health Information (45 CFR Part 160 and 164) 74 Fed. Reg. 42740 (Aug 24, 2009).
  

• OCR Guidance Specifying the Technologies and Methodologies That Render Protected Health Information Unusable, Unreadable, or Indecipherable to Unauthorized Individuals for Purposes of the Breach Notification Requirements Under Section 13402 of Title XIII (Health Information Technology for Economic and Clinical Health Act) of the American Recovery and Reinvestment Act of 2009; Request for Information 74 Fed. Reg. 19006 (April 27, 2009).
  

• Federal Trade Commission: Health Breach Notification Rule: Final Rule -- Issued Pursuant to the American Recovery and Reinvestment Act of 2009 -- Requiring Vendors of Personal Health Records and Related Entities To Notify Consumers When the Security of Their Individually Identifiable Health Information Has Been Breached (16 CFR Part 318) 74 Fed. Reg. 42962 (Aug 25, 2009). The FTC has also issued a Breach Notification Form.

UPDATE (July 29, 2010):

Today the OCR/HHS issued a statement that the OCR Interim Final Rule listed above and published on August 24, 2010, is being withdrawn from the Office of Management and Budget (OMB). The full notice published on the OCR website states:

Breach Notification Final Rule Update

The Interim Final Rule for Breach Notification for Unsecured Protected Health Information, issued pursuant to the Health Information Technology for Economic and Clinical Health (HITECH) Act, was published in the Federal Register on August 24, 2009, and became effective on September 23, 2009. During the 60-day public comment period on the Interim Final Rule, HHS received approximately 120 comments.

HHS reviewed the public comment on the interim rule and developed a final rule, which was submitted to the Office of Management and Budget (OMB) for Executive Order 12866 regulatory review on May 14, 2010. At this time, however, HHS is withdrawing the breach notification final rule from OMB review to allow for further consideration, given the Department’s experience to date in administering the regulations. This is a complex issue and the Administration is committed to ensuring that individuals’ health information is secured to the extent possible to avoid unauthorized uses and disclosures, and that individuals are appropriately notified when incidents do occur. We intend to publish a final rule in the Federal Register in the coming months.

Create WV Conference 2009: A personal invitation to attend . . .

Over the last few years I have been involved in Create West Virginia, an organization affiliated with Vision Shared whose mission to create and stimulate new economy growth and empower West Virginians to grow creative communities in West Virginia. Communities centered on innovation, technology, entrepreneurship, education, quality of life and arts/culture.

Each year Create WV holds an annual conference. The first annual conference was held in 2007 and attracted approximately 250 attendees. Last year’s event held at Snowshoe Resort and attracted 395 attendees. This year’s Create West Virginia 2009 Conference is set for October 18-20 in Huntington, WV at the Big Sandy Arena.

I want to personally invite you to attend the Create West Virginia Conference 2009. Check out the keynote speakers and sessions.

A special attraction this year will be a live Mountain Stage performance on Sunday evening at the Keith Albee Theater featuring West Virginia native, Kathy Mattea, and The Songcatchers, The Ahs, Shannon Whitworth and Or, The Whale.

Click here for more information about the conference including how to register.

Feel free to forward a link of this invitation to others who you think might be interested in attending the conference.

West Virginia's Statewide Health Information Technology Strategic Plan

Over the past several months I have been involved with a group in developing West Virginia's statewide strategic plan for health information technology.

The final draft of the West Virginia Health Information Technology Statewide Strategic Plan, September 2009 is now available for review and comment. Additional comments and feedback on the strategic plan are welcome.

The strategic plan is a part of West Virginia's efforts to position itself as a national leader in implementing and adopting health information technology to improve our health care system. The strategic plan will be a part of the the state's efforts to submit applications to the Office of the National Coordinator for Health Information Technology (ONC) for funding under the State Health Information Exchange Cooperative Agreement Program and the Health Information Technology Extension Program: Regional Centers Cooperative Agreement Program, both programs developed under the American Recovery and Reinvestment Act of 2009, Title XIII - Health Information Technology, Subtitle B.

The project has been lead by the Adoption of Health Information Technology Workgroup under the West Virginia Health Improvement Institute. Both private and public stakeholders from across West Virginia have collaborated and provided input into the development of the strategic plan.

Mandatory Reading Before President Obama's Speech Tonight On Health Care

This morning I finally got around to reading the article by David Goldhill, CEO of the Game Show Network, in the Atlantic. How American Health Care Killed My Father is a thought provoking look at the failure of our current health care system.

On the eve of President Obama's speech to Congress on health care I hope he and his advisors have taken time to read the article. The article eloquently highlights much of what I have come to believe over the last few years is missing from health care. It is a time to step back from the existing complex system and refocus on the health consumer and make fundamental changes to the existing system. Incremental change treating the symptoms and not the underlying disease will only solidify the current "insurance based, employment centered, administratively complex" system now in place.

There are too many great thoughts in this article to quote them all here -- so go read the full commentary.

Some of the quotes that caught my attention:

. . . Why, in other words, has this technologically advanced hospital missed out on the revolution in quality control and customer service that has swept all other consumer-facing industries in the past two generations? . . .

. . . All of the actors in health care—from doctors to insurers to pharmaceutical companies—work in a heavily regulated, massively subsidized industry full of structural distortions. They all want to serve patients well. But they also all behave rationally in response to the economic incentives those distortions create . . .

. . . Accidentally, but relentlessly, America has built a health-care system with incentives that inexorably generate terrible and perverse results. Incentives that emphasize health care over any other aspect of health and well-being. That emphasize treatment over prevention. That disguise true costs. That favor complexity, and discourage transparent competition based on price or quality. That result in a generational pyramid scheme rather than sustainable financing. And that—most important—remove consumers from our irreplaceable role as the ultimate ensurer of value . . .

. . . But health insurance is different from every other type of insurance. Health insurance is the primary payment mechanism not just for expenses that are unexpected and large, but for nearly all health-care expenses. We’ve become so used to health insurance that we don’t realize how absurd that is. We can’t imagine paying for gas with our auto-insurance policy, or for our electric bills with our homeowners insurance, but we all assume that our regular checkups and dental cleanings will be covered at least partially by insurance. Most pregnancies are planned, and deliveries are predictable many months in advance, yet they’re financed the same way we finance fixing a car after a wreck—through an insurance claim . . .

. . . My dry cleaner uses a more elaborate system to track shirts than this hospital used to track treatment . . .

. . . But my father was not the customer; Medicare was . . . Of course, one area of health-related IT has received substantial investment—billing. So much for the argument, often made, that privacy concerns or a lack of agreed-upon standards has prevented the development of clinical IT or electronic medical records; presumably, if lack of privacy or standards had hampered the digitization of health records, it also would have prevented the digitization of the accompanying bills . . . In case you wonder who a care provider’s real customer is, try reading one of these bills . . .

. . . Keeping prices opaque is one way medical institutions seek to avoid competition and thereby keep prices up. And they get away with it in part because so few consumers pay directly for their own care—insurers, Medicare, and Medicaid are basically the whole game. But without transparency on prices—and the related data on measurable outcomes—efforts to give the consumer more control over health care have failed, and always will . . .