Meaningful Use Attestation by Psychiatrists

The ONC released a spreadsheet recently of all the eligible providers (Medicare and Medicaid) who attested to Stage 1 Meaningful Use (MU) of certified electronic health records (EHRs). I downloaded the results and did some pivot table magic to see which EHRs are being used by physicians identifying their specialty as "psychiatry."

There were 285 people who said they were compliant with Stage 1 MU. Interestingly, there were others who identified themselves in other ways. Three were "Community Mental Health Centers," even though HITECH specifically included them (but a doc there can attest, so I guess it's ok); they used Meditech and HCA. Five identified as "psychiatric" (Cerner, Design Clinicals, Siemens, and Wellsoft). And 16 as "psychiatric unit (Epic, Cerner, NextGen, McKesson, GE, HCA, Meditech, Midas+, Siemens). Here is data on the 285 identified as "psychiatry." If I get ambitious, I'll come back and hyperlink the names.

[edit 2/26: the links are in the Clinical Psychiatry News version of this article]

After discounting the large system products (eg, Epic, Cerner), you can get an idea about the EHR products being used in outpatient private practices.

Vendor Name	EHR Product Name	Total	% of all Psychiatrists
Epic Systems Corporation	EpicCare Ambulatory - Core EMR	129
	EpicCare Inpatient - Core EMR	2
Epic Systems Corporation Total		131	46.0%
Practice Fusion	Practice Fusion	22
Practice Fusion Total		22	7.7%
Cerner Corporation	Health Sentry	8
	Millennium Powerchart, Healthe Exchange, IQHealth, Health Sentry, Cerner Health	1
	Powerchart and Cerner Healthe	8
Cerner Corporation Total		17	6.0%
Allscripts	Allscripts ED	1
	Allscripts Enterprise E HR Modular	2
	Allscripts Enterprise EHR	2
	Allscripts ePrescribe	1
	Allscripts MyWay EHR	1
	Allscripts PeakPractice	1
	Allscripts Professional EHR	5
Allscripts Total		13	4.6%
Community Computer Service, Inc.	MEDENT	9
Community Computer Service, Inc. Total		9	3.2%
Valant Medical Solutions, Inc.	Valant Premium Psychiatric Suite	9
Valant Medical Solutions, Inc. Total		9	3.2%
DrFirst	Rcopia MU	8
DrFirst Total		8	2.8%
MedSeek, Inc.	eHealth ecoSystem	8
MedSeek, Inc. Total		8	2.8%
WellCentive	WellCentive Registry	8
WellCentive Total		8	2.8%
eClinicalWorks LLC	eClinicalWorks	6
eClinicalWorks LLC Total		6	2.1%
ICANotes, LLC	ICANotes EHR/EMR for Behavioral Health	6
ICANotes, LLC Total		6	2.1%
NextGen Healthcare	NextGen Ambulatory EHR	5
	NextGen Inpatient Clinicals	1
NextGen Healthcare Total		6	2.1%
McKesson	Medisoft Clinical	4
McKesson Total		4	1.4%
e-MDs, Inc.	e-MDs Solution Series	3
e-MDs, Inc. Total		3	1.1%
MedPlus, A Quest Diagnostics Company	Care360 EHR	3
MedPlus, A Quest Diagnostics Company Total		3	1.1%
UNI/CARE Systems, Inc	Pro-Filer(TM)	3
UNI/CARE Systems, Inc Total		3	1.1%
AmazingCharts.com, Inc.	Amazing Charts	2
AmazingCharts.com, Inc. Total		2	0.7%
Greenway Medical Technologies, Inc.	PrimeSuite	2
Greenway Medical Technologies, Inc. Total		2	0.7%
MedCPU Inc.	Meaningful Use Advisor	2
MedCPU Inc. Total		2	0.7%
Meditab Software, Inc.	IMS	2
Meditab Software, Inc. Total		2	0.7%
MTBC (Medical Transcription Billing Corporation)	MTBC-EHR	2
MTBC (Medical Transcription Billing Corporation) Total		2	0.7%
Nuesoft Technologies, Inc.	NueMD EHR	2
Nuesoft Technologies, Inc. Total		2	0.7%
Office Ally	EHR 24/7	2
Office Ally Total		2	0.7%
TheraManager LLC	MaestroMed	2
TheraManager LLC Total		2	0.7%
Waiting Room Solutions	2011 Waiting Room Solutions Web Based EHR and Practice Management System	2
Waiting Room Solutions Total		2	0.7%
ADP AdvancedMD	AdvancedMD EHR	1
ADP AdvancedMD Total		1	0.4%
athenahealth, Inc	athenaClinicals	1
athenahealth, Inc Total		1	0.4%
DrChrono.com Inc.	drchrono EHR	1
DrChrono.com Inc. Total		1	0.4%
GE Healthcare	Centricity EMR	1
GE Healthcare Total		1	0.4%
HealthFusion	MediTouch EHR	1
HealthFusion Total		1	0.4%
Henry Schein Medical Systems	MicroMD EMR	1
Henry Schein Medical Systems Total		1	0.4%
Ingenix	Ingenix CareTracker	1
Ingenix Total		1	0.4%
IOS Health Systems	Medios	1
IOS Health Systems Total		1	0.4%
iSALUS Healthcare	OfficeEMR	1
iSALUS Healthcare Total		1	0.4%
Medical Informatics Engineering	WebChart EHR	1
Medical Informatics Engineering Total		1	0.4%
SuiteMed	Intelligent Medical Software (IMS)	1
SuiteMed Total		1	0.4%
Grand Total		285

Hmm, the numbers are cut off. I placed this here in a Google Doc so you can see all the data.

Health Insurance Exchange Regs: Mental Health Coverage and 45 CFR Parts 155-156

The NPRM for the Health Insurance Exchanges portion (45 CFR Part 155 & 45 CFR Part 156) of the Affordable Care Act came out yesterday (thanks for the tip-off, +David Harlow). I quickly scanned it for specific mentions of standards related to mental health coverage. See below for relevant sections. (I'll look at Part 153 later.)

First impressions: it does encourage specific considerations for folks with mental illnesses and other disabilities be addressed, but I am so far (just based on the above) unimpressed with provisions ensuring parity for this population -- a population that was heavily marginalized and discriminated against during the managed care cycle from the 80s and 90s. I did not find a single reference to the Mental Health Parity Act (45 CFR Part 146), either. It also mentions the need for accurate provider directories, which are notoriously inaccurate in behavioral health. It encourages input about how to hold Exchanges accountable for accuracy, including indicating whether providers are accepting new patients.

[pg 30] According to section 1311(d)(6) of the Affordable Care Act, Exchanges are required to consult with certain groups of stakeholders as they establish their programs and throughout ongoing operations. We propose that the Exchange consult on an ongoing basis with key stakeholders, including:

• a. Educated health care consumers who are enrollees in QHPs; “educated” is the term used in Section 1311(d)(6)(A) of the Affordable Care Act to describe consumers who must be consulted. We recommend that Exchanges include in these consultations individuals with disabilities;
• b. Individuals and entities with experience in facilitating enrollment in health coverage;
• c. Advocates for enrolling hard-to-reach populations, which includes individuals with a mental health or substance abuse disorder. We also encourage Exchanges to include advocates for individuals with disabilities and those who need culturally and linguistically appropriate services;

[pg 44] In paragraph (e), we propose that the Exchange conduct outreach and education activities to educate consumers about the Exchange and to encourage participation, separate from the implementation of a Navigator program described in §155.210. Exchanges should aim to maximize enrollment of eligible individuals into QHPs to increase QHP participation and competition which in turn increases consumer choice and purchasing clout. This will also reduce the number of individuals without health insurance coverage. We encourage Exchanges to conduct outreach broadly as well as in ways that are accessible to people with disabilities,

individuals with low literacy, and those with limited English proficiency. In addition, we encourage Exchanges to target specific groups including hard to reach populations and populations that experience health disparities due to low literacy, race, color, national origin, or disability, including mental illnesses and substance use disorders.

[pg 186] §155.130 Stakeholder consultation.
The Exchange must regularly consult on an ongoing basis with the following
stakeholders:

• (a) Educated health care consumers who are enrollees in QHPs;
• (b) Individuals and entities with experience in facilitating enrollment in health coverage;
• (c) Advocates for enrolling hard to reach populations, which include individuals with a mental health or substance abuse disorder;
• (d) Small businesses and self-employed individuals;
• (e) State Medicaid and CHIP agencies;
• (f) Federally-recognized Tribes, as defined in the Federally Recognized Indian Tribe List Act of 1994, 25 USC §479a, that are located within such Exchange’s geographic area;
• (g) Public health experts;
• (h) Health care providers;
• (i) Large employers;
• (j) Health insurance issuers; and
• (k) Agents and brokers.

[pg 202] §155.430 Termination of coverage.

...

(c) Termination of coverage tracking and approval. The Exchange must –

• (1) Establish mandatory procedures for issuers of QHPs to maintain records of termination of coverage;
• (2) Track number of coverage terminations and submit that information to HHS on a monthly basis;
• (3) Establish standards for termination of coverage that require issuers of QHPs to provide reasonable accommodations to individuals with mental or cognitive conditions, including mental and substance use disorders, Alzheimer’s disease, and developmental disabilities before terminating coverage for such individuals; and
• (4) Retain records in order to facilitate audit functions.

Risks & Benefits of HIE's: "Sensitive" Health Information

[cross-posted from Shrink Rap]

I participate in a committee that establishes policies for our state's health information exchange (HIE). The HIE is the electronic infrastructure that permits hospitals, physician groups, labs, imaging companies, pharmacies, and others to share information about patients. The idea behind the sharing is to make it easier for your primary care doctor to share your health data (ideally, with your permission) with your cardiologist and your dermatologist. The potential benefits to this sharing include:

• quicker exchange of information than with faxing or mailing
• less likely for papers to get misfiled or lost (eg, think Hurricane Katrina)
• better tracking of who accessed what information
• less duplication of tests ("I know you had a CAT scan at the other hospital last week but I can't wait for the results to be sent to me so I'm getting another one.")
• improved coordination of care
• fewer medical errors due to more information available
• decreased liability due to sharing of important information with other providers

The potential risks include:

• decreased privacy due to potential for data breach, identity theft
• loss of data due to technical problems (viruses, hardware failure, etc)
• failure to secure data due to inadequate authentication, authorization, encryption, etc
• more errors in health record due to automated data collection processes
• increased liability due to sharing of sensitive information with other providers

I wanted to talk briefly about this notion of "sensitive health information." Our committee has spent many hours discussing what this might mean and how to define it. One view is that all health information should be treated as "sensitive," while another is that only certain categories of health information, such as mental illness, substance abuse, HIV status, domestic violence, abortion history, and genetic data, should be treated with additional safeguards against inadvertent access or disclosure. This latter viewpoint promotes the stigma about mental illness that we have been trying to erase. It wasn't so long ago that epilepsy and cancer might have been on this list. My viewpoint is that patients should be the one to decide which elements of their health information should be treated with extra precautions and which should be considered routine.

This was ultimately agreed upon by the other committee members, but it still didn't help us much because the technology for patients to review their health information and mark which bits should be tagged as sensitive is not yet built into nearly any of the electronic health record products or the HIE systems. There is no standard for doing so nor is there even any agreement about how or whether it should be done. Groups like healthdatarights.org and speakflower.org have promoted these ideals, but we are not much closer to achieving them.

Anyway, I discussed this topic in my Shrink Rap News blog post this week over on Clinical Psychiatry News. Read more about it over there. If you are a psychiatrist, log in or register on CPN and join the discussion (my mistake -- other professionals and also consumers are allowed to register over there).

AMIA 2010: Sunday

My first AMIA meeting and I'm finding it filled with all sorts of goodies. There's lots of tweeting going on, too. (Go to TweetChat with hashtag #AMIA2010 to keep up.)

I typed some notes and thought I'd put them here (1) so I can find them again easy and (2) some folks may find them useful (thought maybe somewhat cryptic). (The odd formatting is from OmniOutliner; I've given up on fixing the font colors--the red means nothing--and the bullets don't line up right.)

▼ AMIA 2010 Susan Dentzer, Editor Health Affairs

2010.11.14

▼ "Golden Age" of PPACA (?)

• compared Greek myth of Ae____ to Obama

▼ Open up goldmine of data to public

• CHDI website www.hhs.gov—open

• use data to shape community responses to childhood obesity... Children's Optimal Health

▼ [] l/u Health Affairs 2010 Nov 29:2047

• rapid-cycle improvement of medical home care @Geisnger

• reductions in risk-adjusted chronically ill hospital admission and readmission rates

▼ Three Aims

• 1. Better Health

• 2. Better health care

• 3. Better value

▼ IOM study on variations

• look at var in HC spending, pt diversity, MD decisions on what care to give and evidence

▼ Shared decision making by pts

• ACA provision

• even informed pts don't exercise their options well

• preference-sensitive care

▼ Quotations

• Quotes by George Carlin, Churchill on American People

• Quote by Jerry Garcia re Somebody has to do something and it is pathetic that it must be us

---

▼ Informatics Issues in HIEs

20101114 Rob Kolodner, Session chair

▼ Development and use of a Medication history Service Associated with a health information exchange: Architecture and Preliminary findings

M. Frisse, Vanderbilt Center for Better Health; L. Tang; A. Belsito, M. Overhage, Regenstrief Institute

• Memphis HIE in use 4.5 yrs... still a pilot going to full force

• 48% had full med hx; getting retail pharmacies online made a big different

• 36% pt not located

• $4 generics good for pts, bad for accurate HIE data

---

▼ Emergency Medical Services: the frontier in health information exchange

JT Finnell, M. Overhage, Regenstrief Institute

• Project: push HIE data out to EMS staff in 2 counties in Indiana (Siren by Medusa), using ruggedized tablet PC

• Uses LN, FN DOB Gender, can add zip and SSN optional

• Pushes back a pdf with a bunch of data: med list, allergies, DNR status, NOK notification, PMH

• Started at 15% requests to 26% of field pts seen

• 14% of medics never used

• connectivity a problem

• 41% medics nearly always queried system

• 66% said data was important for providing care

• "truth serum" effect (we can look it up if you don't tell us the truth)

• Value with heavy utilizers and pts "found down"

---

▼ Private Medical Record Linkage with Approximate Matching

E. Durham, Y. Xue; M. Kantarcioglu; B. Malin, Vanderbilt University

• Vanderbilt -- Emory: Flaw in current model for sharing de-identified data

• If pts don't match, they can be overcounted

• prob with fragmented data (spelling, missing data, etc)

• Private Record Matching can improve this using a hash function to maintain privacy but compare individuals

• Steps:

• blocking (toss out some)

• field comparison

• similarity function measures degree of similarity using a comparison vector and into a record pair similarity score

• draw a line where scores above a number are considered a match

• record pair comparison and classification

• Fellegi-Sunter probability vectors: uses log function of an agreement weight and a disagreement weight for each field (eg, FN, LN, MOB)

• Sum the similarity scores across all fields

• Used a data corrupter function to mess up experimental data to see if they get rematched

• looked at accuracy vs runtime

• Main thing they did was to use approximate matching rather than binary matching, leading to increase in accurate matches

• Note: they used a centralized approach but hope to extend ot decentralized model.

---

▼ Continuity of Care Document (CCD) enables Delivery of Medication histories to the Primary Care Clinician

L. Simonaitis, A. Belsito, G. Cravens, C. Shen, J. Over- hage, Regenstrief Institute

• Used INPC (Indiana)... x1995, 6M pts, 3B data items

• Workflow

• pt to front desk... ADT clinic trigger sends CCD request

• printer prints med hx (CCD)

• MD reviews meds

• CCD is generated, pulling in data from SureScripts and MA, and put rx codes from dif stds in same CCD

• Results: used in 1 clinic over 9 docs and 4500 pts

• 90% of cases took less than 2 min

• med hx helped doc discover drugs they didn't know pt taking, controlled rx overuse, and med underuse

• docs usually did not show med hx to pts

• no change to MD workflow

• accommodates paper-based clinic

• [] XSLT transformation of CCD data very promising

IOM to Address Safety of EHRs

Scot Silverstein from the Health Care Renewal blog posted about IOM's recently announced contract with ONC to "identify best policies and practices for improving healthcare safety when using electronic health records."

"Perhaps these studies should have been initiated, say, ten years ago, or at least before the beneficence of health IT and its capacity to revolutionize medicine was openly promoted by the past and current Administrations (the current one going so far as to institutionalize penalties for non adopters)?"

The IOM consensus study, entitled "Patient Safety and Health Information Technology," will be conducted by NAS staffers Samantha Chao, Joi Washington, and Erin Wilhelm:

"The IOM will review the available evidence and the experience from the field on how the use of health information technology (HIT) affects the safety of patient care and make recommendations on how public and private actors can maximize the safety of HIT-assisted health care services. The IOM's final report will be both comprehensive and specific in terms of recommended options and opportunities for public and private interventions that may improve the safety of care that incorporates the use EHRs and other forms of HIT."

While I agree that this effort should have been done long ago, I am glad to see it being addressed. There is much polarization about whether EHRs are the best thing since sliced bread or the worst thing to hit medicine since managed care. Perhaps this IOM study will address both the pros and cons of EHRs from a provider's perspective (though I don't think any of the study staff are providers). Health care providers need to have a voice that can be heard by the vendors and governments when we find that given instances of EHR usability are inefficient or unsafe, and maybe this study will recommendations to address this current gap.

APA Annual Meeting in New Orleans 2010 #apanola2010

Lots of discussion about EHRs at this year's American Psychiatric Association meeting in New Orleans. Other topics of interest to me included TMS (transcranial magnetic stimulation for the treatment of depression), social media, and about the APA's role in helping its members adopt certified electronic health records.

Today at 11am the Committee on Electronic Health Records is presenting in Room 340 at the Convention Center: The Train Has Left the Station: National Incentives and Developments in Electronic Health Records.

Other IT talks were listed in John Luo's article, Your Annual Meeting IT Guide.

HIMSS EMR Adoption Model: 2009 Level 4 (CPOE) Only 14%

Hospitals in 2009 continued to have low CPOE adoption (Level 4), but they did manage to jump from 5.8% to 13.5% having CPOE (Computerized Provider Order Entry) from 2008 to 2009.

Looking at the HIMSS EMR Adoption Model trends, you can see how the 5000+ hospitals in the US are gradually moving up the electronic evolutionary ladder towards Level 7, which is full implementation of a completely interoperable, paperless, electronic medical record (note that HIMSS differentiates an "EMR" (within a single organization) from an "EHR", which it defines to specifically be a "subset of each care delivery organization's (CDO) EMR, ... owned by the patient and has patient input and access that spans episodes of care across multiple CDOs within a community, region, or state...").

As a reminder, here are the definitions of the levels (from HIMSS):

It'll be interesting to see how the HITECH Act's financial incentives accelerates adoption of the higher levels (4 and up). Looking at the cumulative adoption percentages below, I'd expect Level 4 to take off in the same way that Level 3 has over the past several years. But that is the hardest transition to achieve due to the dramatic changes in physician workflow required. This is easier to achieve in hospitals where the majority of the physicians are employed by the hospital; however, physicians at most hospitals (especially community hospitals) are not employed, so these hospitals have less fortitude in requiring them to enter their own orders.

Any guesses as to what the 2010 adoption numbers will be?