American Health Information Community
Electronic Health Records Workgroup
Summary of the 21st Web Conference of This Workgroup
Tuesday, February 12, 2008
PURPOSE OF MEETING
The purpose of the 21st Web conference of the Electronic Health Records Workgroup (EHR WG), chaired by Dr. Jonathan Perlin and Lillee Gelinas, was threefold:
1. To receive an update from the Health IT Adoption on their preliminary ambulatory adoption results and status of the inpatient adoption survey
2. To hear a report from the American Health Information Community’s (AHIC) Ad Hoc Clinical Decision Support (CDS) Planning Group and discuss that group’s draft recommendations
3. To hear a presentation on and give feedback on two draft detailed AHIC use cases: one on consultations/transfers of care and one on immunization/response management
The documents that informed the EHR WG’s discussion are available online at http://www.hhs.gov/healthit/ahic/healthrecords/ehr_archive.html.
INTRODUCTORY REMARKS
Dr. Perlin updated EHR WG members on what had transpired at the AHIC meeting on Jan. 22, 2008, with respect to the EHR WG’s health information technology (HIT) workforce recommendations and letter regarding the report, “Recommended Requirements for Enhancing Data Quality in Electronic Health Records”. Health and Human Services Secretary (HHS) Michael Leavitt was generally very enthusiastic about and supportive of the EHR WG’s recommendations pertaining to the health IT workforce. Karen Bell, MD, Office of National Coordinator (ONC) for Health Information Technology said that she would report back to the EHR WG at a later date on steps taken to implement the workforce recommendations. The EHR WG’s recommendations pertaining to enhancing data quality in the EHR generated a robust discussion but were also agreed to by the Community. Dr. Bell stated that those recommendations would be referred to the Certification Commission for Health Information Technology (CCHIT).
KEY TOPICS
1. Presentation: Survey of HIT Adoption by Physicians in Ambulatory SettingsDr. DesRoches
Dr. Catherine DesRoches, Massachusetts General Hospital Institute for Health Policy reported on a mail survey of health IT adoption by physicians in ambulatory care settings that she and her colleagues at the Massachusetts General Hospital Institute for Health Policy, Harvard School of Public Health, and George Washington University have been conducting. Data from the survey of 5,000 practicing physicians randomly selected from the American Medical Association’s (AMA) Physician Masterfile indicate that the availability of an EHR to physicians in ambulatory settings varies depending on the definition of an EHR is used, as well as by practice size, specialty practice, and primary setting of specialty practice. The survey has identified some major barriers to physicians’ adoption of EHRs, as well as several incentives for the adoption of EHRs. Dr. DesRoches and her colleagues are now collaborating with the American Hospital Association to field an additional survey to learn about hospitals’ adoption of EHRs and other health IT.
EHR Workgroup Members’ Discussion of the HIT Adoption Survey. Dr. Robert Juhasz of the American Osteopathic Association noted that the survey’s reliance on the AMA’s Physician Masterfile for its sample of physicians excluded osteopathic physicians, and he promised to send the EHR WG a survey of osteopathic physicians’ implementation of EHRs that was published in February 2007. Ms. Fischetti noted that a number of profiles for specialty care have been generated using the methodology of the Health Level Seven (HL7) EHR technical committee that developed a functional model for an EHR system and promised to forward that information to Dr. DesRoches.
Bonnie Anton, noting that one barrier to EHR adoption by physicians the survey found was the challenge of finding a system to meet their needs, observed that many physicians know they need some EHR system but do not know how to go about finding out what they need to get. Dr. Bell reported that CCHIT is developing a Web site to help physicians figure out what to think about when purchasing an EHR. She recommended having CCHIT Chair Mark Leavitt make a presentation on this Web site and the roadmap for certification to the EHR WG and stated that the staff of the HHS Office of the National Coordinator for Health Information Technology (ONC) would include this on the agenda for the EHR WG’s April meeting.
Staff Action Item #1: Invite Commission for Health Information Technology (CCHIT) Chair Mark Leavitt to make a presentation at the EHR WG’s April 29, 2008, meeting on CCHIT’s new Web site for helping physicians figure out how to purchase an EHR system and CCHIT’s roadmap for certification.
Several workgroup members asked questions about physicians’ resistance to EHRs (even in practices that have EHRs) as a barrier to the adoption of EHRs. Dr. Bell recommended that the Workgroup think about developing recommendations on how to market the need for interoperable EHRs (social marketing) at its April meeting.
Staff Action Item #2: Plan for a discussion of social marketing to encourage the adoption of EHRs at the Workgroup’s April 29, 2008, meeting.
2. Presentation/Group Discussion: Update from AHIC’s Ad Hoc Clinical Decision Support Planning GroupDr. Middleton
Dr. Blackford Middleton from Partners HealthCare System gave some background on AHIC’s Ad Hoc CDS Planning Group and requested Workgroup members’ feedback on some draft recommendations offered by the group. The Ad Hoc CDS Planning Group headed by John Glaser was formed in May 2007 to develop recommendations to address barriers and enablers of CDS, with the objective of improving clinical outcomes through better shared decisionmaking by providers and consumers. Representatives from five AHIC workgroups (Consumer Empowerment, EHR, Personalized Health and Clinical Care Connections, and Quality) serve on the group.
After giving the Ad Hoc CDS Planning Group’s working definition of CDS, Dr. Middleton presented the group’s draft recommendations. The Ad Hoc CDS Planning Group’s overarching draft recommendation is to establish a public-private task force to plan and provide guidance for implementing CDS recommendations. Its other draft recommendations are grouped in seven specific areas:
1. A standard CDS knowledge repository of common computable rules, algorithms, and agreed upon clinical practice guidelines
2. CDS oversight, accreditation, evidence, data quality, and transparency
3. Integration of CDS with EHR systems and incentives for adoption of CDS systems
4. Workflow issues
5. Ambulatory care
6. Consumer preferences
7. Driving measurable progress toward priority performance goals
Dr. Middleton explained that the plan is to have the various AHIC workgroups review and provide feedback as soon as possible on these draft CDS recommendations. The Ad Hoc CDS Planning Group will convene by teleconference in late February to discuss the preliminary feedback from the AHIC workgroups, then meet again in late March/early April to facilitate final revisions. The final CDS recommendations will be presented at the AHIC meeting on April 22, 2008.
EHR Workgroup’s High-Level Feedback on the CDS Recommendations. Dr. Peter Elkin, Mayo Clinic reported that the Population Health Technical Support Committee of the Healthcare Information Technology Standards Panel (HITSP), which he chairs, will be meeting to discuss CDS standardization in the next few months. He invited anyone interested to participate. Dr. Middleton expressed interest in this work.
Ms. Gelinas asked whether the Ad Hoc CDS Planning Group’s CDS recommendations were built around the knowledge needed by different health professions (physicians, nurses, pharmacists, etc.) or built mostly around medical practice. Dr. Middleton said he and his colleagues recognized the need for orchestrating the efforts of the entire health care team. Dr. Friedman recommended that the scope of the Ad Hoc CDS Planning Group’s recommendations be broadened to address the whole range of what all health professionals, including public health professionals, do.
Dr. Howard Elkin from the Federation of American Hospitals asked whether the proposed national CDS system would include best evidence published in the literature or also incorporate best practices that had not been published in the literature. Dr. Middleton suggested the possibility of setting up a national CDS repository with a feedback mechanism that allows some gathering of impact or outcomes data to update knowledge of best practices or provide new learning in ways that we cannot yet imagine.
Howard Isenstein, also from the Federation of American Hospitals, noted that different hospitals currently have different rules for decision support, and asked whether the proposal was to have just one central system. Dr. Middleton explained that there would probably be a wide spectrum of approachesperhaps common approach in cases where the knowledge is certain more varied approaches where there is less certainty. There would also have to be a clear delineation between practices built on common knowledge versus practices stemming from purely local practices and procedures to implement that knowledge. Ms. Anton noted the importance of allowing customization at the local level to ensure that physicians would not be overwhelmed with information.
Dr. Bell and Dr. Elkin asked whether the CDS recommendations would cover approaches to presenting information to clinicians in a way that is usable and helpful at the point of care. Dr. Middleton replied that what they were aiming at was specifying the data model, data architecture, data structures, so that information could be presented in multiple different ways, and EHR vendors would be able to do what works for themselves and for their customers.
EHR Workgroup’s Comments Regarding the Prioritization of the CDS Recommendations. Dr. Bell asked Workgroup members to identify which of the Ad Hoc CDS Planning Group’s recommendations should be acted on in the near term (1-2 years); mid term 3-5 years; and long term (more than five years). Workgroup members gave some preliminary thoughts regarding the prioritization, and it was agreed that the Workgroup members could mail additional thoughts in via e-mail for the next few days.
- Linda Fischetti said that Recommendation OA.1 (“A public-private task force should be established…”) and all of its subcomponents should be a priority. Dr. Elkin and Dr. Hayes agreed. Dr. Elkin added that the composition of the group should reflect leadership in CDS in knowledge representation and also in logic systems.
- Some members identified Recommendation 1 (“Establish a standard CDS Knowledge Repository Model…”) as another priority:
- Hon Pac said that Recommendation 1.2 (“Identify a specific set of CDS intervention types…”) is important.
- Dr. Juhasz and Dr. Hayes said Recommendation 1.4 (“Develop a national repository of public domain evidence-based best practices…”) is important.
- Ms. Fischetti recommended taking the entire domain of Ambulatory Care (including Recommendation 5.1 and it subcomponents) and then staging those recommendations out in terms of what should be acted on in the near term (1-2 years); mid term 3-5 years; and long term (more than 5 years).
Staff Action Item #3: EHR WG members should submit additional suggestions via e-mail regarding (1) the prioritization of Ad Hoc Clinical Decision Support (CDS) Planning Group’s draft recommendations; and (2) which of the Ad Hoc CDS Planning Group’s draft recommendations should be rolled out in the near term (1-2 years); mid term 3-5 years; or long term (more than 5 years).
3. Presentation/Group Discussion of Two Draft Detailed AHIC Use CasesONC Use Case Team
Copies of two draft detailed AHIC use casesone on consultations and transfers of care and the other on immunizations and response managementwere provided to EHR WG members prior to the meeting, and ONC staff gave a high-level overview of the use cases. The public comment period for these use cases closes on Friday, Feb. 15, 2008, and Dr. Bell explained that ONC wants to make sure that Workgroup members and others with an interest have had an opportunity to review the two draft use cases and give feedback. Dr. Bell requested that EHR WG members or others with additional comments on either draft use case submit them to ONC by Friday, Feb. 15, 2008.
EHR Workgroup’s Comments on the Consultations & Transfers of Care Use Case. Noting that the workflows for “consultations” and “transfers of care” are quite different, several EHR WG members, including Dr. Bell, Dr. Juhasz, Dr. Robert Smith, Dr. Middleton, and Dr. Elkin, recommended splitting the “consultations” and “transfers of care” portions of the use case into two different use cases.
Dr. Bell stated that the terms “consultations” and “referral,” have different meanings across the country. She and other EHR WG members emphasized that it was important not to define the terms too narrowly (e.g., in a way that would exclude telecom referrals) in the use case. ONC staff explained that the use case relies on a functional definition of “consultation” meaning that means that one provider (e.g., a primary care physician) requests that another provider (e.g., a specialist) provide care but the patient continues to be managed by the requesting physician.
Dr. Elkin, noting that he sometimes refers a patient to someone for a consult and the consulting physician does not answer the question he asked, recommended that the use case incorporate a question from a referring physician that is tied to the data that drove the question and is available to the person doing the consultation, so that can the person doing the consultation can give an appropriate answer and also attach additional data from the record electronically.
Dr. Elkin also suggested that the people transporting a patient from a community hospital to a tertiary care facility or from a hospital to a rehab facility be included as one of the perspectives.
EHR Workgroup’s Comments on the Immunizations & Response Management Use Case. Dr. Elkin stated that the HITSP’s Population Health Technical Support Committee that will develop interoperability specifications from the Immunizations & Response Management Use Case is very excited about having this use case to work on, because it will have an immediate and lasting impact. He added that this HITSP committee, which he chairs, has made 97 recommendations pertaining to this use case. Two of them are (1) linking disease registries with immunization registries; and (2) addressing the legal aspects of adult immunization (perhaps with assistance from the Council of State and Territorial Epidemiologists or Centers for Disease Control and Prevention).
Finally, Dr. Elkin said that the use case mentions the Vaccine Adverse Event Reporting System, but quite a few other adverse event reporting systems exist, and adverse event reporting is such a large topic that it probably should have its own use case rather being a small subset of this or other use cases.
Dr. Bell emphasized that it was important to pay attention in the use case to the different delivery systems involved when vaccines are administered routinely as opposed to being administered during an outbreak of a disease.
CONCLUDING REMARKS
Dr. Bell reminded everyone that the next AHIC meeting would be Tuesday, Feb. 26, 2008, at the Healthcare Information and Management Systems Society (HIMSS) Conference in Orlando, Florida, and the next EHR WG Web conference would be Tuesday, April 29, 2008. There were no public comments, and the meeting ended at 3:45 p.m.
SUMMARY OF ACTION ITEMS
Staff Action Item #1: Invite Commission for Health Information Technology (CCHIT) Chair Mark Leavitt to make a presentation at the EHR WG’s April 29, 2008, meeting on CCHIT’s new Web site for helping physicians figure out how to purchase an EHR system and CCHIT’s roadmap for certification.
Update: Dr. Leavitt scheduled to address these issues during his presentation to the WG on 4/29.
Staff Action Item #2: Plan for a discussion of social marketing to encourage the adoption of EHRs at the Workgroup’s April 29, 2008, meeting.
Update: Will be briefly addressed by Dr. Leavitt as he introduces CCHIT’s www.ehrdecisions.org effort. Additional social marketing deferred for a future meeting.
Staff Action Item #3: EHR WG members should submit additional suggestions via e-mail regarding (1) the prioritization of Ad Hoc Clinical Decision Support (CDS) Planning Group’s draft recommendations; and (2) which of the Ad Hoc CDS Planning Group’s draft recommendations should be rolled out in the near term (1-2 years); mid term 3-5 years; or long term (more than 5 years).
Update: Completed. CDS letter presented to AHIC on 4/22. Update on CDS efforts and AHIC discussion to take place during 4/29 workgroup meeting.
MEETING MATERIALS
Agenda
DRAFT Meeting Summary (Dec. 4, 2007 Meeting)
DesRoches: HIT Adoption by Physicians in Ambulatory Settings
Middleton: Clinical Decision Support Proto-Recommendations
Clinical Decision Support Proto-Recommendation Background Letter
Consultations and Transfers of Care IRM Draft Detailed Use Case Overview for the AHIC EHR Workgroup
Consultation & Transfers of Care Detailed Use Case
Immunizations & Response Management Draft Detailed Use Case
Electronic Health Records Workgroup
Members and Designees Participating in the Web Conference
| Co-chairs | |
| Lillee Gelinas | VHA, Inc. |
| Jonathan Perlin | Hospital Corporation of America |
| Office of the National Coordinator for Health Information Technology Staff | |
| Karen Bell & David Hunt | |
| Alicia Bradford | |
| Members and Designees | |
| Bonnie Anton | University of Pittsburgh Medical Center |
| Peter Elkin | Mayo Clinic |
| Linda Fischetti | Veterans Health Administration |
| Richard Hays & Jason Kreuter | American College of Cardiology |
| Howard Isenstein (for Charles Kahn) | Federation of American Hospitals |
| Robert Juhasz | American Osteopathic Association |
| Mike Kappel (for Pam Pure) | McKesson |
| Hon Pac | Department of Defense |
| Robert Smith | Veterans Health Administration |
| Jon White | Agency for Healthcare Research and Quality |
| Presenters: | |
| Catherine DesRoches | Massachusetts General Hospital Institute for Health Policy |
| Blackford Middleton | Partners HealthCare System |
Disclaimer: The views expressed in written conference materials or publications and by speakers and moderators at HHS-sponsored conferences do not necessarily reflect the official policies of HHS; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.