Needless to say that it’s a good two years plus since ARRA was signed

Hope this helps.

SURPRISE! If you are planning on seeing the MEDICAID money soon, please note that you are at THE STATE’S MERCY IRRESPECTIVE OF FEDERAL REGULATION.

The Medicaid EHR Incentive Program is offered and administered voluntarily by states and territories. States can start offering their program to eligible professionals as early as 2011. The program continues through 2021. Eligible professionals can participate for 6 years throughout the duration of the program. The last year to begin participation in the Medicaid EHR Incentive Program is 2016.

• To qualify for Medicaid incentive payments, Medicaid eligible professionals must adopt, implement, upgrade, or demonstrate meaningful use of certified EHR technology in the first year of participation, and successfully demonstrate meaningful use in subsequent participation years.

• There is no reporting period for Medicaid in the first year of adoption, as late as 2016 ( the final year accepted for adoption for Medicaid EPs) since it’s A/I/U for Medicaid in the first participating year,

• EPs have to self attest of adopt/implement/upgrade to a certified version

• 2011 being the first year of program a Medicaid EP has to A/I/U any time between Jan 1, 2011 to Dec 31, 2011.

• However the last day for registration to prove A/I/U for the above period is Feb 29,2012 ( this date extension as I understand is only since its the first year of the program

• EP has to demonstrate MU compliance in the second year for participation ( first reporting period) for 90 days and full year for all subsequent 4 years

• The incentives are paid only once per reporting period ( Medicaid is the calendar year )

• For calendar years 2011–2021, participants can receive up to $63,750 over 6 years under the Medicaid EHR incentive program.

1. EHR incentive payments are made by the state based on the calendar year.

2. $21,250 for the first participation year ( not a reporting year as requirement is self attestation of A/I/U to a certified EHR

3. $8500 for all subsequent reporting periods ( years)

Important Dates

• October 1, 2010 – Reporting year begins for eligible hospitals and CAHs.
• January 1, 2011 – Reporting year begins for eligible professionals.
• January 3, 2011 – Registration for the Medicare EHR Incentive Program begins.
• January 3, 2011 – For Medicaid providers, states may launch their programs if they so choose.
• April 2011 – Attestation for the Medicare EHR Incentive Program begins.
• May 2011 – EHR Incentive Payments expected to begin.
• July 3, 2011 – Last day for eligible hospitals to begin their 90-day reporting period to demonstrate meaningful use for the Medicare EHR Incentive Program.
• September 30, 2011 – Last day of the federal fiscal year. Reporting year ends for eligible hospitals and CAHs.
• October 1, 2011 – Last day for eligible professionals to begin their 90-day reporting period for calendar year 2011 for the Medicare EHR Incentive Program.
• November 30, 2011 – Last day for eligible hospitals and critical access hospitals to register and attest to receive an Incentive Payment for Federal fiscal year (FY) 2011.
• December 31, 2011 – Reporting year ends for eligible professionals.
• February 29, 2012 – Last day for eligible professionals to register and attest to receive an Incentive Payment for calendar year (CY) 2011.

Context

A Medicaid qualified FQHC upgrades to a certified version of an EHR in 2011, and applies for and receives payment in 2011 for the Adoption, Upgrade, and Implementation Meaningful Use Incentive in 2011 of $21,250 per eligible provider.

Scenario 1:

The FQHC begins its Meaningful Use Stage 1 90-day compliance reporting period September 1, 2011 and completes the 90 day period on December 1, 2011. Can the FQHC apply for the $8,500 per provider Stage 1 compliance incentive on January 1, 2012? Can you give me citations in the regulation where this is covered?
FQHC does not have to show 90 day for fist year of participation as the first year is not a reporting year for Medicaid. FQHC gets $21,250 for self attesting to have A/I/U any time from Jan 1, 2011 to Dec 31, 2011. So I assume they have collected ( ha ha when the states are ready if ever) $21,250 for the first year. They are eligible for the next $8500 only for the first reporting year ( second year of program) which will be Jan 1, 2012 to Dec 31, 2012 during which they have to demonstrate MU for 90 days.

Scenario 2:

The same FQHC begins its Meaningful Use Stage 1 90-day compliance reporting period December 1, 2011 and completes the 90 day period on March 1, 2012. Is it still only required to do 90 days of reporting? What citations cover this scenario?

Again in the first year they do not have to have 90 days compliance. FQHC can show it A/I/U on Dec 31, 2011 and be eligible for $21,250 for the first year

Scenario 3:

The same FQHC begins its Meaningful Use Stage 1 90-day compliance reporting period January 2, 2012 and completes the 90 day period on April 1, 2012. Is it still only required to do 90 days of reporting? What citations cover this scenario?

If the same FQHC has demonstrated or proved A/I/U for 2011 ( before Dec 31,2011) and self attested for $21,250 and is starting the second year on Jan 2,2012 they are eligible for the second year $8500 for demonstrating MU for a period of 90 days from Jan 2,2012

I am privileged to be involved in the EMR projects of several health centers in Massachusetts from 2005 onwards. These few years had been the transformational stages for EMR/EHR products. I have been involved in several areas of health IT but there is no other job which is more satisfying that helping providers, nurses and medical assistants navigate the complex world of an EMR system. Above all it’s a huge change that several of them never contemplated would happen to them

Community Health centers (CHC) are possibly the most complex of ambulatory segments that one can find. They are small hospitals without the beds. CHCs serve uninsured, underinsured, underprivileged, and undocumented and a variety of demographics that one does not see in a physician practice. They also have several disciplines like behavioral health, vision and dental in addition to primary care, pediatrics and OBGYN.

How does one go about preparing a CHC for a change such as an HIT implementation?

There are four stake holders

1. Leadership (including Board of Directors)
2. Clinical
3. IT
4. Operations (non clinical)

One of the initial misconceptions is that an EMR project is an IT project. It is not. An EMR project is not tactical automation but a technology investment that needs an effective integration of people, processes and technology to succeed.

Key considerations for the leadership are the needs assessment, budgets, manpower, change management and inherent barriers among other things.

The composition of the project committee is critical to the success. As a best practice the CEO of the organization must chair the EMR project committees and Board level supervision is advisable.

Clinical leadership often does not have much knowledge about EMRs. However the younger generation of providers considers an EMR environment as a motivating factor at work.

An EMR project is all about optimizing workflows. The transition from an as-is paper environment to a to-be paperless environment. Mapping of current workflows will identify inherent barriers that may well be corrected without and EMR. An EMR project is also a very opportune moment to initiate those organizational changes that were difficult to implement

Here are some of the key considerations to bear in mind while approaching an EHR project. This list is only indicative and I will attempt to keep adding to it. Some are what you don’t see in any text books

1. is the implementation only for an EMR or does it include Practice Managements system as well? If so are the non clinical staff prepared for the change. These include front office, billing and others who will be working on this system.
a. Are you considering a parallel run with paper for some time to avoid revenue loss during implementation?
b. Have you considered the billing impact and the codes?

2.Workflows: Its all bout the workflows. How well you can map out the simplest of workflows which are efficient. This provides a standardized and easy way for users to access and use the system, workflows must be done considering the entire workforce within a user group. For e.g. among providers there may be ones who are challenged and there would be champions. Standardize a workflow that is easy and user friendly for all the users. Champions can eventually have their own workflows. I have done lot of as-is and to-be workflows. Some of those wonderful Visio charts. What I find most useful are the workflows incorporating the EHR system which is most beneficial. I used to follow a system of mapping as-is workflows and marking out red stars as barriers or challenges can be a time consuming process which is beneficial in identifying inherent barriers. My experience has taught me that mapping out a to-be workflow with the EHR maybe an economical and more efficient step. The EHR vendor will have generic workflows which experience tells us that are as ineffective as having no workflow. Every practice, clinic or even user may require customization of workflow. Its very important for the HER committee and the leadership to determine and ascertain standardized workflows. This also doubles up as cheat sheets, training manuals and a very good orientation tool for new hires. In one health center we had these files as PDF and loaded them into the back end of the EHR system which could be easily accessed using a help menu from the system. (similar to Microsoft help)Very often the as-is workflows are stored away as Visio charts

3.Communications: There are two aspects to communication 1) medium must reach all targeted audience 2) medium must be one that the target audience frequently visits 3) The language must be simple and understandable across the workforce

4.Open items list: Start and maintain an open items list to track and document changes that are done. Some examples of classification of the categories are: 1) on the EHR system 2) Workflows 3) Management and Policy 4) Technology 5) external factors. The first one being customization done to the system is crucial.

5.Customization: each practice, specialty and sometimes even user requires a different configuration or customized version. The need for this should not be undermined. These include customizing 1) workflows 2) templates 3) reports 4) databases 5) tables etc.

6.Technology and hardware: There must be a formal change management process for making changes to the EMR system. This is critical so as to ensure that after a certain level of maturity the customizations are minimal and only on an absolutely necessary basis. The technology folks must also keep close liaison with vendors to ensure that all upgrades, patches and hot fixes are implemented on their system in a timely manner and the customized templates are backed up and protected during the upgrades. At the user end laptops, tablets, printers, login, access. Ensure to have all the peripherals configured to respective users. Have you considered the security of hardware?

7.Champions: There will be and there must be champions in every user group. This is a very useful thing for a train-the trainer approach. However be careful of one aspect. These champions sometime are more interested in demonstrating their technology prowess and may not be very cognizant of the entire workgroup. This is significant and its in areas like this a standardized workflow is immensely helpful. Therefore champions must 1) be always positive about the system and be self motivators, 2) they must learn and 3) know the system well and consider that their suggestions will impact the their peers

8.Training and go-live: Train-the trainer approach and training on the job is also very effective in addition to class room sessions. If you anticipate vendor training sessions, be sure to negotiate the hours and rates in the contract. Go-live support is critical. I have spent hours and days and weeks hooked on to pager. Trust me this is one of the most rewarding of experiences for me. Often sitting on corridors, jumping from one computer to the next. It is worthwhile to engage consultants for this effort.

9.Abstraction: There must be an organizational policy on abstraction as to what needs to be abstracted and who needs to do it. Very often it is seen that a provider has a patient in front of her and no histories, problem lists, allergies or medications are abstracted. In my opinion there may soon be federal and state government policies around abstraction but as governments are reactive this may arise out of lawsuit.

10.In house expertise: several people ask me as to what are the staff benchmarking levels for EHR systems. Are they similar to IT 9(where it is 1 for every 50 or so). I would say that have at least one expert who will do template and report customization and able to provide go-live support and training. If for a large health center with more than 50 providers it may be useful to have two people one focusing on the practice management system ( registration, scheduling and billing)

11.Leadership engagement: the importance of leadership engagement cannot be stressed enough. This includes leadership across the functional areas and executive leadership

12.Meetings: Please make meetings relevant and decisive. One of the best definitions for a meeting I have heard is “place where minutes are saved and hours wasted”. Keep meetings sharp. Make decisions.

13.Contract negotiation: Vendors are most responsive before you sign the contract. Negotiate hard and you will be surprised that you will get it.

a. Look at comprehensive pricing for Practice Management and EMR systems
b. Upgrades ( if charged)
c. Meaningful use compliance
d. Training hours and rates
e. Customer support ( telephone, WebEx and in person)
f. Customization hours and rates
g. Licenses ( full and part time and mid level providers, residents etc)

14.Change: Above all bear in mind that the implementation of an EHR system is a great opportunity to effect change and remove some of those old barriers. So don’t lose this opportunity!!

Dear friends
I am your classmate Alex and I am running for student council.

Thank you.

For those of us whose universe is health IT/ EMR/EHR et al. the term “ meaningful use” is probably the two most important words.

For any others who are reading this it simply means that if you adopt and implement electronic medical record systems which are certified by authorized organizations you as a provider or hospital are eligible for substantial incentives from CMS ( Medicare is $44,000 over 5 years and Medicaid is 63,750 over 6 years per provider). This is part of the efforts by Obama administration to increase adoption of health IT or EHR systems which in turn will save costs and increase efficiency, safety and quality (clinical) outcomes.

This is appropriated by American Recovery and Reinvestment Act (ARRA). The total expected outflow is close to $40 billion and about $27 billion is for the above CMS incentive program, the rest being funding to other agencies like Office of the National Coordinator of Health IT, Health Resource Service Administration, and Agency for Healthcare Research and Quality among others for research and to increase EHR adoption within specific sectors.

The expectation is that at least 100,000 providers will adopt interoperable and certified EHR systems and the information can be freely exchanged through a secure Nationwide Health Information network (NHIN). CMS was chosen as a catalyst because its the largest player in the healthcare market commanding physician affiliation from practically all physicians in the country (Medicare and Medicaid may include almost all physicians except pediatricians who do not cater to Medicaid patients)

Consider an alternate scenario where if the government had decided to invest in an EHR system and give it free ( along with implementation support) to all Medicare and Medicaid physicians. Well for sure that would have been socialist or even Communist? Right? BUT would it have done the job so much better at a fraction of the cost and with an effective carrot and stick policy to encourage and demand reporting physicians to use this system?

The Veterans Administration is a great example. They have their own EHR system VistA which facilitates health information exchange among the VA hospitals. Here is a chronology of the evolution of VistA

History VA EMR system ( source: presentation at REC summit by Dr. Kirk Stanley @Pittsfield MA 9-15-2010)

1. 1970: Proof of concept

2. 1978: 20 VA hospitals on EMR

3. 1980 : Widespread adoption of EHR

4. 1994: VistaA adopted

Results

1. Decreased Medication Errors

2. Decreased waiting times

3. Decreased no: of lab tests

4. Decreased costs

Savings to VA : $ 3 Billion

Couldn’t CMS or the Federal Government have done this? What would it have cost? I am not the CBO or an economic expert to crunch numbers but I can safely say that this would have cost a whole lot less. Here is small paper I wrote as a mock testimony for term paper in school.

Testimony of Alex Alexander before

The US Senate Committee on Health, Education, Labor and Pensions

Role of Medicare in increasing adoption of Electronic Medical Records in the Unites States April 16, 2008

Good morning Mr. Chairman and members of the committee and thank you for the opportunity to speak before you today on the increasing importance of Electronic Medical Records (EMR) and the role of Medicare in increasing its adoption. My name is Alex Alexander, an independent international consultant on Health Information Technology (HIT) here on your invitation as a subject matter expert to provide my testimony on the above subject.

Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are either age 65 and over, or who meet other special criteria such as disability.

With 44 million beneficiaries in 2007[1] and annual total outlays of $480.6 bn [2] in 2007, Medicare is the largest single purchaser of healthcare services in the Unites States.
With close to 700,000 physicians participating in Medicare in 2004[3], Medicare has the unique opportunity to catalyze EMR adoption through incentives and financing programs. Medicare should identify and clearly lay out its technology goals, incentivize the physicians and establish its own standards and criteria for EMR systems. My testimony here today is an attempt to identify and indicate specific steps where Medicare can influence and be the key player in increasing of EMR adoption among physicians in the Unites States.

Current Status of EMR in Medicare

With almost all physicians in the US (with the exception of possibly pediatricians) participating in Medicare, it has the unique distinction of being the largest government healthcare entity as well as being the prime mover in the healthcare market. As of date Medicare has not yet paid physicians directly other than for HIT/EMR pilot projects. Whereas successful private- sector initiatives like Massachusetts e Health collaborative funded by Blue Cross Blue Shield of Massachusetts remain as pilots without any framework provided by the government for a statewide rollout or nationwide adoption. Medicare, commanding the economies of scale that it does, is in a position to establish its own EMR system and exponentially increase adoption of EMR among US physicians.

Administration of Medicare

The Centers for Medicare and Medicaid Services (CMS), a component of the Department of Health and Human Services (HHS), is the administrative body that controls the operations of Medicare. The Social Security Administration is responsible for determining Medicare eligibility and processing premium payments for the Medicare program. CMS Medicare benefits are financed primarily by payroll taxes, general tax revenues, and beneficiary premiums. In addition, beneficiaries are responsible for paying a portion of the cost for most covered services in the form of deductibles and coinsurance.
Below are my recommendations where CMS or congress can have a targeted approach for the increased usage on EMR in Medicare. Medicare is singled out among the services offered by CMS, as I consider it to be the logical first step, purely due to its magnitude of operation. On successful implementation of these steps in Medicare, these efforts could be widened to include other services of CMS
Role of National Coordinator of Health Information Technology (ONCHIT)
The Office of the National Coordinator for Health Information Technology provides counsel to the Secretary of Health and Human Services (HHS) and Departmental leadership for the development and nationwide implementation of an interoperable health information technology infrastructure.[4]
The ONCHIT also provides management of and logistical support for the American Health Information Community (AHIC). The AHIC is a federally-chartered advisory committee that makes recommendations to the Secretary of HHS on how to make health records digital and interoperable, encourage market-led adoption and ensure that the privacy and security of those records are protected at all times.
Empowerment of ONCHIT with a funded mandate towards Medicare is a step in the right direction. I propose the establishment of an ONCHIT Medicare division that may be named as Medicare HIT (MEDIHIT) whose mandate could include the policy and administration of HIT and EMR systems in Medicare with a separate budget appropriated from the ONCHIT budget. The mandate of MEDIHIT could include among other things, development of a ‘Medicare EMR system’ (MMR), facilitating and negotiating prices of hardware (participating physicians will have access to these at negotiated prices), providing consultancy and logistic support during implementation, facilitate to develop training curriculum along with education materials and provide periodic upgrades to keep MMR at the cutting edge of technology. MEDIHIT will be within the administrative hierarchy of CMS exclusively dealing with HIT initiatives of Medicare.

Type of EMR and standardization criteria

MEDIHIT could select a single vendor to develop/supply EMR system to all participating physicians similar to system adopted by the Veterans Administration (VA). Medicare commands the volumes and critical mass for a reputed vendor to develop a ‘Medicare EMR system’ (MMR). Standards of certification similar or same as laid down by CCHIT (Certification Commission for Health Information Technology) and HITSP (Health Information Technology Standardization panel) could be adopted as the system specification requirement for the development of MMR. A Standardized EMR system and architecture will provide the necessary interoperable environment which will enable seamless and efficient portability and transfer of the medical records of Medicare beneficiaries. A comprehensive standardized MMR may also motivate hospitals and health organizations to purchase this system for their non Medicare patients and provide an additional revenue source for Medicare. This will also have the added advantage of encouraging health organizations, hospitals and physicians to fully migrate to EMR.

Financing and incentivizing Physicians

Participating physicians could be offered incentives by Medicare based on established criteria with a clear timeline for implementation. A carrot and stick approach by CMS would be an effective strategy whereby practicing physicians could be mandated to electronically report to Medicare through MMR, in return for compliance incentives. Mandating physicians to respond to these reporting criteria would possibly be the best way to enhance rapid adoption, drive quality and efficiency standards.
Medicare could also look at providing physicians with partial or complete assistance in the initial investment in EMR systems based on the level of investment and other need based criteria. These investment incentives may be provided either as financial grants or as discounts in the purchase of the MMR system.

Implementation support

In addition to funding and incentives, what health organizations need is support and consultancy from the procurement to the go-live (EMR fully operational) stage of an EMR implementation. MEDIHIT could have an enrollment program in each state for established consultants in HIT who will provide these services to participating physicians at MEDIHIT approved rates. The consultancy services could include expertise in organization/practice reengineering, adopting best practices, information technology (IT) infrastructure & technical support, with a single goal to maximize the benefit of the implementation dollar and avoid time and cost overruns in implementation.

Evaluation and monitoring and training

Evaluation criteria based on best practices in tune with cutting edge IT could be established and periodically monitored at fixed intervals. An incentive system based on levels of adherence to usage and reporting criteria could be built into the evaluation system. Adequately trained personnel are an essential factor to the success of any technology initiative. MEDIHIT will build its own team of subject matter experts who will develop pedagogy of training curriculum and use these to train the trainers in each individual state. The training team at the state level will in turn devise its own training schedules to hospitals and physicians.

Replication and Roll out of Pilots

A phased implementation plan is, in my opinion is the best suited and most effective prior to a national rollout. The fist phase could involve organizing efforts at NCHIT to establish MEDIHIT, development or procurement and customization of MMR and establishing interoperability standards. Further phases could be pilots involving four states (based on a competition or current performance ranking of Medicare). Feedback from the pilots could be reviewed by MEDIHIT in consultation with subject matter experts from academia like Harvard and fine tuned before a nationwide rollout.

Smart cards for mobility

Mobility is of prime concern for Medicare beneficiaries who may spend their retirement in travel and leisure. With MMR becoming a reality I wish to suggest the development of a comprehensive Medicare card ‘MEDICARD’ a scalable and upgradable smart card with interoperable capabilities to port and access the health records of Medicare beneficiaries. The smart card could be integrated or replace the current Medicare enrollment card and could have the scalable capabilities to add onto it other benefits available now to
Medicare beneficiaries or ones that are added in future. In effect the MEDICARD will be the storage of all the administrative, billing and clinical information of the beneficiary in addition to serving as a photo identity for the person.

Conclusion

It is indisputable that EMR will significantly improve quality and efficiency standards in healthcare. EMR is on the agenda of every Presidential candidate without clearly spelling out what are the concrete steps to increase adoption. It is logical to consider that any significant change can only be effected by a large market player either on the demand or supply side of healthcare. Medicare is that player in the US healthcare market and possibly the only player that can exponentially increase and catapult HIT reform. My attempt has been to outline specific steps to empower the ONCHIT with firm mandates to increase EMR adoption in Medicare.
Thank you very much Mr. Chairman and I will be happy to answer any questions.

References:

1.http://www.cms.hhs.gov/MedicareEnRpts/Downloads/HISMI07.pdf
2.http://www.cbo.gov/budget/factsheets/2006b/medicare.pdf
3.Sheera Rosenfeld, Cathy Bernasek, and Dan Mendelson ; Medicare’s next Voyage: encouraging Physicians to Adopt Health Information Technology; Health Affairs-Volume 24,Number 5
4.http://www.hhs.gov/healthit/onc/mission/

One would have thought that with that blown call Gallaraga’s chance into MLB history also went crashing. Well yes, for a perfect game but not as a beacon of stellar character and a role model for millions of children now and in the future.

Gallaraga’s reaction was astounding and even more unbelievable than Joyce’s call. There were protests from the coach, players and the whole world at large, I am sure even by Indians fans but none from Gallaraga. Nada, Zilch, Zip! Not a word of contest from him. He went back to the mound. Joyce knew he had blown it and later apologized to Gallaraga. “It was the biggest call of my life and I kicked the (expletive) out of it,” Joyce said to reporters. “I just cost that kid a perfect game.” Gallaraga further amazed everyone by being magnanimous in his response to Joyce. Here is the guy who has the most right to be upset with Jim Joyce and this is what he said? “We’re human. We all make mistakes,” Gallaraga was quoted as saying.

Joyce’s mistake was made in front of millions. Joyce admitting his mistake and showing genuine remorse and Gallaraga’s almost unbelievable response are indeed stellar examples of character.

There was however one person who could correct a wrong and that was Bud Selig the MLB commissioner. Instead he presumably took the high road and said he accepts that it was a wrong call but will not correct it because of all the right reasons of setting precedence, a call cannot be reversed etc. Talking of precedence factor alone how often a perfect game would be stolen away by a clearly blown call and the umpire would later admit it.

Seldom is a person’s life is one called to perform an act of greatness and seldom still in the public face. This was one such moment for Bud Selig and he blew it. His act of reversal would have transcended more than Baseball but somehow he could not understand it.

Rules are made for man and not man for rules. Magnifying trifles into principles or shooting butterflies with bullets are not the best of ideas.

People in power of sports organizations like MLB should also be constantly aware that in addition to the multi billion enterprises they run and control, they are also character setters/ influences for millions of children. They can influence the early lives of children just as much as the players.

When I told the story (rather the incident) to my son Alex (who just made the major little league this year) his first response was that he hoped someone would correct the call. His little sister Lisa chimed in and agreed. Alex was also quick to point out what a great pitcher Gallaraga was and I am sure he was just not talking about Gallaraga’s pitching skills.

Gallaraga would always be etched into little Alex’s and Lisa’s memories and they would certainly try and emulate him on the field and in life. Thank you Armando.

Commissioner Selig: You too had that chance and you blew it.

I still strongly feel that if POTUS had put his weight behind a public option it would have passed and the option would have been so much better fiscally and otherwise. Here is my analogy. In a country of 100 people, 80 are insured by 10 insurers. This new bill calls for the uninsured 20 to be insured (mandating health insurance) by the same 10 people. If the 20 cannot afford health insurance from the 10 insurance companies they can buy through a public pool. Is this pool paid by tax payers? A public option is not a free program but an affordable option which the uninsured and others could buy into creating automatic competition and revenue. Wouldn’t that have been a better option?

I think so.

In any case none can dispute the historic event. Tried and failed by almost every President from Teddy Roosevelt.

Here are things that the bill would do immediately. It all needs to be seen how this is all going to play out. In terms of access, quality and cost both to the nation and the consumer. Are they ever separate?
Here is an excerpt from John B. Larson’s (Chairman of the Democratic Caucus) Tweet. As soon as health care passes, the American people will see immediate benefits. The legislation will:

• Prohibit pre-existing condition exclusions for children in all new plans;
• Provide immediate access to insurance for uninsured Americans who are uninsured because of a pre-existing condition through a temporary high-risk pool;
• Prohibit dropping people from coverage when they get sick in all individual plans;
• Lower seniors’ prescription drug prices by beginning to close the donut hole;
• Offer tax credits to small businesses to purchase coverage;
• Eliminate lifetime limits and restrictive annual limits on benefits in all plans;
• Require plans to cover an enrollee’s dependent children until age 26;
• Require new plans to cover preventive services and immunizations without cost-sharing;
• Ensure consumers have access to an effective internal and external appeals process to appeal new insurance plan decisions;
• Require premium rebates to enrollees from insurers with high administrative expenditures and require public disclosure of the percent of premiums applied to overhead costs.

As the (NHIN) incrementally evolves from its current status into a ‘network of networks’ as envisaged by the ONC it requires adequate support and infrastructure necessary for all the stake holders to transport and transfer critical health information in the most secure of environments. The desired outcome is to promote a more effective marketplace, greater competition, and increased choice through accessibility to accurate information on healthcare costs, quality, and outcomes.

The stake holders include providers who deal with patients at the transactional level by capturing clinical and claims data through the respective Electronic Medical Records (EMR) and Electronic Practice Management ( EPM) systems to the Regional Health Information Organizations ( RHIO) albeit private or government to the Federal agencies who look at aggregate Electronic Health records ( EHR) and the consumer/patient who would want to securely view his/her health information via a Personal Health Record (PHR) system. Critical to the success of NHIN is the anticipated exponential increase in adoption of providers, physician practices, community health centers etc. to EMR/EHR systems, catalyzed through the Center for Medicare and Medicaid “meaningful use” incentives program.

NHIN would also fully utilize the power of Web 2.0 and Health 2.0/Medicine2.0 to transport data, improve quality of care and enhance clinical outcomes using health IT.
ONC also requires development and continual improvement of an on-boarding process to facilitate and ease the entry onto the NHIN. This requires an understanding of the key stake holders in NHIN and the various policy and regulatory frameworks involved at the federal, inter-state and organizational and transactional levels.

The importance of an efficient On-boarding process

On-boarding can be defined as the process of acquiring, accommodating, assimilating and accelerating new users into a system, culture or methodology. ONC requires development and continual improvement of an on-boarding process to facilitate ease of entry of applicants onto the NHIN. This involves gaining the commitment of providers and other stakeholders within systems of care to embrace the necessary technologies and become part of a national health information network. An effective on-boarding process consists of a number of key elements such as (1) improved care/services (2) education (3) incentives (4) technology etc. In addition the on-boarding process must understand the reservations and barriers that are present and have well proven methodologies of mitigation available. Knowledge of the key stake holders in NHIN and the various policy and regulatory frameworks involved at the federal, inter-state, organizational and transactional levels makes the LM team uniquely qualified to effectively design and administer an on boarding process.

Critical to the success of the on boarding process is an in-depth understanding NHIN and of the key stake holders which include providers, hospitals, RHIOs, state health information exchanges, Federal agencies etc.

Creation and design of the on-boarding process will consider and incorporate management and operational best practices into the evaluation criteria for testing, application, review, approval, legal and certification requirements, technology and innovation in addition to the policies and procedures guiding the coordination committee

A winning combination of understanding of NHIN, its stake holders, best practices, process redesign and innovation will contribute to an effective and efficient on-boarding process and facilitate the speedy transition of NHIN to the ONC vision of a secure, real time and bidirectional ‘networks of networks’ to transport sensitive health information across the internet.

NHIN Direct

An Electronic Medical Record (EMR) implementation can be a daunting task that is offer underestimated in terms of resources and effort. When I say an EMR implementation in an ambulatory setting, it involves two parts. Fist is implementing the EMR itself which is the clinical piece and second implementing the Electronic Practice Management (EPM) system which is the practice management side that involves scheduling, registration and billing. Claims data is captured through the EPM and clinical data is captured through the EMR system. One of the key objectives for the practice is to maximize efficiency of the provider time. This simply means that using EMR systems a provider should be able to see more patients and improve the quality of care meted to the patients. This is often much easier said that done.

What concerns the practice is that during the implementation of an EMR system there is bound to be a lack of productivity in the providers 1) schedules will need to be reduced 2) time will need to be set apart for training 3) learning curves of a heterogeneous group of providers will need to be considered.

Some things to consider:

1. Risk mitigation
a. Remote connectivity
b. Wireless
c. Rooms
d. Training in small groups. Train the Trainer approach
e. Identify in house EHR expert
f. Go live support ( for at least two weeks)
g. Workflow guidance documents as PDF help files which providers can consult without closing EMR
h. Use consultants

2. Capacity v Utilization : E.g.: No shows v Walk Ins

From my experience if these small steps are considered and executed efficiently the productivity loss can be mitigated to a minimum or say 25% average during a six month implementation.

A: Your heart only good for so many beats, and that it…don’t waste on exercise. Everything wear out eventually. Speeding up heart not make you live longer; it like saying you extend life of car by driving faster. Want to live longer? Take nap.

Q: Should I cut down on meat and eat more fruits and vegetables?

A: You must grasp logistical efficiency. What does cow eat? Hay and corn. And what are these? Vegetables. So steak is nothing more than efficient mechanism of delivering vegetables to your system. Need grain? Eat chicken. Beef also good source of field grass (green leafy vegetable). And pork chop can give you 100% of recommended daily allowance of vegetable product.

Q: Should I reduce my alcohol intake?

A: No, not at all. Wine made from fruit. Brandy is distilled wine, that mean they take water out of fruity bit so you get even more of goodness that way. Beer also made of grain. Bottom up!

Q: How can I calculate my body/fat ratio?

A: Well, if you have body and you have fat, your ratio one to one. If you have two bodies, your ratio two to one, etc.

Q: What are some of the advantages of participating in a regular exercise program?

A: Can’t think of single one, sorry. My philosophy is: No pain…good!

Q: Aren’t fried foods bad for you?

A: YOU NOT LISTENING! Food are fried these day in vegetable oil. In fact, they permeated by it. How could getting more vegetable be bad for you?!?

Q: Will sit-ups help prevent me from getting a little soft around the middle?

A: Definitely not! When you exercise muscle, it get bigger. You should only be doing sit-up if you want bigger stomach.

Q: Is chocolate bad for me?

A: Are you crazy?!? HEL-LO-O!! Cocoa bean! Another vegetable! It best feel-good food around!

Q: Is swimming good for your figure?

A: If swimming good for your figure, explain whale to me..

Q: Is getting in shape important for my lifestyle?

A: Hey! ‘Round’ a shape! Well, I hope this has cleared up any misconceptions you may have had about food and diets. And remember: Life should NOT be a journey to the grave with the intention of arriving safely in an attractive and well-preserved body, but rather to skid in sideways – Chardonnay in one hand – chocolate in the other – body thoroughly used up, totally worn out and screaming “WOO-HOO, what a ride!!”

AND…..

For those of you who watch what you eat, here’s the final word on nutrition and health. It’s a relief to know the truth after all those conflicting nutritional studies.

1. The Japanese eat very little fat and suffer fewer heart attacks than Americans.

2. The Mexicans eat a lot of fat and suffer fewer heart attacks than Americans.

3. The Chinese drink very little red wine and suffer fewer heart attacks than Americans.

4. The Italians drink a lot of red wine and suffer fewer heart attacks than Americans.

5. The Germans drink a lot of beer and eat lots of sausages and fats and suffer fewer heart attacks than Americans.

CONCLUSION: Eat and drink what you like. Speaking English is apparently what kills you.

What happened in Massachusetts is a thundering reverberation of the power of the independent mind of a voter. It could be a Republican, Democrat, Conservative or Liberal but a mind that refuses to be boxed into any ideology but one’s own. I think the independent mind of a voter must be differentiated from the mind of an independent voter. Underestimating the power of the ballot box is a serious error in democracy. The same independent minded has voted powerful people in and out of office with alarming accuracy and speed.  This is a luxury the electorate has in a democracy and they exercise this power through the ballot.

In my opinion there is a paradigm shift on established ideologies redefining conservatives, liberals etc. One could be morally conservative and socially liberal or a thousand such permutations and combinations. This adds to the complexity of understanding the voter behavior. There will be courses and case studies written on this election. Aren’t Scott Brown pro choice or definitely ‘not’ pro life and moderate on several issues including voting for the universal healthcare coverage in Massachusetts? The message is that my ideology is my own. This may or may not affect how I vote. Do not expect me to vote blindly based on an ideology that’s not my own. I live by my ideology but when it comes to vote, there are other things that I need to see in my leader.

The Massachusetts results could not have been a referendum on any issue. Though the post election polls say that this is a severe back lash against healthcare I do not think so. Spin as anyone may if that was the case how one explains the polls which showed Coakley in double digit lead just two weeks before the election. Wasn’t there a poll that said more than 60% of American people wanted a public option? How could the electorate be so educated and knowledgeable in 20 days on issues so complex that no one understands? Each voter felt that his/her vote mattered and they went out in numbers even in the weather. It is just the independent mind of voter expressing his/her anger at being told at what to do and a severe backlash against the entitlement of a seat by the Democratic Party. If after seeing the Coakley campaign in the last two weeks and if anyone expected her to win, they were blind. It was hers to lose with a 20+ lead as late as end of Dec.

Scott Brown was a terrific but underdog candidate who connected and resonated well with ordinary folks, stayed on the message and ran a great campaign and refused to go negative on his own. Remember that several prominent Republicans passed on this opportunity for fear of certain failure. The voters started paying attention to what he had to say and identified their views with his He caught the ball in the final minutes and ran with it for a winning touch down as Martha Coakley waited for a flag, crying foul and calling it illegal till the game ended.

The turning points were when Brown declared almost extempore that this is the ‘people seat’ and when the Brown girls defended their father against the negative ads. The former will be an electoral moment like Bentsen on Quayle and one which David Gergen will forever regret. The democrat leaning independents just told the candidates that ‘you can’t take us for granted and stop telling us what to do or staking claims on our seat’. The independent mind was simply tired of being taken for granted that all independents in MA would vote the democratic way and the notion that this was a Kennedy family seat. Did the Kennedy’s also think so? For sure they were conspicuously absent during the Coakley concession speech. They would have been there if the result had been otherwise.

If at all it were referendum, it was on the character traits of President Obama he so eloquently convinced the electorate during his campaign. Things like anti war, transparency, lobbyists etc. People expected a change from the status quo on these issues and seem disappointed. It is an interesting coincidence that on the day after Martin Luther King’s birthday the electorate in MA decided to judge someone by the strength of his character as it played out.

It may be too late for the all stars of the Obama campaign to come in. In my opinion people like David Pluffe was needed to drive the messages of healthcare, more troops to Afghanistan etc to the American people. It is also in some sense shocking to hear from the President that he is even alluding to a one term Presidency in the interview with Dianne Sawyer. He said he would rather be a “really good one term President than being a mediocre two terms President.” I think the question of one term Presidency doesn’t arise if you are a really good President and you need to worry of it only if you are mediocre.

Again if at all it was a referendum it was also on the ineffectiveness of governing by the Democrats. One would wonder if the pendulum has ever swing so rapidly that in a year    (almost exactly to the date) the moods are reversed. The 60 vote majority is discussed as if it’s an absolute necessity which shows the partisan way of thinking and not willing to recon ciliate. A simple majority if often a luxury in a democracy and people reach across the aisles to formulate meaningful programs and public policy. This is a wake up call.

It is also (one would hope so) a shrill alarmed wake up call for the administration and democratic leadership in the House and Senate that the voters can shift your agenda. Health care was taking its time and the deadline for submission of the assignment was only in November 2010. That just got shifted two weeks ago by the voters in MA and the powers that be were caught off guard and how? The time table was just advanced to submission time ‘in the next 15 days’ and Washington was not ready.

This is also a wake up call to all the aspiring and current politicians to relook at their strategies if they want to keep their jobs. You will be held accountable for the negative things you say. There is no blank check on negative campaigns. Pollsters and pundits will always say that though people may not like negative campaigns they do work. But in this case it did not. If for a sitting attorney general all that you had to say was negative things about your opponent, there is something wrong. Even the president went so far as to pick on the Brown ‘pick up truck’. John Kerry ridiculed Brown for the truck. The lesson is to clearly understand the mood of the voters and make them identify with yourself and what you stand for.

Now to Scott Brown: Take a deep breath and take good notice of your victory. Savor it while it lasts. Well begun is half done but do not ignore the other half. Look what happened to President Obama. We the electorate is going to hold you a very tight leash and accountable. They want to know day after day that you remain the same man they elected. My friend it’s a marriage and you need to work hard to keep. Remember that running for office and governing/law making/legislation are two different things. Do not focus on changing the system. Work the system, manage the system and influence the system. Your score card will be kept by us voters and not by pundits and analysts. If we the electorate did the unthinkable, we will act again. Even when you need to change for whatever reasons, be transparent and open to us. There will be counter forces that are determined to pull you down. The higher you are the steeper the fall will be. We will support you and stand by you. Above all be yourself and stay the regular guy that you are.

On the policy front please focus on Credit, Jobs and Housing. Do all what you can to (1) let banks loosen up the credit especially to small businesses which will (2) help them employ more workers  which will ( 3) help people pay their mortgages.

Do what you can on healthcare. But for God’s sake ask your colleagues to make the bill simple so that we can understand. After all it’s our and our kids’ health we are talking about. Unlike any other field the consequence of this is life and death literally. The president had all good intentions but the White House lost the message and started being reactive rather than being proactive and staying on the message. Now no one knows what’s in or out of the 2000+ page bill.

Remember that any good policy is only as good as the screw ups in its execution. All our government programs like Medicare, Social security, Fanny/Freddie etc are all excellent and unparallel but the management and execution of these are nightmares. They are all case studies in mismanagement. They could well be run like how a family budget is run, with accountability and spending within one’s means. But we don’t. It is not that there are good managers in the USA but for lack of political will and strength of character. Do not tell me that we the American people will not understand the need for sacrifices albeit as personal engagement like what we do in Haiti or unpopular policies for common good. No one understands it better than us if told and explained. Surgical solutions are sometimes needed to remove the tumor and we all accept it.

 Please be one of us the American people that politicians keep referring to in the third person. Refer to us as US and WE if you can.

Whether you like it or not, you have also been propelled into filling the space of a leader that the Republican Party so desperately needed. Gov. Palin comes closest but she has a lot of baggage from the last campaign. Bobby Jindal blew it in one night. Play this safe. Be who you are and stay comfortable and confident in your own skin. Loop back and rely on your family always. Just like President Obama came long, so have you. Don’t blow it. You could have been giving the Republican response to the State of the Union on this 27^th and will one day end up in the White House. Remember the electorate can do the unthinkable as seen in the case of President Obama and you in about a year. That is the power of democracy and of the independent mind. Our founding fathers knew this and are all having the last laugh. Good luck and God Speed Senator.