One of the components of the HITECH Act is funding for the State Health Information Exchanges (HIE) Cooperative Agreement Program. A total of 56 states, territories, and “qualified State Designated Entities” have received awards.
Health Information Exchanges are defined as:
” The movement of health care information electronically across organizations within a region or community. HIEs provide the capability to electronically move clinical information between disparate health care information systems while maintaining the meaning of the information being exchanged. The goal of HIE is to facilitate access to and retrieval of clinical data to provide safe, timely, efficient, effective, equitable, patient-centered care.”
The HITECH HIE awardees are charged with accelerating the exchange of patient specific health data, both within the state and across state lines. As with all of the objectives of HITECH, the purpose is to improved efficiency, access, and quality of health care. There are many components of HIE sustainability that are being addressed across the many different health and cultural landscapes: policies, governance, technical framework and services, business operations, and financial structures. Local commitment is a requirement of this program, as HIEs must also match a portion of the grant awards beginning in year 2 of the 4-year program. An HIE Toolkit made available by ONC provides additional details and resources for awardees and those who want additional information.
These types of entities have been around for some time. You may have heard of Regional Health Information Exchanges or “RHIOs.” Often the terms RHIO and HIE are used interchangeably. Dr. David Brailer commandeered the concept back in 2007 as part of the ONC’s mission to create a National Health Information Network (NHIN). The NHIN—today operating as the NHIN Connect is considered critical to assuring data and information exchange for care coordination. Look at what your state is doing!
Today, the Nutrition Informatics Committee kicked off the ambitious set of objectives or “deliverables” (if you have ever worked for the government) for how we integrate nutrition informatics into our culture of nutrition. As with any change, it is not easy--but will require the collaborative efforts of many. Within ADA’s framework, there are “SIX” Areas of Practice. Most dietitians do not concern themselves with those outside of their own framework, but in terms of Nutrition Informatics, we are enthusiastic about including them all. Because nutrition informatics touches all areas of practice, and includes optimizing many areas which support the profession—the evidence analysis library, the nutrition care process and model (NCPM), the international Dietetics and Nutrition Terminology,, quality management, and all areas of ADA which impact the training and education of dietitians, there are many moving parts to integrate! Now is a critical time to collaborate and communicate the work of dietitians! We invite you to join the discussion!
There is no lack of discussion, opinion, statistics, or collaboration in health care today. The drive for adoption of health information technology (HIT) and in particular, electronic health records (EHR) has brought together almost every profession in an attempt to improve health care. Last night, I had a rather interesting discussion with a scientist at the Health 2.0 Health Informatics Pulse (HIP) event in Washington, DC. This is a “meet-up” event put on by the incredible group at Aquilent. A series of 5 minute presentations (try it—it goes by in a flash!) give way to questions and discussions on a variety of health informatics topics.
After the presentations, there is time to mingle and meet others in this field. As it turned out, I happened into a discussion on health care, its ails, the “nonsense of EHRs”, “meaningful use” and the HITECH Initiatives. This well trained scientist gave me a very passionate (ok—heated) dissertation on why EHRs are a waste. “Nothing is wrong with health care.”
This discussion took me very quickly to a recent presentation by Regina Holliday, a medical advocate who is an awesome artist and muralist. Her story of caring for her husband and the angst of navigating the medical system is heartbreaking. At a recent conference, she participated in a panel discussion on what patients want and need. In response to a question, she spoke in detail about how little information and access she had to her husband’s care and how lack of coordination near the end of his life was particularly painful. She passionately implored need for dignity (which includes providing access, explanations and information) during the health care process. When she finished, you could have heard a pin drop in the room of 300 people. Thank you, Regina—it is not just about technology.
Given the broad scope of the HITECH Act, there is one recurring theme which likely will provide a powerful catalyst to move health care to one of better consistency—that of standards harmonization. The Standards and Certification Interim Final Rule represents the “first step in an incremental approach to adopting standards, implementation specifications, and certification criteria to enhance the interoperability, functionality, utility, and security of health IT and to support its meaningful use.” (http://healthit.hhs.gov) While these standards are guidelines for one-step in “meaningful use” for providers to receive financial incentives, it also establishes a consistent framework of standards for all of health care.
Included in the standards rule is the validation of SNOMED-CT as a terminology for clinical terms. You may be wondering what this has to do with nutrition. At present, the ADA has created an International Dietetics and Nutrition Terminology (IDNT), which is a nutrition vocabulary that allows for coding of clinical nutrition assessment, diagnoses, intervention, and monitoring/evaluation. This work has been underway for over five years for providing a consistent approach to identifying and coding clinical components of the nutrition care evaluation process. While the two are not mandatory partners in care, IDNT is a logical extension of the Nutrition Care Process and Model (NCPM).
In order for nutrition to be a strong component of the electronic health record—and have an impact on quality care, it will be necessary to create a workflow that accomplishes the nutrition care of patients—then work with EHR vendors to assure that the functionality (technical capability within the EHR) is created and maintained within the system. With the NCPM and IDNT, there is no need to start from scratch—but instead integrate these standards into the EHR—and join in the nationwide efforts to provide a consistent approach to providing care.
Electronic Health Records (EHR) have been around for several decades, yet most of the focus on nationwide adoption has occurred since President Bush’s Executive Order in 2004 which directed that all Americans should have access to an EHR by the year 2014. Given the complexity of EHRs, the multitude of different settings, uses and infrastructure—it is not surprising that measuring adoption rates is a challenge.
Several different sources are available and they all provide an estimate for how many physicians and health care facilities have implemented an EHR. Complexities abound in how this should be measured: are functionalities (what functions the system performs) still used? By what percentage of total users? and what impact on patient care.
The Office of the National Coordinator of Health Information Technology (ONC) provides perhaps the quickest insight to several studies: Most estimates for physician implementations still hover near 17 percent of practices. The results of these surveys are based upon the descriptions of two levels of adoption: basic and full.
The Health Information Management and Systems Society (HIMSS) also has an EMR Adoption Model, which registers adoption rates depending upon different stages of functionality.
Either way, adoption of health information technology is moving slowly. The HITECH Act has served to “light a fire” under the process. Now is a critical time for dietitians to become involved in the process by volunteering for EHR Adoption Committees, working with EHR vendors to assure that the Nutrition Care Process and Model and the International Dietetics and Nutrition Terminology is included in how we deliver nutrition care. These resources, amongst others will provide the necessary framework for designing nutrition care in EHRs—and consistency across providers will allow for nutrition notes and consults to be an expectation of exchanging data.
Health—Information—Technology—in that order. While we usually assume this is one concept from three words, a closer look spells out the genuine priority of health information technology or “HIT”. As health care moves towards adoption and use of HIT, many times people grow weary of the “technology” part. Where is the “killer app?” Why all this interest in technology when there are so many problems within our health care culture? Take a closer look. The words are in the correct order of importance.
First and foremost-- the reason for the discussion—is our health. As dietitians, we realize the potential for improving the quality of health Americans have through nutrition and diet. We are in an unprecedented time of discussion and policy concerning our health care.
Second is the “information” piece—data about our particular situation and evidence based “information” on what the expectations are based upon a given set of circumstances. If I have high blood pressure and am 50 pounds overweight, then I can use the information that weight loss is usually accompanied by a reduction of blood pressure to improve my health.
Last is the “technology” piece. It is only a tool—albeit a powerful one when used wisely—to implement and deliver quality health care. It has great potential to make the process more efficient by assimilating data and sharing it so you only have to answer all those family history questions once. It can reduce costs when your physician has access to lab or radiology results so he/she does not have to reorder them. It can allow you to track your progress in a meaningful way so you understand the changes over time. However, without the other two – health and information—it is a meaningless tool. The challenge to us as dietitians is to uncover the many ways we can use technology to manage our health (and our patients/consumers health) more efficiently.
The Centers for Medicare and Medicaid Services launched their website for the HITECH Electronic Health Records Incentive Program. As a dietitian (who is not considered an “eligible provider” for this incentive program), you may ask: what does that have to do with nutrition? At first gloss, this is an understandable response. Upon closer examination, consider the following:
Dietitians working with small hospitals who are eligible for incentives (meaning they are committing to EHR adoption) should inquire about the EHR Implementation Team, ask to participate, and work to assure inclusion of nutrition in the EHR for that facility. The sooner dietitians get involved in this process, the more likely they will be able to negotiate the best nutrition related functionality in the EHR. The alternative is that nutrition is excluded (meaning dietitians cannot perform their expected work), someone else adds, what they “think is needed for nutrition” or nutrition content is added at the end (which drives costs, timeline for implementation and professional angst out the roof!)
Dietitians who work independently with small group physician practices need to inquire about participation in the incentive program and offer assistance in assuring that a nutrition component is included. Yes, a time commitment, but one which will establish collaboration and a reminder to include the dietitian in referrals and patient care.
The movement to Electronic Health Records creates a perfect time to implement the Nutrition Care Process and Model and the International Dietetic and Nutrition Terminology. This allows for a standard process to be established so that health nutrition data can be exchanged across all providers.
States are responsible for their own management of the Medicaid incentives, so each state will have a different process for support.
Utilize ADA’s resources related to EHR Adoption and Nutrition Inclusion:
EHR Tool Kit
“Electronic Medical Records and Personal Health Records: A Call for the Creation and Inclusion of a Nutrition Database”
International Dietetics and Nutrition Terminology
Nutrition Care Process and Model
I would love to hear what more dietitians are doing in this area!
More and more frequently, a great article will surface showing how dietitians work together with other professionals to demonstrate our shared passion: improving health and health care. Here is a great story about how collaboration between dietitians, a chef and yes—a dietitian informaticist (Lee Unangst at the National Institutes of Health) contribute to best results for the First Lady’s Let’s Move! ambitious campaign against childhood obesity. Chef treats his NIH kitchen like a Laboratory
Perhaps one of the most exciting parts of health informatics is our climate of information abundance, multiple “applications” for managing data, and a host of technologies at our fingertips. Historically, nutrition has always been very data—and information rich. Along came the internet, then information was suddenly more available to whomever was tenacious enough to search. Enter “Health 2.0” where there is an enormous opportunity for interaction between individuals online. Will the new “informatics” world in which we live prompt more motivation—even inspiration for behavioral change?! Early indications are there is great potential.
I am forever intrigued by the subtle combinations of information, people, events, and ideas that nudge us to make significant changes in our behavior. Take my college son’s bedroom. Yesterday I did my usual “Will you please clean your room, strip the sheets off the bed…” routine. This morning I entered his room—fully expecting that my request had had only minor impact. Wow. Room clean, sheets off, books lined on shelf and clothes hung. Instinctively, I backed out of the room and looked at the outside of the room (an old habit from years of hospital work—verifying I was in the correct room!) Yes—his room. Hmm…Do not get me wrong—he is a wonderful kid! College Kid. Home from a messy college dorm. Cleaning rooms isn’t his forte. What caused this major change in behavior? Perhaps my “information” that the sheets needed to be washed? That had little impact in the past. I looked in the mirror—maybe I look a bit tired and he felt bad? ? Increased maturity? What was the combination that created a great result?! After all—I want to repeat it!!
Such is our new opportunities with informatics, the processes, and tools available. Dietitians have the information and skills, and sharing them with consumers/patients, hope to impact individual and population health. We have a powerful potential to create behavioral change—by utilizing informatics—and finding the mix and match combinations that work to improve health!
One of the components of the HITECH Act is the provision of $84 million in funding for the Health IT Workforce Development Program. The Office of the National Coordinator of Health Information Technology (ONC) estimates that at least 51,000 individuals trained in the adoption and use of electronic health records (EHR) will be needed over the next five years.
Below are links to the programs where the training programs will begin in Fall 2010 (yes, in a few short months.) In some cases, the deadline for application is JULY 1, 2010.
The first is the University Based Training Program provides $32 M to nine universities. The program is designed to “rapidly and sustainably increase the availability of individuals qualified to serve in specific health IT professional roles requiring university-level training.”
The training program prepares you for any one of the following six roles. Universities are required to select at least three of these to focus on. These programs are ones that students can complete in one year or less, such as certificates of advanced studies and master’s degrees that do not require a thesis or equivalent major research project. Training may be either online, in-person or a combination of both.
- Clinician/Public Health Leader
- Health Information Management and Exchange Specialist
- Health Information Privacy and Security Specialist
- Research and Development Scientist
- Programmer and Software Engineer
- Health IT Sub-Specialist
Fine Print: Because these grants are to bring NEW people to the field, the following people do not qualify for the program:
- Students in training positions already existing as of the date on which the Funding Opportunity Announcement was published (December 17, 2009)
- Students who were enrolled in a health IT professional training program of any institution of higher education as of the date on which the Funding Opportunity Announcement was published (December 17, 2009)
Please note that the institutions of higher education are the direct funding recipients. Individual students receive support for the types of educational expenses delineated above by enrolling in a training program funded under this grant. Such student support is received from, and administered by, the institution of higher education. The maximum duration of each grant is 39 months. A limited number of tuition subsidies are available at $10,000 provided the degree is completed in 12 months.
George Washington University
Johns Hopkins University
Priority given to applications received by July 1, 2010.
Oregon Health & Science University
AMIA/ADA 10x10 Site: Collaboration with Dr. Bill Hersh
Deadline: July 1, 2010
Texas State University
University of Colorado Denver College of Nursing
University of Minnesota
There are some things humans do best; there are some things that computers do best. It is important to make sure you optimize both. HIMSS Virtual Conference
A concept in informatics which has received a good bit of attention recently is that of “clinical decision support.”
While there are multiple definitions, here is the one from our great friends at the Health Information Management and Systems Society (HIMSS) http://bit.ly/bQJtDa
“CDS is defined broadly as a clinical system, application or process that helps health professionals make clinical decisions to enhance patient care. Clinical knowledge of interest could range from simple facts and relationships to best practices for managing patients with specific disease states, new medical knowledge from clinical research, and other types of information.”
Most of the discussion for CDS has been based upon medication choice and administration. For example, if a patient has diabetes, congestive heart failure, and high blood pressure, which medication would likely work best and inflict the least side effects?
Little research to date has focused on inclusion of a “consumer controlled” choice for desired outcomes or any inclusion of evidence-based nutrition care. The intent is not to provide all the answers via an electronic means, but rather “suggest” best practices. My favorite example to use is a simple one: It is well documented that weight loss (sometimes as little as 10-15 pounds) will help reduce blood pressure. If the “decision support” nudged the provider to consider offering the patient an option to “lose weight” (with RD guidance of course!), prior to starting medication—perhaps the long term side effects of blood pressure medications could be lessened. There will never be a “one-size-fits-all” design that works—but it would allow the patient to take a more engaged role in their own care.
I recently had a comment from an RD after I sent a survey inquiring about CDS. I would be interested in your thoughts, any experience in this area, and/or ideas.
“All RD's have years and years of education that should not be placed in a computer… to be computerized and told what to do... Medicine is not an exact science. People are not an exact science. Science is for study not for stagnant theory, instead we want reality theory where we can use our brains and exercise our right to think of new ways of doing things.”
Yesterday I had the pleasure of helping out in the first “Health 2.0 Comes to Washington” Conference. http://www.health2con.com/dc-2010/ If you are not familiar with Health 2.0, it is an exciting place to be for those interested in managing health. The best description of the Conference comes directly from the site: “The Health 2.0 Conference is the leading showcase of cutting-edge technologies in health care, including Online Communities, Search, and lightweight Tools for consumers to manage their health and connect to providers online.”
My first step into the collaborations around Health 2.0 and similar events made me feel like I was leading a double life! After 20+ years in traditional healthcare, inside hospitals and academic medical centers, the vibrant, innovative discussions on “thinking outside the box” for healthcare left me feeling that I did not fit in. Luckily, the consistently entertaining leaders of Health 2.0 (Matthew Holt and Indu Subaiya) have brought the diverse crowds from both camps together in great discussions. One feature—the 4-minute presentation from Innovators—allows the audience to view a glimpse of new products and services. One of interest to dietitians is: ScanAvert http://www.scanavert.com/—an iPhone or Droid application that can scan ingredient labels and identify ingredients which serves as “Detection and Alarm Against Ingredient Harm.”
The next best content was the mention of an “innovation contest.” Most of us have heard of “meaningful use” and think of it in relation to electronic health records (EHR) and the “eligible provider” incentive programs of the HITECH Act. There are SO many opportunities in the area of nutrition—and an abundance of creative thinkers in dietetics! Please consider participating—and let me know if you do!
Health 2.0 Developer Challenge http://health2challenge.org/ Health 2.0 will host a series of events leading up to the final Challenge during the Health 2.0 Annual Conference October 6-9, 2010, the culminating event of Health Innovation Week, October 3-10, in San Francisco CA.
VA Innovative Initiative http://www4.va.gov/vai2/The Veteran’s Administration awarded Industry Innovation Competition support for specific areas of concern to health care for Veterans, amongst them Telehealth.
The ADA/AMIA 10x10 Informatics Course began this week and the mix of talents and diversity is most impressive! Based upon the Introductions thus far, we have 40 students--representing 16 different states, the District of Columbia, Puerto Rico, and Germany! Student experience in informatics varies from those “just interested and wanting to learn more” to those who have been working with electronic health records (EHR) since 1986! Participant talent comes from all six ADA areas of practice plus those who have a purely informatics position. Education level varies from undergrad degrees to multiple masters ; a variety of certifications, DTR, and RDs! Oh, and we have a baby due (well, one of the students) any day—this is much more exciting than I even anticipated!
As we learn more together in this exciting course, we will be sure to follow and post ideas and comments. Please join us in the discussion!!
Today is an exciting day for nutrition informatics—it is the start of the American Medical Informatics Association (AMIA)/ADA 10x10 Course! https://www.amia.org/amia-ohsu-ada-10x10-offering Today is the deadline for registration for this online course in biomedical informatics with a focus on nutrition informatics. This course, a collaboration with Dr. Bill Hersh of Oregon Health and Science University and AMIA, will allow an online venue for discussion about the nutrition aspects of informatics.
In addition, June 1 (yesterday!) marked the official start of the Nutrition Informatics Committee at ADA. This committee will continue the work of the Nutrition Informatics Work Group. Kudos to the ADA Executive Team for acknowledging this important area-- and for ADA Staff and members for their dedication in this area!
Given the vast amount of information that is part of working in field of nutrition—there are many opportunities! We have heard from dietitians who are already working in this area as well as those who plan to. Let us know your thoughts, suggestions, and ideas—it is exciting to hear of the creative work in nutrition informatics!
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