Office Of The National Coordinator Research Articles

Medical Health Record using Block Chain

The future of healthcare systems is being shaped by incorporating emerged technological innovations to drive new models for patient care. By acquiring, integrating, analyzing, and exchanging medical data at different system levels, new practices can be introduced, offering a radical improvement to healthcare services. We present a novel smart and secure Medical health record system which, leverages blockchain technologies, permits patient centric medical records transactions .Office of the National Coordinator (ONC) for Health Information Technology is seeking patient-centric MHR designs that shift data ownership from providers to patients. There are multiple barriers to patient-centric MHR in the current system, such as security and privacy concerns, data inconsistency, timely access to the right records across multiple healthcare facilities. After investigating the current workflow of MHR, our system provides a feasible solution to these challenges by utilizing the unique features of blockchain. In particular, we develop a blockchain-based architecture and enable a flexible configuration thereof, which optimize medical data sharing between different health entities and fulfill the diverse levels of Quality of Service (QoS) that MHR may require. Finally, we highlight the benefits of the proposed MHR system and possible directions for future research.

Documentation Burden in Nursing and Its Role in Clinician Burnout Syndrome.

The purpose of this study is to understand the relationship between documentation burden and clinician burnout syndrome in nurses working in direct patient care. The Office of the National Coordinator considers documentation burden a high priority problem. However, the presence of documentation burden in nurses working in direct patient care is not well known. Furthermore, the presence of documentation burden has not been linked to the development of clinician burnout syndrome. This paper reports that the results of a cross-sectional survey study comprised of three tools: (1) The burden of documentation for nurses and mid-wives survey, (2) the system usability scale, and (3) Maslach's burnout inventory for medical professionals. Documentation burden has a weak to moderate correlation to clinician burnout syndrome. Furthermore, poor usability of the electronic health record (EHR) is also associated with documentation burden and clinician burnout syndrome. This study suggests that there is a relationship between documentation burden and clinician burnout syndrome. The correlation of poor usability and domains of clinician burnout syndrome implies the need for more work on improving the usability of EHR for nursing documentation. Further study regarding the presence of documentation burden and its correlation to clinician burnout syndrome should focus on specific areas of nursing to understand the drivers of documentation burden variation within and across specialty domains.

New EHR certification requirements and their association with duplicate tests and images.

Certified electronic health record (EHR) technology has been adopted by most hospitals and health care providers. In 2015, the Office of the National Coordinator for Health Information Technology (ONC) published new EHR certification requirements, known as the 2015 Edition. To date, no research has examined the impact of hospitals' adoption of the 2015 Edition on health care delivery. We analyzed aggregated, longitudinal data drawn from a repository of deidentified health insurance claims collected by FAIR Health, the repository was estimated to represent about 75% of the privately insured in the United States. These data were linked with the American Hospital Association (AHA) Information Technology Supplement Survey to obtain hospitals' health information technology characteristics. A fixed effects specification was used to assess the incidence of duplicate testing and imaging in both inpatient and outpatient settings before and after the hospitals' adoption of the 2015 Edition. Hospitals with the 2015 Edition were less likely to perform duplicate imaging for inpatients by 5 percentage points (or 50% from baseline). Hospitals that adopted the 2015 Edition and actively engaged in interoperable data exchange were even less likely to perform duplicate lab tests. Adoption of the 2015 Edition certified EHR was negatively associated with the incidence of lab and imaging test duplication in both the outpatient and inpatient settings. However, the results were not robust across specifications. Given that multiple factors influence care delivery decisions, improvements in certification standards alone are unlikely to eliminate unneeded duplicate lab and imaging tests.

Impact of the 2015 Health Information Technology Certification Edition on Interoperability among Hospitals

Abstract Objective Most nonfederal acute care hospitals use electronic health records (EHRs) certified by the Office of the National Coordinator for Health Information Technology. In 2015, the Office of the National Coordinator for Health Information Technology finalized the 2015 Health IT Certification Edition and adoption by hospitals began in 2016. We examine the impact of the 2015 Edition on rates of interoperable exchange among nonfederal acute hospitals. Materials and Methods The study applies a standard difference-in-differences design and a recently developed fixed effects estimator that relaxes the assumption of treatment effects being constant across groups and time. In the analysis, we identify separate effects of the 2015 Edition for hospitals that switched EHR developers and forecast hospitals’ interoperability over 2015 Edition adoption rates. Results The adoption of the 2015 Edition increased hospitals’ rates of interoperable exchange and especially benefited hospitals that switched EHR developers in the post-implementation period. Forecasting results indicate that if all hospitals adopted the 2015 Edition, 53% to 61% of hospitals would engage in interoperable health information exchange compared with the current rate of 46%. Discussion Hospitals’ levels of interoperability have been rising over the last few years. Adoption of newer technology improved hospitals’ interoperability and accounts for up to 12% of the rise in interoperability. Conclusions Certified technology is one mechanism to ensure providers use recent and safe technologies for interoperable exchange. Adoption of certified EHRs improves the nation’s interoperable exchange; however, it has a clear limited effect. Other mechanisms are necessary for achieving comprehensive interoperable exchange.

10 minutes with Dr. Brian Anderson, Chief Digital Health Physician at the MITRE Corporation, Massachusetts, USA

### Biography Dr. Brian Anderson is the Chief Digital Health Physician at the MITRE Corporation. After completing his undergraduate degree in Social Anthropology at Harvard College, he received his medical...

Push Button Population Health: The SMART/HL7 FHIR Bulk Data Access Application Programming Interface

The 21st Century Cures Act requires that certified health information technology have an application programming interface (API) giving access to all data elements of a patient’s electronic health record, “without special effort”. In the spring of 2020, the Office of the National Coordinator of Health Information Technology (ONC) published a rule—21st Century Cures Act Interoperability, Information Blocking, and the ONC Health IT Certification Program—regulating the API requirement along with protections against information blocking. The rule specifies the SMART/HL7 FHIR Bulk Data Access API, which enables access to patient-level data across a patient population, supporting myriad use cases across healthcare, research, and public health ecosystems. The API enables “push button population health” in that core data elements can readily and standardly be extracted from electronic health records, enabling local, regional, and national-scale data-driven innovation.

A Patient-Centric Health Information Exchange Framework Using Blockchain Technology.

Health Information Exchange (HIE) exhibits remarkable benefits for patient care such as improving healthcare quality and expediting coordinated care. The Office of the National Coordinator (ONC) for Health Information Technology is seeking patient-centric HIE designs that shift data ownership from providers to patients. There are multiple barriers to patient-centric HIE in the current system, such as security and privacy concerns, data inconsistency, timely access to the right records across multiple healthcare facilities. After investigating the current workflow of HIE, this paper provides a feasible solution to these challenges by utilizing the unique features of blockchain, a distributed ledger technology which is considered "unhackable". Utilizing the smart contract feature, which is a programmable self-executing protocol running on a blockchain, we developed a blockchain model to protect data security and patients' privacy, ensure data provenance, and provide patients full control of their health records. By personalizing data segmentation and an "allowed list" for clinicians to access their data, this design achieves patient-centric HIE. We conducted a large-scale simulation of this patient-centric HIE process and quantitatively evaluated the model's feasibility, stability, security, and robustness.

Harnessing Data Science Through Healthcare IT Interoperability

Harnessing Data Science Through Healthcare IT Interoperability

2019 Medicare Fee Schedule Drops Proposal to Collapse E/M Payments

2019 Medicare Fee Schedule Drops Proposal to Collapse E/M Payments

A Pharmacogenomics Clinical Decision Support Service Based on FHIR and CDS Hooks.

Pharmacogenomics (PGx) is often considered a low-hanging fruit for genomics-electronic health record (EHR) integrations, and many have expressed the notion that drug-gene interaction checking might one day become as much a commodity in EHRs as drug-drug and drug-allergy checking. In addition, the U.S. Office of the National Coordinator has recognized the trend toward storing complete sequencing data outside the EHR in a Genomic Archiving and Communication System (GACS) and has emphasized the need for "pilots that test Fast Healthcare Interoperability Resources (FHIR) Genomics for GACS integration with EHRs." We sought to develop a PGx clinical decision support (CDS) service, leveraging the emerging FHIR and CDS Hooks standards, and based on an assumption that pharmacogene sequencing data would be stored alongside the EHR in a GACS. We developed a PGx CDS service as a functional prototype. The service is triggered by a medication order in the EHR. When evoked, the service looks for relevant genetic data in a GACS and returns corresponding recommendations back to the ordering clinician. Where the patient has no genetic data on file, the service can recommend pretreatment genetic testing where applicable. Overall, we were able to meet our objectives and deploy a functional prototype, interfaced with a commercial EHR. We identified several areas where FHIR or CDS Hooks lacked necessary semantics or have implementation ambiguity. Primary FHIR challenges included multiple ways to say the same thing, which exacerbated the complexity of variant to allele conversion and lack of representation of deoxyribonucleic acid region(s) studied. Primary CDS Hooks challenges included the complexity of executing an authenticated query against one system (GACS) upon being triggered by a different system (the EHR), and limitations in the types of actionable recommendations that can be returned to the EHR. In conclusion, we have found that PGx CDS based on FHIR and CDS Hooks appears to represent a promising means of genomics-EHR integration. More real-world testing along with a set of use-case driven GACS interface requirements will push us closer to the U.S. National Human Genome Research Institute vision of a plug-in PGx app.

The National Academies of Practice (NAP): A Key Stakeholder for the Office of the National Coordinator (ONC) for Interprofessional Digital Healthcare

The National Academies of Practice (NAP): A Key Stakeholder for the Office of the National Coordinator (ONC) for Interprofessional Digital Healthcare

Ten factors to consider when developing usability scenarios and tasks for health information technology

The quality of usability testing is highly dependent upon the associated usability scenarios. To promote usability testing as part of electronic health record (EHR) certification, the Office of the National Coordinator (ONC) for Health Information Technology requires that vendors test specific capabilities of EHRs with clinical end-users and report their usability testing process – including the test scenarios used – along with the results. The ONC outlines basic expectations for usability testing, but there is little guidance in usability texts or scientific literature on how to develop usability scenarios for healthcare applications. The objective of this article is to outline key factors to consider when developing usability scenarios and tasks to evaluate computer-interface based health information technologies. To achieve this goal, we draw upon a decade of our experience conducting usability tests with a variety of healthcare applications and a wide range of end-users, to include healthcare professionals as well as patients. We discuss 10 key factors that influence scenario development: objectives of usability testing; roles of end-user(s); target performance goals; evaluation time constraints; clinical focus; fidelity; scenario-related bias and confounders; embedded probes; minimize risks to end-users; and healthcare related outcome measures. For each factor, we present an illustrative example. This article is intended to aid usability researchers and practitioners in their efforts to advance health information technologies. The article provides broad guidance on usability scenario development and can be applied to a wide range of clinical information systems and applications.

Barriers to Pediatric Health Information Exchange.

* Abbreviations: CMS — : Centers for Medicare & Medicaid Services DM — : direct messaging EHR — : electronic health record HIE — : health information exchange MU — : meaningful use ONC — : Office of the National Coordinator The Office of the National Coordinator (ONC) included in stage 2 meaningful use (MU) the requirement for eligible providers to transmit a summary of care record electronically for at least 10% of patients referred or transferred to another setting of care or provider of care.1 The transmission of summary of care records, particularly from ambulatory pediatricians to specialists in tertiary care centers or in hospitals caring for children, would be extremely helpful to children and pediatricians and would improve safety and quality of care. Such transmissions would also reduce costs through avoidance of unnecessary testing, duplicate procedures, and allergic reactions, as well as radiation exposure from unnecessary duplicate radiology tests. Regrettably, means to exchange health information among health care entities remain complex, inefficient, and grossly underutilized.2–5 Outpatient pediatricians have 3 ways to exchange records: (1) participate in the Nationwide Health Information Network; (2) use exchange capabilities available through regional delivery networks through electronic health record (EHR) systems with some health information exchange (HIE) capabilities; or (3) direct messaging (DM), a secure and relatively inexpensive method designed for exchange of patient health information across different networks theoretically available to every provider or facility using a certified EHR. None of these options is widely pursued. Neither referring organizations nor outpatient pediatricians have made participating … Address correspondence to Christoph U. Lehmann, MD, Vanderbilt University Medical Center, Suite 1475, 2525 West End Ave, Nashville, TN 37203. E-mail: culehmann{at}gmail.com

Evidence-based public policy comes to Washington.

The impact public policy has had on our profession in the last 8 years is staggering. Think about it: in 2009 the Centers for Medicare and Medicaid Services (CMS) had just finalized a rule meant to give physicians a small payment incentive to use electronic prescribing, and Dr Francis Collins was being given the keys to a new office as the 16th director of the National Institutes of Health (NIH). Nearly 8 years later, more than 96% of US hospitals1 and 83% of US office-based physicians2 are using much more robust informatics tools to deliver clinical care, and the NIH is on track to begin enrolling 1 million Americans as part of the Precision Medicine Initiative Cohort Program. Since passage of the HITECH Act in 2009, lawmakers and regulators in Washington, DC, have expanded health informatics–related policymaking in all directions. What was the domain of CMS and the Office of the National Coordinator of Health Care Technology (ONC) a few short years ago is now pervasive across all corners of Health and Human Services (HHS). Over the last 12 months, AMIA has worked diligently to inject …

A review of biomedical and health informatics education: A workforce training framework

Objective: The purpose of this paper is to review the current state of health information technology (HIT) training programs and identify limitations in workforce expectations and student/trainee level of preparedness. A framework is proposed to build a more effective training program, differentiate HIT and health informatics, and emphasize the critical role of interprofessional collaboration for informatics-related curriculum. We define interprofessionalism as the multi-sector collaborations among academia, industry (Health Care Organizations), and vendors to produce competent informaticians.Methods: Critical review of published HIT and health informatics curricular competencies was conducted, including those published by the Office of the National Coordinator (ONC) for HIT, the American Medical Informatics Association (AMIA), the International Medical Informatics Association (IMIA), and the Council on Accreditation for Health Informatics and Information Management. A review of literature related to HIT and health informatics education and training was also completed.Results: The paper presents a framework for promoting health informatics training with an interprofessional foundation. The core components of the curricular competencies include understanding the healthcare system, biomedical data, computer programming, data analytics, usability, and technology infrastructure. To effectively deliver the content, programs require collaboration between academic institutions, healthcare organizations, and industry vendors.Conclusions: HIT and health informatics-related training programs, in their current form, are not meeting industry needs. The proposed framework addresses the current limitations by providing unique pathways for content delivery by promoting interprofessional collaboration and partnerships between academia and industry.

A framework for evaluating electronic health record vendor user-centered design and usability testing processes.

Currently, there are few resources for electronic health record (EHR) purchasers and end users to understand the usability processes employed by EHR vendors during product design and development. We developed a framework, based on human factors literature and industry standards, to systematically evaluate the user-centered design processes and usability testing methods used by EHR vendors. We reviewed current usability certification requirements and the human factors literature to develop a 15-point framework for evaluating EHR products. The framework is based on 3 dimensions: user-centered design process, summative testing methodology, and summative testing results. Two vendor usability reports were retrieved from the Office of the National Coordinator's Certified Health IT Product List and were evaluated using the framework. One vendor scored low on the framework (5 pts) while the other vendor scored high on the framework (15 pts). The 2 scored vendor reports demonstrate the framework's ability to discriminate between the variabilities in vendor processes and to determine which vendors are meeting best practices. The framework provides a method to more easily comprehend EHR vendors' usability processes and serves to highlight where EHR vendors may be falling short in terms of best practices. The framework provides a greater level of transparency for both purchasers and end users of EHRs. The framework highlights the need for clearer certification requirements and suggests that the authorized certification bodies that examine vendor usability reports may need to be provided with clearer guidance.

Patient Education for Consumer-Mediated HIE. A Pilot Randomized Controlled Trial of the Department of Veterans Affairs Blue Button.

Consumer-mediated health information exchange (HIE) is one of the three types of HIE designated by the Office of the National Coordinator. HIE is intended to improve the quality of care while reducing cost, yet empirical support for this claim is mixed. Future research should identify the contexts whereby HIE is most effective. This study was conducted as a pilot two-arm randomized controlled trial. In the intervention arm, 27 veterans were taught how to generate a Continuity of Care Document (CCD) within the Blue Button feature of their VA patient portal and were then asked to share it with their community non-VA provider. In the attention control condition, 25 Veterans were taught how to look up health information on the Internet. The impact of this training on the next non-VA medical visit was examined. Nineteen (90%) veterans in the intervention arm shared their CCD with their non-VA provider as compared with 2 (17%) in the attention control arm (p<0.001). Both veterans and non-VA providers indicated high satisfaction with the CCD. Comparison of medical records between the VA and non-VA providers did not indicate improved medication reconciliation (p=0.72). If veterans shared their CCD prior to their non-VA providers ordering laboratory tests, the number of duplicate laboratories was significantly reduced (p=0.02). In this pilot randomized controlled trial, training 52 veterans to share their CCD was feasible and accepted by both patients and providers. Sharing this document appeared to reduce duplicate laboratory draws, but did not have an impact on documented medication list concordance.

Evolving Physician Reimbursement Structures: Moving the Medical Group to Value-Based Success

With passage of the Medicare Access and CHIP Reauthorization Act, what changes can physicians expect with regard to payment incentive models?Repeal of the Medicare SGR formula and passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) are bringing about significant changes to the Medicare physician fee schedule and reimbursement methodology (Centers for Medicare & Medicaid Services [CMS], 2015). MACRA established annual positive or flat fee updates for 10 years and implemented a two-track fee update thereafter. In addition, MACRA created MIPS and consolidated the current Medicare fee-for-service incentive initiatives. The law also provides a mechanism for physicians to participate in alternative payment methods, including the patient-centered medical home model and others to be defined. In repealing the SGR and passing MACRA, Congress's intent was to move away from the fee-for-service payment methodology and toward a value-based payment system.In preparation for changes to current fee-for-service incentive models, physicians and physician groups should be aware that 2016 is the last reporting period under the current Physician Quality Reporting System (PQRS) methodology. The 2016 reporting period will affect 2018 reimbursement, meaning that providers who do not meet reporting and participation requirements in 2016 will experience a 2% reduction in Medicare reimbursement in 2018 (CMS, 2016b). Satisfactory participation currently includes reporting on nine measures in three quality domains, as defined by CMS. Changes for 2016 include adding measures where gaps exist and eliminating measures that have topped out, are duplicative, or have been replaced by more robust measures.Legislative changes to the Electronic Health Record (EHR) Incentive Program are leading to a stricter definition of certified EHRs. These changes will align with the Office of the National Coordinator for Health Information Technology and govern the requirements for information and how it can be submitted. In addition, the current Meaningful Use (MU) program will be restructured and consolidated into MIPS.CMS will continue a phased approach to public reporting on the Physician Compare website. In addition to providing access to all individual- and group-level reported measures, Physician Compare will post scores for providers who report satisfactory performance on the new PQRS Cardiovascular Prevention measures and received a positive adjustment for the Value-Based Payment Modifier (VBPM) program. By including the downloadable VBPM database, Physician Compare will provide consumers with information regarding performance (i.e., high, low, or neutral on cost and quality) and indicate if a provider or group did not report data on these measures.Implementation of MACRA will drive the consolidation of the current incentive plans. Beginning in 2017, MACRA will include elements of each of the three programs (PQRS, MU, and VBPM) as well as a fourth-clinical practice improvement activities (CPIA)-currently under development. These programs will be rolled together and result in a composite score for practitioners and practices. Each provider or practice will receive a positive, neutral, or negative adjustment in reimbursement on the basis of the score in relation to a threshold. The incentive or penalty will be based on reporting and performance 2 years earlier, meaning the 2019 incentive or penalty will be based on reporting and performance in 2017. Providers or groups above the threshold will receive positive adjustments, whereas those below the threshold will receive negative adjustments. The payment adjustments will gradually increase from 4% in 2019 to 9% in 2022. CMS projects that this system will be budget neutral, meaning poor performers will pay for above-average performers. In the event that everyone is above the threshold, CMS has built in an additional $500 million in funding for the top performers between 2019 and 2024. …

The Impact of Emerging Markets on the Pharmaceutical Industry

The Impact of Emerging Markets on the Pharmaceutical Industry

So You Give Great Care; Do You Have Data To Back That Up?

So You Give Great Care; Do You Have Data To Back That Up?