"Welcome to our company blog. Within these blog posts, we hope to share our insights on clinical quality management, the patient-centered medical home, chronic disease management in primary care, evidence-based medicine, and the use of technology in ambulatory care settings."

- David Morin, CEO and Donald Nease Jr., MD, Chief Medical Officer

Nice piece published by the George Washington University School of Public Health and Health Services on data warehouses and quality improvement - "Health Center Data Warehouses: Opportunities and Challenges for Quality Improvement". The Michigan Primary Care Association is truly a leader in this concept and this paper highlights the pitfalls and promise of using a data warehouse for QI, a must-read if you considering this.

Dave Morin
Cielo MedSolutions

Cielo MedSolutions now provides periodic email updates on the implementation of this Act and its impact on an ambulatory care practice. Below is our first update. If you'd like to be on the email list, simply let us know at info@cielomedsolutions.com.

Of course, the usual disclaimers are in place: this is a rapidly changing landscape as no final decisions have been made on the HITECH Act and views expressed in this document are only opinions.

SNOMED-CT is the Problem and Procedure Vocabulary

From the HIT Policy Committee, August 14, 2009, Report From Clinical Operations Workgroup update slides:

“Primary vocabulary standards:
· Clinical problems and procedures: SNOMED CT
· Drugs: RxNorm
· Ingredient allergies: UNII
· Lab tests: LOINC
· Units of measure: UCUM
· Administrative terminology: CAQH CORE and HIPAA”

From the HIT Policy Committee, August 14, 2009, Clinical Quality Workgroup: Progress Report update slides:

"· Multiple versions of measures to provide options
o 2011 – ICD 9 or SNOMED CT
o 2013 – ICD10 or SNOMED CT
o 2015 – SNOMED CT
· Can use internal codes using SNOMED CT expertise to map to SNOMED CT
· EHR certification should require problem list”

Views: it looks as though problem lists will ultimately need to be built with SNOMED CT versus ICD9 or ICD10 and the open question is the year it needs to be done. This could be a significant issue for systems that do not have a clinical thesaurus that can cross-reference problem terms across different vocabularies (in other words, a system needs to be able to know how an ICD9 or ICD10 code maps to a SNOMED code). In addition, registry and EMR systems that only utilize billing files for problem documentation may struggle with using an alternative coding system (problems will still come in from billing files only in ICD9). Because Cielo uses a clinical thesaurus (the ENCODE table mapped to ICD9, ICD10 and ICPC) and one of Cielo’s Medical Advisory Board members is leading a committee to map ICPC to SNOMED, this will not be an issue for Cielo Clinic.

Registries called out as key to ARRA

From the National Committee on Vital and Health Statistics Report of Hearing on “Meaningful Use” of Health Information Technology, April 28-29, 2009:

"Testifiers reported that the ability to get data out of EHRs easily – both for reporting and for creating panels of patients, is difficult with today’s EHRs. However, it was noted that in addition to embedding registry functionality in an EHR, such functionality (and others) may better be delivered through applications and services that are not part of a single all-encompassing application, such as population or disease registries."

Views: This testimony from industry leaders reinforces the growing sentiment that registry solutions are a very viable solution for meaningful use.

Modular Approach Available through EHR-M

From the HIT Policy Committee Review of Initial Recommendations by the Certification and Adoption Workgroup, Paul Egerman and Marc Probst, Intermountain Healthcare, August 14, 2009:

“Recommendation 4 – Flexible Software Sources - provide for certification of components so EHRs can be purchased from multiple sources”

Views: a registry can be certified via EHR-M. You will be able to assemble best of breed components from a variety of vendors to meet meaningful use. You will probably find this can be done at a total price-point lower than a monolith EMR. Cielo is assembling the best-of-breed products that, together, will be pre-interfaced and meet meaningful use.

Submissions Will be Electronic

“CMS noted that only measures that "can be submitted electronically" will be allowed.”

Source: CMS Sheds Light on Meaningful Use, HDM Breaking News, August 14, 2009

Views: electronic submission is good. We predict the constructs in place for registry reporting on PQRI will be used for meaningful use submissions. Therefore, a system already doing PQRI uploads, like Cielo Clinic, should have an advantage.

Dave Morin
CEO and Co-Founder
Cielo MedSolutions LLC

I haven't seen this covered in any of the daily health care newsletters I receive, but I certainly think it warrants great attention.

"Initial Lessons From the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical Home" is a paper published in the May/June 2009 edition of the Annals of Family Medicine. In it, the authors summarize the findings of the American Academy of Family Physicians' National Demonstration Project where a model of the patient-centered medical home was tested in 36 family practices across the US.

For anyone working toward or contemplating a Medical Home model, you really need to pay attention to the outlined Initial Lessons Learned and Practice Recommendations.

In summary, it shows that moving to a medical home is not easy, in fact, it's really hard to do. And it takes a huge commitment.

Regarding technology, there's a great quote in the paper "For example, it is possible and sometimes preferable to implement e-prescribing, local hospital system connections, evidence at the point-of-care, disease registries and interactive patient Web portals without an EMR." 1

In other words, Cielo Clinic with e-prescribing may be what you need for a medical home.

Cielo is a big proponent of the medical home model and our software supports what it requires. But, I also believe that the items in this paper regarding the transformation process are what's most important to consider if you are taking this journey.

I urge you to read this paper, it's in the Annals of Family Medicine, Vol 7, No 3, May/June 2009.

1 Annals of Family Medicine 7:254-260 (2009)


Dave Morin
CEO and Co-Founder
Cielo MedSolutions LLC