Meaningful use is the focus of this book.
This book is the first candid attempt to bridge the gap between
clinicians and IT staff.
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Health IT and Medical Science 3
Meaningful Use and What It Means to Be an EHR 4
Why So Late? 5
Health IT in Health Reform 7
Evolution of Meaningful Use 7
Accountable Care Organizations 8
EHR Functionality in Context 10
2. An Anatomy of Medical Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
How Patients Reach Healthcare Organizations 14
Lab Sample Collection Before a Visit or Admission Date 17
HIPAA and Patient Identification 17
Intake, Demographics, Visits, and Admissions 20
Precertification and Prior Authorization 21
Emergency Admissions 21
Prioritization and Triage 23
Outpatient Care 24
Inpatient Care 25
Labs 27
Imaging 27
Administration and Billing 28
3. Medical Billing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Who Pays, and How 32
Claims 32
Eligibility 33
Treatment 35
Billing 37
iii
The Billing Process 38
Complexities in Billing 39
Adjudication 40
The Patient’s Burden 42
4. The Bandwidth of Paper . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Workflow Tokens 47
Why Leave Paper? 48
Step 0: Health IT Humility 49
Normalized Data 52
Good Boundaries Mean Good Data 53
Data at Peace with Itself: Linked Data 55
Flexible Data 56
Assume Health Data Changes 57
Free Text Data 57
5. Herding Cats: Healthcare Management and Business Office Operations . . . . . . . . . 61
Major Business Office Activities 63
Insurance 63
Records 64
Demographics 64
Revenue Collection 65
Auditing 65
Accounting 66
Reporting 66
Licensing, Credentials, and Enrollments 67
Nonhealthcare Interactions 68
The Evolution of the Business Office 68
6. Patient-Facing Software . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
The PHR as Platform 71
Sharing Data in Patient-Facing Software 75
Patients Using Normal Social Media 75
E-patients 77
The Quantified Self 78
Patient-Focused Social Media 80
Patient Privacy in PHR Systems 81
Specific PHR and Patient-Directed Meaningful Use Requirements 83
7. Human Error . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
The Extent of Error 85
Dangerous Dosing 87
Discontents of Computerization 90
iv | Table of Contents
Process Errors and Organizational Change 92
Deep Medical Errors and EHR Solutions 94
Errors Caused by Human-Computer Mismatch 95
Best Practices 96
8. Meaningful Use Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Outpatient Guidelines and Requirements 100
Inpatient Guidelines and Requirements 116
9. A Selective History of EHR Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
MUMPS: The Programming Language for Healthcare 129
Where Can We Buy Some Light Bulbs? 130
Fragmentation 131
In an Environment with Gag Clauses and No Consumer Reports 131
VistA History 132
10. Ontologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
A Throw-Away Ontology 136
Learning from Our Example 138
CPT Codes, Sermo, and CMS 141
International Classification of Diseases (ICD) 144
E-patient-Dave-gate 145
Crosswalks and ICD Versions 147
Other Claims Codes 149
Drug Databases 149
SNOMED to the Rescue 154
SNOMED Example 155
SNOMED and the Semantic Web 157
UMLS: The Universal Mapping Metaontology 158
Extending Ontologies 159
Other Ontologies 160
Sneaky Ontologies 161
Ontologies Using APIs 162
Exercising Ontologies 162
11. Interoperability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Some Lessons from Earlier Exchanges 166
The New HIE Rules 168
Strong Standards 168
Winning Protocols 171
The Billing Protocols 171
HL7 Version 2 173
First-Generation and Second-Generation HIEs 182
Table of Contents | v
Continuity of Care Record 182
HL7 v3, RIM, CDA, CDD, and HITSP C32 185
The IHE Protocol 189
HIE with IHE 191
Managing Patient Identifiers with IHE 192
IHE Data Exchange, the Library Model 193
IHE in the NWHIN 194
The Direct Project/Protocol 196
The PCAST Report 198
The SMART Platform 199
Technology and Policy Were Sitting in the Tree 199
12. HIPAA: The Far-Reaching Healthcare Regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
Does HIPAA Cover Me? 205
Responsibilities of Covered Entities 206
HIPAA: A Reasonable Regulation 213
Duct-Tape HIPAA Strategies 214
Breach Notification Rules 215
In Summary 217
13. Open Source Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
Why Open Source? 220
Major Open Source Healthcare Projects 221
ClearHealth 222
Mirth Connect 223
VistA Variants and Other Certified Open Source EHR Systems 223
OpenMRS 224
Appendix: Meaningful Use Implementation Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . 227
vi | Table of Conten
