Influential amplifiers

Evaluation of significant amplifiers

Summary

This page aims to review the wealth is schematically useful information and its equivalent, schematically useful energy, to paraphrase Beinhocker.  It is useful because an agent has schematic strategies that can utilize the information or energy to extend or leverage control of the cognitive niche.    potential of the hospital business models.  Following Hamel we highlight powerful forces that help the business be: Efficient, Unique, Self-reinforcing, and highly profitable.  We highlight complex adaptive system strategies that support: reinforcement: VDS alignment, Strategic Flexibility, Prophylaxis, and Centralization; and profit boosters: Network effects, Infrastructure amplifiers, and evolved amplifiers


Introduction

The major amplifiers that have influenced the analysis and prioritizations are summarized. 


Contents



Efficient operations


Stand alone clinics: Surgery, Imaging, Laboratories, Oncology; are problematic for general hospitals. 



Standalone value added surgery centers

These VASC is value added surgical center, a treatment facility with an optimized business model and processes. 
hospitals are designed to accept patients who have already been diagnosed and have straight forward problems which are effectively treated with surgery.  They must organize to effectively, conveniently, and economically is the study of trade between humans.  Traditional Economics is based on an equilibrium model of the economic system.  Traditional Economics includes: microeconomics, and macroeconomics.  Marx developed an alternative static approach.  Limitations of the equilibrium model have resulted in the development of: Keynes's dynamic General Theory of Employment Interest & Money, and Complexity Economics.  Since trading depends on human behavior, economics has developed behavioral models including: behavioral economics. 
integrate: preadmission, surgery, rehabilitation and discharge - have costly handoff problems reviewed by project BOOST.  When discharge takes too long it ties up acute bed space which can result in adding up to 30% more (unnecessary) capacity when improved discharge would translate into additional revenue.  Various interventions aim to improve the execution of the process including: CTI, TCN and RED for discharge to outpatient; InterAct for discharge to SNFs and BPIP to HHAs.  Discharge information can include:
  • Patient info
  • Behavioral summary
  • Treatment history
  • Medical history
  • Treatment objectives
  • Insurance policy
  • Discharge plans


In part the focused repetitive nature of the value added processes supports increased quality and allows Shewhart cycles to make the 'agents' and standardized processes highly effective.  Complications occur less often.  0.5% vs. 5 - 10% for surgery at a general hospital.  When complications do occur the surgery centers processes have defined a response.  Checklists can support this improvement. 

VASC business model

These facilities are being used increasingly for screening procedures such as for colon cancer is a major hereditary cancer also called colorectal cancer.  It:
  • Follows a slow, many yearlong, progression from a benign polyp to a localized cancer to an invasive one.  Two bacteria: Bacteroides fragilis, Escherichia coli variant; from the gut microbiome have been implicated in the early stages of tumor induction (Feb 2018).  It
  • Is often associated with Ras mutations and the high risk allele TCF7L2.  30 to 50% of colon cancers have KRAS mutations.  Intensive medical surveillance and removal of polyps can be lifesaving for those at high risk.  Types of colon cancer include the single gene mutation hereditary: FAP, HNPCC; 
  • Is linked to obesity. 
.  This process has increased costs relative to the PCP is a Primary Care Physician.  PCPs are viewed by legislators and regulators as central to the effective management of care.  When coordinated care had worked the PCP is a key participant.  In most successful cases they are central.  In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements.  Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments. 
or specialist's office based procedure that was previously used.  High throughput operations are very lucrative in FFS is fee-for-service payment.  For health care providers the high profits were made in hospitalizations, imaging and surgery.  Due to its inducing excessive treatment activity it may be replaced by FFV bundled payment.  

The 6am to 4pm nature of the VASC business allows optimizations in a competition with a general hospital:

Specialists, particularly in internal medicine, radiation oncology, and ophthalmology have invested in standalone labs, imaging and surgery centers and the infrastructure systems they use to capture returns from any referals and treatments that are performed. 

VASC Colonoscopy procedure (screening decision, process constrained)

VASC Screening decision:
VASC Screening process via colonoscopy:
VASC colonoscopy process constrained:


An example of a VASC is PAMF's Palo Alto surgical centers




Standalone Oncology clinics


New Mexico Cancer Center

NMCC is operated by New Mexico Oncology Hematology Consultants, Ltd. 
CEO is Dr. Barbara McAneny

Provides care to one in three New Mexicans facing cancer is the out-of-control growth of cells, which have stopped obeying their cooperative schematic planning and signalling infrastructure.  It results from compounded: oncogene, tumor suppressor, DNA caretaker; mutations in the DNA.  In 2010 one third of Americans are likely to die of cancer.  Cell division rates did not predict likelihood of cancer.  Viral infections are associated.  Radiation and carcinogen exposure are associated.  Lifestyle impacts the likelihood of cancer occurring: Drinking alcohol to excess, lack of exercise, Obesity, Smoking, More sun than your evolved melanin protection level; all significantly increase the risk of cancer occurring (Jul 2016). 
.  Focus on adult cancers and blood cancers.  Provide care in Alburquerque, Gallup, Silver City, Las Cruces. 



Imaging Centers (Free standing Radiology clinics vs. hospital)





There are a variety of images which may be ordered:
Result of radiology is a report and images. 

Director/ PACS Administrator/ Head Radiologist

Workflows include: PACS is Picture Archiving and Communications System - a workflow for radiology imaging.  An alternative to RIS. 
and RIS is Radiology Information System a workflow for radiology images.  Alternative to PACS.   based.  VNA is vendor neutral imaging or visiting nurse association.  Vendor neutral imaging aims to present imaging data from vendor systems such as PACS with a vendor neutral form and protocol such as DICOM. 
strategy aims to support effective IOP via a standard storage and comms. 

PAMA is the Protecting Access to Medicare Act of 2014.  It includes:
  • Delays of the SGR cut to Medicare until March 2015 ('doc fix').  The delay is partly funded with cuts to Medicare's funding of SNF, lab tests, physician and other provider services.  The rest is offset by moving Medicare sequester cuts from 2025 to 2024.  This SGR cut has been iteratively delayed for 10 years and was finally removed in 2015. 
  • Helps states establish CCBHCs through section 223 the Excellence in Mental Health Act demonstration program.  This stipulated that CCBHCs may receive an enhanced Medicaid reimbursement rate based on their anticipated cost of care. 
  • Directs HHS to develop VBP and readmissions strategies for SNFs
  • Directs HHS to: Develop, Promote the use by ordering and furnishing agents of, Make the interfaces public of; rules for imaging services appropriateness criteria.  The rules held in a radiology CDSS will remove the need for pre-authorization of the procedure. 
  • Enhances clinical diagnostic laboratory tests coverage, payment rates;
  • Alters end stage renal disease payments, audits;
has constrained the interaction of ordering and furnishing physicians with radiology.  It must use a radiology CDSS is Clinical decision support system.  These support clinicians decision making by combining patient data with known medical knowledge to provide alerts, such as drug combination interactions or remiders of best care practices.  
  • Radiology CDSS order interactions are governed by PAMA and will use ACR select transactions. 
which should improve the validity and cost effectiveness of the diagnostics ordered. It will replace the requirement to obtain pre-authorization for the diagnostic procedure. 

The ACR is the American College of Radiology.  It is HHS's PAMA applicable imaging services appropriate use criteria standards body. 
specifies the content that must be provided and the Select web services that must be used to interact with the CDSS. 

Technology evolution is expected to make the taking and interpretation of imaging a low skill, low cost activity carried out by specialists. 


In such a scenario hospitals will be forced to unbundle the capability weakening their overall business model. 

Free standing imaging centers are outpatient based. 




Reference Laboratories (Free standing business vs. hospital)


Tests include:
Reference laboratories focus is on specimens.  Revenue growth from physician base. 

Reference laboratories can improve profitability, relative to hospital laboratories, by limiting opening hours to prime time employing one shift of staff. 

Most reference laboratories have a portal strategy.  But many results are still faxed 2013.  Urgent results will be phoned to the requesting physician. 




Uniqueness

VDS alignment

  • Geisinger notes the powerful synergies between its stable population, health plan (GHP), EHR refers to electronic health records which are a synonym of EMR.  EHR analysis suggests strengths and weaknesses:
    • The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
    • The EHR does not necessarily reflect the patient's situation accurately. 
    • The EHR often acts as a catch-all.  There is often little time for a doctor, newly attending the patient, to review and validate the historic details. 
    • The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patient setting. 
    • As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient.  Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes.  With the EHR 12 minutes may be required to update the record!
    and the medical organization's structure.  But this integration with GHP places Geisinger's business in conflict with the major health plans

  • Strategic flexibility

    Prophylaxis

    Centralization

    Business rule centralization



    Centralization of business rules in a repository ensures business process flows can apply an agent like use of sensors to leverage the 'executable' derivative of the plan to select how to proceed.  The use of audit, monitoring, lifecycles and business editing capabilities allows the PDCA is the Plan Do Check Act (PDCA) cycle developed at Bell Labs by Walter Shewhart.  Each activity that an organization identifies it will 'do' is formally described in a 'plan' including a model of the expected outcomes of the act if it successfully achieves its goals.  If a subsequent 'check' of the results of the action relative to the predicted model is unsatisfactory the initial plan is modified to correct for identified problems and the cycle is re-executed.  The cycle allows learning to become represented in the improved plan.  Following the process institutionalizes the learning. 
    to interactively improve the schematic plan

    The application of a genetic algorithm to improve the viability of the rule set is offset by the centralized ability to alter key aspects of the rules.  Given the need to specialize the rules by facility, business relationship and environment which would seem to benefit from a GA and the goal of central control and architectural understanding which would seem to be undermined by a GA the real implementations are not surprisingly challenged. 

    The products like FICO's Blaze Advisor that implement these complex rule sets are like computer programs written in primitive languages like BASIC without type checking, scope control, or memory management support.   Therefore they become brittle and difficult to manage. 




    Network effects

    Insurance subscriber, provider and physician networks are difficult to build out from scratch, undermining ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care).  In part it is designed to make the health care system costs grow slower.  It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s.  It funds these changes with increased taxes on the wealthy.  It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew.  The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO).  The ACA did not include a Medicare buy in (May 2016).  The law includes:
    • Alterations, in title I, to how health care is paid for and who is covered.  This has been altered to ensure
      • Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
      • That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).  
      • Children, allowed to, stay on their parents insurance until 26 years of age. 
    • Medicare solvency improvements. 
    • Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision. 
    • Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.  
    • Medical home models.  
    • Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health. 
    • Qualifications for ACOs.  Organizations must:
      • Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers. 
      • Participate in the MSSP for three or more years. 
      • Have a management structure. 
      • Have clinical and administrative systems. 
      • Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO. 
      • Be accountable for the quality and cost of care provided to the Medicare FFS patient population. 
      • Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care; 
      • Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.  
    • CMMI Medicare payment experimentation.  
    • Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act). 
    • A requirement that chain restaurants must report calorie counts on their menus. 
    's health insurance cooperatives.  They display typical network effectsNarrow networks - When all health insurance plans are comparable on line people are expected to choose narrower less costly plans.  This has the effect of encouraging providers and PCP to compete to be part of the narrow plan by reducing their charges and driving down the prices of the plans.  By limiting the number of providers/doctors offered in the plans the few that are included should get more business.  Across the US in 2015 39% of health plans offered in public exchanges are narrow (30 - 70% of areas providers) or ultra-narrow (30% or less of providers).  In large cities narrow networks are even more common.  Typically if consumers go outside of the choices offered in their narrow network they will be responsible for the high bills.  There are problems induced by narrow network constraints:
    • Queuing issues - while a surgeon and a hospital may be in-network other agents in an operation, such as anesthesiologists or anesthetists, may not have the same set of insurance contracts.  Even if a subset do, once these are allocated to a task the hospital must then manage a complex set of resource constraints to keep its ORs running.  If it does this by ignoring the 'out of network' status of these necessary resources the patient will be impacted by a high bill.  
    • Success is more likely when the plan maintains a broad list of PCPs but a narrow list of specialists and hospitals (Oct 2016). 
    should be easier for insurers to develop.  But they also provide the insurers with opportunities to exclude doctors and providers, increasing the insurers' power
  • Insurers leverage legal, financial and physical network effects:
  • Operators respond building network effects too

  • Infrastructure amplifiers


    Private equity is the pooling of commitments from fund investors, to: buy assets that are not publicly traded: companies, real estate, and debt; improve their acquisition's value and sell them again, returning the sale cash to the fund investors.  Private equity companies gain competitive advantage from being lightly regulated, and wealth from the fees and special tax privileges.  Private equity companies were initially corporate raiders. 
    provides funding and strategic pressure to hospitals. 


    Private equity is the pooling of commitments from fund investors, to: buy assets that are not publicly traded: companies, real estate, and debt; improve their acquisition's value and sell them again, returning the sale cash to the fund investors.  Private equity companies gain competitive advantage from being lightly regulated, and wealth from the fees and special tax privileges.  Private equity companies were initially corporate raiders. 
    companies pool money from partners (wealthy is schematically useful information and its equivalent, schematically useful energy, to paraphrase Beinhocker.  It is useful because an agent has schematic strategies that can utilize the information or energy to extend or leverage control of the cognitive niche.    individuals, endowments, sovereign and pension funds (33-50% of their assets) keen for high returns) to buy companies which they aim to make more attractive for public sale: private equity companies are the former corporate raiders.  The returns have been high (Dec 2015) but that is no longer the case (Jul 2016).  Bain Capital operates as a private equity company. 




    Private equity is the pooling of commitments from fund investors, to: buy assets that are not publicly traded: companies, real estate, and debt; improve their acquisition's value and sell them again, returning the sale cash to the fund investors.  Private equity companies gain competitive advantage from being lightly regulated, and wealth from the fees and special tax privileges.  Private equity companies were initially corporate raiders. 
    's move into banking has been matched by their investments in infrastructure development and ownership: Housing, Rail, Hospitals, Municipal golf courses; using a sophisticated strategy which includes getting close to government as contractors and partners on public projects and through owning companies which:
    • Win government contracts
    • Shape public policy including undermining consumer protection legislation to improve profits from subsequently legal high interest loans. 
    • Flow profits and added debt to the private equity company through fees, while isolating them from the risk from debt and cash flow problems in the operations. 
      • The private equity owners are not liable for the company's acquired debt so they face relatively little risk.  They require companies to take on debt and then use the money to pay fees to the private equity firm. 

    Power brokers and legislators move to keep the internal operations and associations of private equity from general view (Jul 2016). 




    They use data based on internal rate of return which allows for leeway in estimating the values of portfolio companies held by a fund prior to its liquidation.  Academic studies avoided this measure and found poor performance across the industry since 2006 (Jul 2016). 



  • US is the United States of America.   Private Equity is the pooling of commitments from fund investors, to: buy assets that are not publicly traded: companies, real estate, and debt; improve their acquisition's value and sell them again, returning the sale cash to the fund investors.  Private equity companies gain competitive advantage from being lightly regulated, and wealth from the fees and special tax privileges.  Private equity companies were initially corporate raiders. 
    moving into infrastructure investments




  • The use of centralized EHR refers to electronic health records which are a synonym of EMR.  EHR analysis suggests strengths and weaknesses:
    • The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
    • The EHR does not necessarily reflect the patient's situation accurately. 
    • The EHR often acts as a catch-all.  There is often little time for a doctor, newly attending the patient, to review and validate the historic details. 
    • The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patient setting. 
    • As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient.  Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes.  With the EHR 12 minutes may be required to update the record!
    systems is required in health care delivery. 


    The federal government seems intent on acting both as a sensor and evolved amplifier for its health care infrastructure.  ONC is the Office of the National Coordinator for Health Information Technology of the US Department of Health and Human Services.  It was required to support the President's 10 year goal of interoperable EHR, and lead the nation in the strategic planning for nationwide interoperable HIT.  It develops the US HIT strategic plan.  It specifies the standards, implementation specifications and certification criteria used to certify meaningful use.  It develops key programs: RECs, HITRC, State HIE Cooperative Agreements, Beacon Communities, Health IT Workforce Development, SHARP, National Health Information Network, FHA, CONNECT.  It must encourage the development of RHIOs to facilitate community and regional clinical data exchange.   is chartered to act as a path finder sponsoring radical architecture projects: such as eHealth exchange is a network ONC now facilitates together with private foundations, to exchange health care information.  It focuses on web-services based specifications designed to securely exchange health care related data.  It is implemented by the Connect Project.  It is related to the Direct Project.  Sponsoring private foundations include: Markle foundation, Robert Wood Johnson foundation, and the California healthcare foundation. 
    ; and the direct project at ONC specifies (2) a simple, secure, scalable, standards-based way for participants to send via email authenticated, encrypted health information directly to known, trusted recipients over the Internet.  The email addresses are trusted having been issued by ONC.  .  ONC then identifies best practices which can be driven through HIT the health information technology infrastructure.
    • The HIT strategic plan includes 5 goals:
      1. Achieve adoption and Information Exchange through Meaningful Use of health IT.  ONC and AHRQ identified best practices will be distributed by HITRC and REC to providers in the community.  HITECH Beacon community grants have created 17 demonstration communities using HIT.  CMMI will test innovative payment and service delivery models.  There are 3 objectives:
        1. Accelerate adoption of EHRs.  Incentives for Meaningful use.  Provide implementation help. Train an implementation workforce.  Add meaningful use to professional certification.  Certify EHR technology that supports meaningful use.  Promote the benefits.  Align federal programs.  Encourage private payers to align. 
        2. Facilitate information exchange to support meaningful use of electronic health records.  Support exchange based business models.  Fill gaps in provider options.  Develop standards. 
        3. Support heath IT adoption and information exchange for public health and populations with unique needs.  Ensure public health agencies can exchange EHRs.  Track health disparities and promote HIT that reduces them.  Support HIT adoption in post-acute, behavioral health and ER. 
      2. Improve Care, Improve Population Health, and Reduce Health Care Costs through the Use of Health IT.  There are 4 objectives:
        1. Support more sophisticated uses of EHRs (viewed as a necessary step to the three aims) and other health IT to improve health system performance.  ICD-10 migration is viewed as necessary to obtain fine granularity of health care treatments, outcomes and costs.  Enrollment in federal health programs will be improved by development of interoperable and secure standards and protocols for enrollment. 
        2. Better manage care, efficiency, and population health through EHR-generated reporting measures.  HHS National Quality Strategy has 6 priorities which will be the focus of measures.  These will then be incorporated in EHR. 
        3. Demonstrate health IT-enabled reform of payment structures, clinical practices, and population health management.  Beacon demonstrator best practices will be replicated into the community.  Payment reforms were also piloted (bundled payments, medical home).  CMS will translate the best practices into policy. 
        4. Support new approaches to the use of health IT in research, public and population health, and national health security.  CDC is encouraging deployment of Health IT and communications infrastructure at public health departments. 
      3. Inspire Confidence and Trust in Health IT.  There are 3 objectives:
        1. Protect confidentiality, integrity, and availability of health information.  HIPAA is being strengthened by the OCR to match HITECH.  EHRs must be encrypted, with access controls, audit logs, and login timeouts.  EHRs will be made granular so certain aspects can be withheld from sharing (substance abuse notes for example).  Assess security vulnerabilities of EHR systems.  Identify privacy/security requirements and best practices and communicate them. 
        2. Inform individuals of their rights and increase transparency regarding the uses of protected health information.  Transparent policy making and explanations of rights. 
        3. Improve safety and effectiveness of health IT.  Safety concerns of patients researched and monitored. 
      4. Empower Individuals with Health IT to Improve their Health and the Health Care System.  There are 3 objectives:
        1. Engage individuals with health IT.  Most individuals don't use EHR.  HIT argues if they did their health data could become centered on them and enable Tele-health including local sensors reporting back to the HIT infrastructure and applications providing [social] support and advice.  It is also presumed it would enable new classes of health care market.  HIT hopes that involving individuals in the policy making through participation via HITPC and HITSC will increase confidence in EHR.  Ensuring individuals are aware of the benefits of HIPAA privacy and that EHR supports HIPAA may build confidence and use of EHR.  HIT also promotes generating AIDA via social networks and social media. 
        2. Accelerate individual and caregiver access to their electronic health information in a format they can use and reuse.  HIT is using Medicare and Medicaid EHR incentives to encourage providers to give individuals and caregivers access to EHRs as PHRs and secure m-Health applications.  Blue Button presents a use case. 
        3. Integrate patient-generated health information and consumer health IT with clinical applications to support patient-centered care.  ONC will use device certification to enable the integration of consumer health device data with the individuals EHRs.  HHS is studying how to enable the integration of patient generated insights from blog entries, health journals etc.  Diabetes management is being used to identify tools for benefiting from EHR data. 
      5. Achieve Rapid Learning and Technological Advancement.  There are 2 objectives:
        1. Lead the creation of a learning health system to support quality, research, and public and population health.  HIT conjectures that electronic records will provide a foundation for learning about the population's health.  Examples include tracking and managing epidemics (CDC) and improving quality and efficiency of prevention and care (FDA sentinel).  New standards (spearheaded by IOM) will be developed for technologies supporting de-identification, aggregation, querying and analysis of population health data.  Individuals and providers will be encouraged to share information with the learning health infrastructure users. 
        2. Broaden the capacity of health IT through innovation and research.  CHDI is making many large data sets and tools to analyze them available.  The best practices from SHARP funded (NIH and AHRQ) research programs will be promoted into the practice of medicine.  The focus topics are: usability of EHRs, clinical decision support, consumer health IT, HIEs and Tele-health.  NITRD is developing the programs and strategic plans that HITECH requires to coordinate research and development relating to Heath IT.  VA, DOD and CMS are acting as test beds for Health IT.  
    into the mainstream health care provider network is the owned health system and its extended network of partners.  EHR refers to electronic health records which are a synonym of EMR.  EHR analysis suggests strengths and weaknesses:
    • The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
    • The EHR does not necessarily reflect the patient's situation accurately. 
    • The EHR often acts as a catch-all.  There is often little time for a doctor, newly attending the patient, to review and validate the historic details. 
    • The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patient setting. 
    • As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient.  Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes.  With the EHR 12 minutes may be required to update the record!
    is a key example of the amplification process.  But ONC is concerned about business driven EHR silos (May 2015). 

    The EHR refers to electronic health records which are a synonym of EMR.  EHR analysis suggests strengths and weaknesses:
    • The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
    • The EHR does not necessarily reflect the patient's situation accurately. 
    • The EHR often acts as a catch-all.  There is often little time for a doctor, newly attending the patient, to review and validate the historic details. 
    • The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patient setting. 
    • As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient.  Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes.  With the EHR 12 minutes may be required to update the record!
    regulators evolved a preexisting legislative and regulatory CAS.  This provides coherence to the legal and regulatory framework but makes the technical challenges of implementation and compliance truly complex. 

    The Federal Government's agenda is summarized (from ONC is the Office of the National Coordinator for Health Information Technology of the US Department of Health and Human Services.  It was required to support the President's 10 year goal of interoperable EHR, and lead the nation in the strategic planning for nationwide interoperable HIT.  It develops the US HIT strategic plan.  It specifies the standards, implementation specifications and certification criteria used to certify meaningful use.  It develops key programs: RECs, HITRC, State HIE Cooperative Agreements, Beacon Communities, Health IT Workforce Development, SHARP, National Health Information Network, FHA, CONNECT.  It must encourage the development of RHIOs to facilitate community and regional clinical data exchange.   10 year IOP paper) as:
    The stated strategies for achieving this agenda are to facilitate government and private sector to develop five building blocks of a IOP infrastructure:
    1. Core technical standards and functions (via a vision like the JASON architecture for a robust health data infrastructure)
      1. Methods to accurately match individuals, providers, and their information across data sources
      2. Directories of the technical and human readable end points for data sources for discovery
      3. Methods for authorizing users  when they want access
      4. Methods for authenticating users
      5. Methods for securing the data
      6. Methods to represent the data
      7. Methods for handling the data
    2. Certification to support adoption and optimization of health IT products and services
    3. Privacy and security protections for health information
    4. Supportive business, clinical, cultural is how we do and think about things, transmitted by non-genetic means as defined by Frans de Waal.  CAS theory views cultures as operating via memetic schemata evolved by memetic operators to support a cultural superorganism.  Evolutionary psychology asserts that human culture reflects adaptations generated while hunting and gathering.  Dehaene views culture as essentially human, shaped by exaptations and reading, transmitted with support of the neuronal workspace and stabilized by neuronal recycling.  Damasio notes prokaryotes and social insects have developed cultural social behaviors.  Sapolsky argues that parents must show children how to transform their genetically derived capabilities into a culturally effective toolset.  He is interested in the broad differences across cultures of: Life expectancy, GDP, Death in childbirth, Violence, Chronic bullying, Gender equality, Happiness, Response to cheating, Individualist or collectivist, Enforcing honor, Approach to hierarchy; illustrating how different a person's life will be depending on the culture where they are raised.  Culture:
      • Is deployed during pregnancy & childhood, with parental mediation.  Nutrients, immune messages and hormones all affect the prenatal brain.  Hormones: Testosterone with anti-Mullerian hormone masculinizes the brain by entering target cells and after conversion to estrogen binding to intracellular estrogen receptors; have organizational effects producing lifelong changes.  Parenting style typically produces adults who adopt the same approach.  And mothering style can alter gene regulation in the fetus in ways that transfer epigenetically to future generations!  PMS symptoms vary by culture. 
      • Is also significantly transmitted to children by their peers during play.  So parents try to control their children's peer group.  
      • Is transmitted to children by their neighborhoods, tribes, nations etc. 
      • Influences the parenting style that is considered appropriate. 
      • Can transform dominance into honor.  There are ecological correlates of adopting honor cultures.  Parents in honor cultures are typically authoritarian. 
      • Is strongly adapted across a meta-ethnic frontier according to Turchin.  
      • Across Europe was shaped by the Carolingian empire. 
      • Can provide varying levels of support for innovation.  Damasio suggests culture is influenced by feelings: 
        • As motives for intellectual creation: prompting detection and diagnosis of homeostatic deficiencies, identifying desirable states worthy of creative effort.
        • As monitors of the success and failure of cultural instruments and practices
        • As participants in the negotiation of adjustments required by the cultural process over time 
      • Produces consciousness according to Dennet. 
      , and regulatory environments - including:
      • Improve policy and funding levers to create the business and clinical imperitive for interoperability and electronic health information exchange. 
      • Define the role of health IT in new payment models
      • Supporting efforts driving appropriate  health information exchange for improvements in care and to see any regulatory and business barriers preventing data flow are reduced. 
    5. Rules of engagement and governance


    Hospitals have been encouraged to deploy conforming EHR refers to electronic health records which are a synonym of EMR.  EHR analysis suggests strengths and weaknesses:
    • The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
    • The EHR does not necessarily reflect the patient's situation accurately. 
    • The EHR often acts as a catch-all.  There is often little time for a doctor, newly attending the patient, to review and validate the historic details. 
    • The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patient setting. 
    • As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient.  Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes.  With the EHR 12 minutes may be required to update the record!
    systems through HITECH the Health Information Technology and Economic and Clinical Health Act 2009.  Central to the act is the establishment of the Medicare and Medicaid EHR incentive programs which make available $27 Billion over 10 years to encourage eligible professionals and hospitals to adopt and meaningfully use certified EHR technology.  It is assumed that over time use of the new infrastructure will grow exponentially.  HITECH established a formal mechanism for public input into HIT policy - the HITPC and HITSC.  Hitech is a key evolved amplifier driving the migration to and installation of Epic and Cerner EHR systems. 
    financial incentives and meaningful use is the set of standards defined by CMS Incentive Programs that governs the use of electronic health records and allows eligible providers and hospitals to earn incentive payments by meeting specific criteria.  It aims to ensure that ARRA subsidies for HIS are used to generate health improvements.  It is staged:
    1. 2011-2012 Data capture and sharing - Criteria focus on electronically capturing health information in a standardized format.  Using that information to track key clinical conditions.  Communicating that information for care coordination processes.  Initiating the reporting of clinical quality measures and public health information.  Using information to engage patients and their families in their care.  Achieving meaningful use stage 1 requires meeting all core and selected menu objectives. 
    2. 2014 Advance clinical processes - More rigorous health information exchange requirements.  Increased requirements for e-prescribing and incorporating lab results.  Electronic transmission of patient care summaries across multiple settings.  More patient-controlled data.  A patient portal is required.  CMS hospital core measures, CMS hospital menu set measures, NPRMs of stage 2 meaningful use and certification criteria have been announced (2013).  
      • MU2 requires EHR systems to support direct messaging to send PHI to registered users. 
    3. 2016 Improved outcomes - Improving quality, safety, and efficiency, leading to improved health outcomes.  Decision support for national high-priority conditions.  Patient access to self-managed tools.  Access to comprehensive patient data through patient-centered HIE.  Improving population health.  
    requirements. 
    The EHR systems help hospitals:


    MACRA is Medicare Access and CHIP Reauthorization Act of 2015 is designed to encourage physicians to move to FFV and to link Medicare payment to quality & value.  It alters the way Medicare pays for part B physician services encouraging physicians and other ECs to conform to one of two value based payment schemes: Advanced APMs (where the EC can become a QP) or MIPS.  MACRA does not apply to hospitals which have their own meaningful use.  MACRA is designed to promote transformation and includes: Data reporting by ECs, New practice models, Changing clinical standards, and Physician evaluations; with hundreds of millions of dollars in penalties and bonuses.  It authorizes CMS to develop and deploy new rules.  It provides for PCPs in PCMHs to qualify as advanced APMs via a special lower risk pathway.  It replaced the problematic physician SGR formula. 
    encourages doctors offices to also deploy EHR systems. 

    The EHR vendors, with ten to twenty year old products, encouraged the evolution, which pushed their systems firmly into the US hospital operations.  Now the system must continue to evolve itself with the equivalent of SAP upgrades (Cerner spaghetti) to perform in parallel.  It seems clear that integrating an EMR with clinical operations and evidence is difficult. Epic's strategy includes encouraging friendly startups (Moxie) to improve the integration. 

    PHR is a Personal Health Record.  Goal is to place patients in control and make them accessible.  Early vision differentiated between standalone PHR and EHR tethered patient portals.  There are various PHR services.  Privacy, security, data integrity, ownership, cost, and quality are all unresolved issues.  Can be loaded onto a cell phone or app but then the health care privacy regulations don't apply.   systems may improve EHR access:

    While the EHR has been criticised (legitimately Oct 2014, Dec 2015) for focusing the doctors and nurses on the workstation rather than the patient new approaches such as Augmedix leverage of Google Glass to interface to the EHR show that this issue may eventually be removed. 

    The EHR records for a patient aim to reflect the diagnosis and medication records of the patient creating a history to consult.  However, it is noted (Laguna Honda admitting) that the nature of acute, ED is emergency department.  Pain is the main reason (75%) patients go to an E.D.  It has traditionally been part of an acute care hospital but recently is being deployed standalone as a catchment funnel to the owning hospital.  The EMTALA legislation requires E.D. treatment to stabilize every person seeking treatment by most hospitals.  Unreimbursed care is supported from federal government funds.  E. D. profitability has been helped by hospitals contracting with 3rd party companies who are able to improve margins through surprise billing.  The standalone E.D. competes with the positioning and brand power of lower cost urgent care clinics.  Commercial nature of care requires walk-ins to register to gain access to care.  With the focus on treatment of pain, E.D.s are a major distributor of opioids (5% of opioid prescriptions) and a major starting point of addiction in patients but are cutting back (Jun 2016). 
    and ICU is intensive care unit.  It is now being realized that the procedures and environment of the ICU is highly stressful for the patients.  In particular sedation with benzodiazepines is suspected to enhance the risk of inducing PTSD.  Intubation and catheterization are also traumatic.  Sometimes seperated into MICU and SICU.  eICU skill centralization may bring down costs. 
    treatments risks adding diagnosis and medications to solve immediate problems.  It can require considerable time to unpick the mis-diagnosis (Sep 2015, Oct 2015, Aug 2016) and treatments from the root causes and to correct the record.  Often a drive for efficiency (2) undermines that option. 

    The focus of HCIT is health care information technology.  The AHRQ argues HCIT consists of a complex set of technologies, policies, standards and user sets.  Technically they represent it as a set of layers: Application: CPOE, CDS, e-prescribing, eMAR, Results reporting, Electronic documentation, Interface engines, etc.; Communication: Messaging standards (HL7, ADT, NCPDP, X12, DICOM, ASTM, etc,) Coding standards (LOINC, ICD10, CPT, NDC, RxNorm, SNOMED CT, etc.), Process: HIE, MPI, HIPAA security & privacy, etc.; Device: Tablet and PC, ASP, PDAs, Bar Coding, etc.; 
    regulations, including the HITECH the Health Information Technology and Economic and Clinical Health Act 2009.  Central to the act is the establishment of the Medicare and Medicaid EHR incentive programs which make available $27 Billion over 10 years to encourage eligible professionals and hospitals to adopt and meaningfully use certified EHR technology.  It is assumed that over time use of the new infrastructure will grow exponentially.  HITECH established a formal mechanism for public input into HIT policy - the HITPC and HITSC.  Hitech is a key evolved amplifier driving the migration to and installation of Epic and Cerner EHR systems. 
    act, and CFR is the Code of Federal Regulations or in OKR terminology it is Conversations: about optimizing performance, Feedback: in all directions to evaluate progress and guide improvement, Recognition of individuals for their contributions.   final rule (Federal Register 45 CFR Part 170) and the HIT SC is the HIT Standards Committee.  , on supporting meaningful use is the set of standards defined by CMS Incentive Programs that governs the use of electronic health records and allows eligible providers and hospitals to earn incentive payments by meeting specific criteria.  It aims to ensure that ARRA subsidies for HIS are used to generate health improvements.  It is staged:
    1. 2011-2012 Data capture and sharing - Criteria focus on electronically capturing health information in a standardized format.  Using that information to track key clinical conditions.  Communicating that information for care coordination processes.  Initiating the reporting of clinical quality measures and public health information.  Using information to engage patients and their families in their care.  Achieving meaningful use stage 1 requires meeting all core and selected menu objectives. 
    2. 2014 Advance clinical processes - More rigorous health information exchange requirements.  Increased requirements for e-prescribing and incorporating lab results.  Electronic transmission of patient care summaries across multiple settings.  More patient-controlled data.  A patient portal is required.  CMS hospital core measures, CMS hospital menu set measures, NPRMs of stage 2 meaningful use and certification criteria have been announced (2013).  
      • MU2 requires EHR systems to support direct messaging to send PHI to registered users. 
    3. 2016 Improved outcomes - Improving quality, safety, and efficiency, leading to improved health outcomes.  Decision support for national high-priority conditions.  Patient access to self-managed tools.  Access to comprehensive patient data through patient-centered HIE.  Improving population health.  
    via EHR refers to electronic health records which are a synonym of EMR.  EHR analysis suggests strengths and weaknesses:
    • The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
    • The EHR does not necessarily reflect the patient's situation accurately. 
    • The EHR often acts as a catch-all.  There is often little time for a doctor, newly attending the patient, to review and validate the historic details. 
    • The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patient setting. 
    • As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient.  Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes.  With the EHR 12 minutes may be required to update the record!
    technology has created a force that has driven investment and effort into the development, deployment and implementation of EHR systems in ambulatory and hospital inpatient environments.  The thrust of regulations creates barriers to entry, and ongoing costs which should improve the competitive position of the leading EHR vendors.  As additional leverage is made of the platform based on the EHR requirements CMS is the centers for Medicare and Medicaid services.  , agencies, hospitals, PCP is a Primary Care Physician.  PCPs are viewed by legislators and regulators as central to the effective management of care.  When coordinated care had worked the PCP is a key participant.  In most successful cases they are central.  In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements.  Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments. 
    s and leading EHR technology suppliers should become increasingly phenotypically aligned


    If the key privacy requirement is to protect the identity of the patient, it would seem an alternative strategy to the current EHR direction would be to make the linkage between the identity (highly encrypted) and all other details - totally open in the repositories, would allow simpler mechanisms for research on architectures, and sharing of the non secure data.  That would allow for an IETF, the internet engineering task force controls the processes that manage the architecture of the internet.   like infrastructure to be developed by computer scientists that would become deployed once the current strategy of proprietary database silos and gateways becomes unmanageable and counter productive. 

    Code of Federal Regulations (CFR is the Code of Federal Regulations or in OKR terminology it is Conversations: about optimizing performance, Feedback: in all directions to evaluate progress and guide improvement, Recognition of individuals for their contributions.  )

    45 CFR part 160 and 162 (HIPAA CFRs)
    45 CFR Part 160 and 162 interim final rule Jul 8 2011, associates HIPPA operating rules define the rights and responsibilities of all parties, security requirements, transmission formats, response times, liabilities, exception processing, error resolution etc. in the form of business rules and guidelines to encourage uniform use and hence facilitate ACA mandated administrative simplification and successful HIPAA transaction interoperability between data systems of different entities.  with the ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care).  In part it is designed to make the health care system costs grow slower.  It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s.  It funds these changes with increased taxes on the wealthy.  It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew.  The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO).  The ACA did not include a Medicare buy in (May 2016).  The law includes:
    • Alterations, in title I, to how health care is paid for and who is covered.  This has been altered to ensure
      • Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
      • That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).  
      • Children, allowed to, stay on their parents insurance until 26 years of age. 
    • Medicare solvency improvements. 
    • Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision. 
    • Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.  
    • Medical home models.  
    • Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health. 
    • Qualifications for ACOs.  Organizations must:
      • Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers. 
      • Participate in the MSSP for three or more years. 
      • Have a management structure. 
      • Have clinical and administrative systems. 
      • Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO. 
      • Be accountable for the quality and cost of care provided to the Medicare FFS patient population. 
      • Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care; 
      • Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.  
    • CMMI Medicare payment experimentation.  
    • Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act). 
    • A requirement that chain restaurants must report calorie counts on their menus. 
    legal requirements to improve the utility (uniformity) and reduce the administrative cost of HIPAA is the Health Insurance Portability and Accountability Act of 1996.  It added part C (administrative simplifications) to the SSA. 
    • CFR 45CFR 160.103 is the general provisions section of the regulations.  HIPAA Transactions and Code Sets Standards regulations 45CFR 162.923(a) Covered entities must use adopted transaction standards for inter and intra covered entity transactions.  
    • HIPAA only applies to health care providers, health insurers, clearinghouses of health care data, and their BAs. 
    • Initially HIPAA was designed to specify a secure standardized MPI.  Late in the development of the legislation the MPI was viewed as too risky and was removed from the legislation.  
    • The law does not prohibit health care providers from sharing information with family, friends or caregivers unless the patient specifically objects.  Providers can use 'professional judgement' to disclose information to a relative or friend if it is in the best interest of an incapacitated patient. 
    • It is also allowed to share general information about a patient's condition and location in a facility. 
    • Family members can provide information.  
    • Caregivers who are a patient's personal representative, such as: a health care proxy or guardian or with power of attorney; or who have had the patient authorize the release of information must be provided with it.  
    • HHS office of Civil Rights enforces HIPAA but typically they try to fix problems rather than applying penalties.  
    compliant integration of the RCM is either:
    • Restrictive cardiomyopathy, a rare disease where scar tissue makes the heart muscle rigid and reduces the efficiency.  Or
    • Revenue Cycle Management aligns treatment with reimbursement.  Customer service will be involved.  IT will architect the core billing, decision support and ad-hoc services, constructed by RCM vendors, into systems to support RCM.  The Hospital's central business office will aim to maximize cash recoveries.  As per Deming, mistakes in the RCM pipeline result in rework and lost cash flow and revenue of between 4 - 12%.  The staff must be trained and fully engaged in the design and operation of the pipeline.  The front end processes are best placed to capture all the information needed to make the cycle successful.  The activities include:
      • Scheduling and Appointments - where visits and procedures are booked and demographic and insurance information is collected.  If this information is incorrect it is likely the claims will not forward to third party payers.  When resources and their states are accurately known an optimal set of plans can be constructed to efficiently and effectively flow patients through the system.  But that is difficult to guarantee because of a number of interrelated problems:
        • Scale - as the number of resources increases the ability of a central scheduling system to represent all of them accurately and reliably becomes impossible. 
        • Ubiquity - a CAS strategy for ensuring availability is to have an over-abundance of equivalent resource that can be used for schedule allocation.  But often these resource levels are set by local decision makers who all respond at about the same time to imposed funding changes.  The effect is to suddenly and unpredictably undermine the guarantee of over-abundance.  Sometimes the assumption of equivalence also fails as in the desire of a patient to see only a specific surgeon. 
        • Changes can ripple through the plans requiring coordination meetings and notifications or guaranteed receipt of status updates. 
      • Verification checks for:
        • Referral - Is there PCP authorization?  Is the PCP referred service covered by the patient's plan,
        • Authorization - obtain Insurance authorization if required, and
        • Pre-certification - is there 'need' for inpatient care or other care before admission by the MCO.  Otherwise could introduce problems including not obtaining/verifying the insurance name, number and eligibility, not securing pre-certification and pre-authorization with time limits, not copying the insurance card, not checking for secondary coverage, not detecting expired referral or authorization,
      • Pre-registration - provide advice about their financial obligations and what documents to bring to the procedure.  If there is a copay or an outstanding payment to be paid these should be processed,
      • Registration - some patients are scheduled outside of the main admitting process (by OP clinic or E.D.) and this must be detected and the scheduling verification and pre-registration process be performed,
      • Time of service payments - co pays and self pays,
      • Coding - identify diagnosis (ICD 9 -> ICD-10 codes) and treatment (CPT) activities and charges for the episode.  More than 80% of hospital cases are coded in error. 
      • Demographics and billing data entry - enter charges and adjust capitated charges,
      • Patient statements - submit primary and secondary claims (following HIPAA formats) with or without involvement of a clearinghouse, produce patient statements including time of service, outstanding balance, charged amount with codes, insurance details, forms used (UB 92/04 and HCFA 1500).  A paper based claims filing has a rejection rate of 30%.  Duplicate claim payment rates of 1 - 2% of medical expenses are common.  Duplicate claims detection is often not part of the process.  Payer's goals are in conflict with Provider goals.  
      • Collections and payment posting - Post all payments and adjustments and deposit money into the bank,
      • Denials and appeals - resubmission and appeal of claims, denial analysis and bad debts and write offs.  To reduce denial rates and appeals the reimbursement contracts payer processes and actual denials must be analyzed and understood. 
      • Account follow up - Patient inquiries, resubmission of claims and issue refunds. 
      • Financial counseling;
    software based: (1) Eligibility for a Health Plan and (2) Health Care Claim Status transactions; infrastructure between covered entities: health care providers, clearinghouses and health plans

    Part 160 covers administrative data standards and related requirements
    Part 162 covers administrative requirements.  Specifies that all HIPAA covered entities must transact using specified ASC is either:
    • An ambulatory surgery center providing same day surgical care, or
    • The accredited standards committee responsible for standard X.12. 
    X.12 parts and NCPDP is the national council for prescription drug programs.  It was accepted as a NCVHS operating rule authorizing entity. 
    telecommunication standard (See table 1) but it accepts that the flexibility in these standards leaves gaps:
    • Performance and system availability: Some health plans require batching of transactions.  Others use interactive processing. 
    • Connectivity and transportation of information: Health plans have specified the connectivity they require for interconnection.  Some require a specific clearinghouse while others use direct connections or both. 
    • Security and authentication: has depended on the covered entities periodic assessments of security risk and vulnerabilities which undermines standardization. 
    • Business scenarios and expected responses
    • Data content refinements: Health plans previously defined companion guides to align the HIPAA transactions with their business flows. There are over 1,200 companion guides! That number adds to the burden on providers and software developers in performing HIPAA transactions.  
    The ACA was designed to include legislation to remove the gaps.  It requires these CFRs to define mandatory business rules and guidelines, validated, and checked for technical coherence and consensus, by the NCVHS is the National Committee on Vital and Health Statistics which advises the Secretary of HHS on health data and statistics.  .  Operating rule authorizing entities that support the NCVHS in this role include the CAQH is the council for affordable quality healthcare.  It includes CORE. 
    's CORE is the CAQH's committee on operating rules for information exchange.  It was accepted as an NCVHS operating rule authorizing entity.  Its HHS accepted rules are:
    • Claim Submission ASC X12N 837
    • Eligibility and Benefit Verification ASC X12N 270/271
      • Eligibility and Benefits Real Time Companion Guide Rule
      • Eligibility and Benefits Connectivity Rule - specifies a common connection that will be provided by all participants
      • Eligibility and Benefits Data Content Rule - minimum requirements of the request and response to inquire about health plan insurance coverage request using ASC X.12 005010X279A1 Eligibility benefit req/res and the responding ASC X.12 005010X279A1 eligibility Benefit req/res. The rule includes:
        • Dates of eligibility for contract and benefit level
        • Patient financial responsibility for each specified benefit at the base contract amounts for both in-network & out-of-network.  
        • Name of the health plan
      • Eligibility and Benefits Batch Response Time Rule - A request sent by 9pm Eastern must be returned by 7am Eastern next business day. 
      • Eligibility and Benefits Real Time Response Time Rule - Maximum of 20 seconds. 
      • Eligibility and Benefits System Availability Rule - requires 86% availability per cal week for realtime and batch transactions. 
      • Claim Status Rule
      • Eligibility and Benefits 270/271 Normalizing Patient Last Name Rule - this aims to improve unique identification but not fully. 
      • Eligibility and Benefits 270/271 AAA Error Code Reporting Rule - allows consistant feedback on failure to uniquely identify the individual so the inputs can be corrected/updated and the transaction resubmitted. 
      • Eligibility and Benefits 270/271 Data Content Rule - requires the provision in the eligibility response of the remaining patient deductible amounts for certain service type codes. 
      • Eligibility and Benefits 270 Connectivity Rule - requires use of tow message envelope standards submitter authentication (user name, password, digital certificates) and metadata.  
    • Prior Authorization ASC X12N 278 
    • Claim Status Inquiry ASC X12N 276/277
    • Claim Payment NACHA Corporate Credit or Deposit Entry with Addenda Record (CCD+)
    • Remittance Advice ASC X12N 835
    • Acknowledgements are currently voluntary. 
    and the NCPDP is the national council for prescription drug programs.  It was accepted as a NCVHS operating rule authorizing entity. 
    .  The NCPDP's Version D.0 standard for retail pharmacies was deemed complete without additional operating rules. 

    The CFR includes studies that were used in assessing the impact and opportunity for change in the transaction system:

    This regulatory application and constraint of selected formal standards with mandated guidelines appears at first inspection to be a beneficial activity.  But, unlike the risk, is an assessment of the likelihood of an independent problem occurring.  It can be assigned an accurate probability since it is independent of other variables in the system.  As such it is different from uncertainty. 
    and progress oriented IETF process, this approach encourages heavy weight implementations that favor incumbents with the capital is the sum total nonhuman assets that can be owned and exchanged on some market according to Piketty.  Capital includes: real property, financial capital and professional capital.  It is not immutable instead depending on the state of the society within which it exists.  It can be owned by governments (public capital) and private individuals (private capital).   to resource all the requirements and rework.  Indeed the incumbents can be expected to:
    • Encourage adding features which will provide some benefits while creating entry barriers,
    • Avoid standardization of interface areas with proprietary value. 
    In 2014 the USHEI report noted:


    45 CFR Part 170
    45 CFR Part 170's final rule applies only to EHR systems and EHR modules is a component of an EHR system that is fully compliant and can be combined with other compliant modules to provide an EHR system which is consequently compliant.   and does not directly regulate the situation in which they operate.  However, other rules and regulations such as meaningful use is the set of standards defined by CMS Incentive Programs that governs the use of electronic health records and allows eligible providers and hospitals to earn incentive payments by meeting specific criteria.  It aims to ensure that ARRA subsidies for HIS are used to generate health improvements.  It is staged:
    1. 2011-2012 Data capture and sharing - Criteria focus on electronically capturing health information in a standardized format.  Using that information to track key clinical conditions.  Communicating that information for care coordination processes.  Initiating the reporting of clinical quality measures and public health information.  Using information to engage patients and their families in their care.  Achieving meaningful use stage 1 requires meeting all core and selected menu objectives. 
    2. 2014 Advance clinical processes - More rigorous health information exchange requirements.  Increased requirements for e-prescribing and incorporating lab results.  Electronic transmission of patient care summaries across multiple settings.  More patient-controlled data.  A patient portal is required.  CMS hospital core measures, CMS hospital menu set measures, NPRMs of stage 2 meaningful use and certification criteria have been announced (2013).  
      • MU2 requires EHR systems to support direct messaging to send PHI to registered users. 
    3. 2016 Improved outcomes - Improving quality, safety, and efficiency, leading to improved health outcomes.  Decision support for national high-priority conditions.  Patient access to self-managed tools.  Access to comprehensive patient data through patient-centered HIE.  Improving population health.  
    provide these constraints in specific environments.  45 CFR Part 170's final rule in tandem with Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS.  Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage.  It includes:
    • Benefits
      • Part A: Hospital inpatient insurance.  As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization.  Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital. 
      • Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
      • Part C: Medicare Advantage 
      • Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices. 
    • Eligibility
      • All persons 65 years of age or older who are legal residents for at least 5 years.  If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived.  Medicare is legislated to become the primary health plan. 
      • Persons under 65 with disabilities who receive SSDI. 
      • Persons with specific medical conditions:
        • Have end stage renal disease or need a kidney transplant. 
        • They have ALS. 
      • Some beneficiaries are dual eligible. 
      • Part A requires the person has been admitted as an inpatient at a hospital.  This is constrained by a rule that they stay for three days after admission.  
    • Sign-up
      • Part A has automatic sign-up if the person is drawing social security.  Otherwise the person must sign-up for Part A and Part B. 
      • Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office.  But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July.  Incremental yearly 10% penalties apply for not signing up at 65.  These penalties apply to all subsequent premiums. 
    • Premiums
      • Part A premium
      • Part B insurance premium
      • Part C & D premiums are set by the commercial insurer.  
    BPCI bundled payments for care improvements is a CMS initiative to explore bundled payments.  Its purpose is to incent multiple types of provider to coordinate care reducing expenses associated with care episodes.  CMMI accepts providers' proposals to test the four different bundled payment models.  The program consists of:
    • Seeking voluntary participation in four bundled payments models. 
    • Model 1: 3 days pre-acute + hospital inpatient stay.  
    • Model 2: 3 days pre-acute + hospital inpatient stay + inpatient MD services + post-acute facility services + post-acute MD services + related readmissions. 
    • Model 3: Post-acute facility services + post-acute MD services + related readmissions. 
    • Models 1 - 3 provide retrospective reimbursement. 
    • Models 2 - 3 include post episode reconciliation.  
    • Model 4: 3 days pre-acute + hospital inpatient stay + inpatient MD services + related readmissions. 
    • Model 4 offers a single prospective payment. 
    • Acute care hospitals, physicians groups, health systems eligible for all models; post-acute facilities may participate without hospitals in Model 3. 
    • Physicians eligible for gain sharing bonuses up to 50% of traditional fee schedule. 
    • For all models, applicants must propose quality measures, which CMS will use to develop a set of standardized metrics. 
    and Medicaid is the state-federal program for the poor.  Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state.  Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program.  Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem.  The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states.  As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year.  In 2017 it pays for 40% of new US births. 
    incentive programs result in EHR system purchasers focusing on deploying qualified EHR modules is a component of an EHR system that is fully compliant and can be combined with other compliant modules to provide an EHR system which is consequently compliant.   and systems that have achieved EHR certification for their targeted environments (such as ambulatory or hospital inpatient).  Such modules and systems have passed the certification criteria adopted by the Secretary of Health and Human Services is the U.S. Department of Health and Human Services.  .  Hence instead of network effects amplifying the deployment of useful emergent technologies defined by an IETF style process, EHR vendors primary focus must be to obtain certification and health care providers will deploy the certified technology to ensure reimbursement is the payment process for much of US health care.  Reimbursement is the centralizing mechanism in the US Health care network.  It associates reward flows with central planning requirements such as HITECH.  Different payment methods apportion risk differently between the payer and the provider.  The payment methods include:
    • Fee-for-service,
    • Per Diem,
    • Episode of Care Payment, 
    • Multi-provider bundled EPC,
    • Condition-specific capitation,
    • Full capitation.  
    .  

    The regulations have adopted consensus standards in line with NTTAA is the National Technology Transfer and Advancement Act 1995.  It requires Federal agencies to use, unless prohibited, technical standards that have been developed or adopted by voluntary consensus standards bodies. 
    statute except for:

    The regulations have adopted the strategy of specifying constraints as goals with measures and certification criteria.  The certification criteria are able to reflect particular environments such as hospital inpatient and ambulatory allowing development of focused complete EHR is CFR 45CFR Part 170's definition of an EHR technology solution which is able to perform, at a minimum, all of the applicable capabilities required by certification criteria adopted by the Secretary of HHS.   systems.  Examples of such constraints would be:
    The 45 CFR Part 170 regulation's final rule aims to be coherent with other regulations requirements.  The rule both defines standards, implementation specifications and certification criteria for HITECH the Health Information Technology and Economic and Clinical Health Act 2009.  Central to the act is the establishment of the Medicare and Medicaid EHR incentive programs which make available $27 Billion over 10 years to encourage eligible professionals and hospitals to adopt and meaningfully use certified EHR technology.  It is assumed that over time use of the new infrastructure will grow exponentially.  HITECH established a formal mechanism for public input into HIT policy - the HITPC and HITSC.  Hitech is a key evolved amplifier driving the migration to and installation of Epic and Cerner EHR systems. 
    and leverages and aligns with other existing ones such as HIPAA is the Health Insurance Portability and Accountability Act of 1996.  It added part C (administrative simplifications) to the SSA. 
    • CFR 45CFR 160.103 is the general provisions section of the regulations.  HIPAA Transactions and Code Sets Standards regulations 45CFR 162.923(a) Covered entities must use adopted transaction standards for inter and intra covered entity transactions.  
    • HIPAA only applies to health care providers, health insurers, clearinghouses of health care data, and their BAs. 
    • Initially HIPAA was designed to specify a secure standardized MPI.  Late in the development of the legislation the MPI was viewed as too risky and was removed from the legislation.  
    • The law does not prohibit health care providers from sharing information with family, friends or caregivers unless the patient specifically objects.  Providers can use 'professional judgement' to disclose information to a relative or friend if it is in the best interest of an incapacitated patient. 
    • It is also allowed to share general information about a patient's condition and location in a facility. 
    • Family members can provide information.  
    • Caregivers who are a patient's personal representative, such as: a health care proxy or guardian or with power of attorney; or who have had the patient authorize the release of information must be provided with it.  
    • HHS office of Civil Rights enforces HIPAA but typically they try to fix problems rather than applying penalties.  
    and 70 FR 67579 rule for Medicare Part D is a federal program to subsidize the costs of outpatient prescription drugs for Medicare beneficiaries enacted as part of the MMA and delivered entirely by private companies.  It is an evolved amplifier with MMA schematic rules ensuring catalytic tax subsidies: reinsurance; flow to a broad group of elderly voters and a small but influential group of payers: UnitedHealth, Humana, CVS Health; while pharmaceutical companies also benefited from increased sales of reimbursed drugs.  It includes:
    • E-prescribing regulations.  Health care providers that electronically prescribe Part D drugs for Part D eligible individuals under 42 CFR 423.160(a)(3)(iii) may use HL7 or NCPDP SCRIPT standard to transmit prescriptions & related information internally but must use NCPDP SCRIPT (or other adopted standard) to transmit information to another legal entity.  
    • Premium subsidy set by a market average.  Medicare collects bids from all plans that reflect their costs of providing the minimum required level of drug coverage. It then sets the subsidy at 74.5% of the average bid.  
    • Premium coverage gap (doughnut hole) between the 74.5% premium subsidy and the catastrophic-coverage threshold.  The BBA of 2018 required Part D insurers cover 5% of the beneficiaries coverage gap and drug companies provide discounts that reduce federal spending by a total of $7.7 billion through 2027. 
    e-prescribing is sending prescriptions electronically.  It is constrained by a CMS rule to communicate using NCPDP SCRIPT.  A code set must be adopted for the communication identifying the medicine such as RxNorm.  Prescribing is complicated due to:
    • The need to adjust drug strengths based on patient weight.  This is especially important in pediatrics. 
    • The prescribing of controlled substances is governed by different rules and workflows.  
    .  Compliance of EHR or EHR modules with adopted standards is solely reflected in the certification criteria which state how to achieve the compliance in terms of including 'specified capabilities implemented in accordance with' the required standards, implementation specifications and certification criteria.  Contexts and circumstances are not specified in 45 CFR Part 170 because they will be inherited from prior regulations when these (such as HIPAA and Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS.  Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage.  It includes:
    • Benefits
      • Part A: Hospital inpatient insurance.  As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization.  Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital. 
      • Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
      • Part C: Medicare Advantage 
      • Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices. 
    • Eligibility
      • All persons 65 years of age or older who are legal residents for at least 5 years.  If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived.  Medicare is legislated to become the primary health plan. 
      • Persons under 65 with disabilities who receive SSDI. 
      • Persons with specific medical conditions:
        • Have end stage renal disease or need a kidney transplant. 
        • They have ALS. 
      • Some beneficiaries are dual eligible. 
      • Part A requires the person has been admitted as an inpatient at a hospital.  This is constrained by a rule that they stay for three days after admission.  
    • Sign-up
      • Part A has automatic sign-up if the person is drawing social security.  Otherwise the person must sign-up for Part A and Part B. 
      • Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office.  But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July.  Incremental yearly 10% penalties apply for not signing up at 65.  These penalties apply to all subsequent premiums. 
    • Premiums
      • Part A premium
      • Part B insurance premium
      • Part C & D premiums are set by the commercial insurer.  
    ) apply. 

    45 CFR 164.308(a)(1) the security risk assessment final rule specifies access control requirements of EHR modules is a component of an EHR system that is fully compliant and can be combined with other compliant modules to provide an EHR system which is consequently compliant.  .  Audit trails and alerts on configured events are required, including deletion of data.  It must be possible to detect reading of classified data from audit logs.  Automatic logoff is assumed. 
    68 FR 8355 HIPAA is the Health Insurance Portability and Accountability Act of 1996.  It added part C (administrative simplifications) to the SSA. 
    • CFR 45CFR 160.103 is the general provisions section of the regulations.  HIPAA Transactions and Code Sets Standards regulations 45CFR 162.923(a) Covered entities must use adopted transaction standards for inter and intra covered entity transactions.  
    • HIPAA only applies to health care providers, health insurers, clearinghouses of health care data, and their BAs. 
    • Initially HIPAA was designed to specify a secure standardized MPI.  Late in the development of the legislation the MPI was viewed as too risky and was removed from the legislation.  
    • The law does not prohibit health care providers from sharing information with family, friends or caregivers unless the patient specifically objects.  Providers can use 'professional judgement' to disclose information to a relative or friend if it is in the best interest of an incapacitated patient. 
    • It is also allowed to share general information about a patient's condition and location in a facility. 
    • Family members can provide information.  
    • Caregivers who are a patient's personal representative, such as: a health care proxy or guardian or with power of attorney; or who have had the patient authorize the release of information must be provided with it.  
    • HHS office of Civil Rights enforces HIPAA but typically they try to fix problems rather than applying penalties.  
    's security final rule considers emergency access a required part of access control. 

    75 FR 36158 the temporary certification program final rule specifies security and privacy requirements of EHR modules is a component of an EHR system that is fully compliant and can be combined with other compliant modules to provide an EHR system which is consequently compliant.  

    NIST is the National Institute of Standards and Technology. 
    • NIST has released the CIF to encourage the standardization and enhancement of testing of EHR systems. 
    (FIPS is the Federal Information Processing Standards. 
    140-2) approved encryption.  Message data is required to be able to be encrypted and signed to detect tampering.  The EHR technology must have the capability to encrypt the data. 

    OCR is HHS Office of Civil Rights.  It enforces four key privacy and security laws:
    1. HIPAA Privacy Rule.  
    2. HIPAA Security Rule. 
    3. HIPAA Breach Notification Rule. 
    4. Confidentiality provisions of the Patient Safety Rule. 
    must regulate a final rule prior to its adoption for EHR technology certification. 

    It seems likely that EHR vendors will be highly constrained and will focus significant effort on discovery and adherence to the extended CAS rules and regulations.  For example the patient summary certification focuses on data such as problem and medication lists.  It seems clear from project Boost (Better Outcomes for Older adults through Safe Transitions) aims to improve hospital discharge processes.  It has released a fact sheet and discharge planning advisor.  It illustrates the complexity of problems encountered in discharge.  (Often resources will be required to sustain contacts with the patients.  So, poorly funded hospitals in poor communities are less likely to cope.)  Examples of problems include:
    • Poor discharge forms which confuse the patients.  They should also describe what has occurred at the hospital so that a patient can share them with a PCP and they will be useful rather than misleading.  
    • Medication list incorrect at discharge. 
    • Insufficient resources to call discharged patients. 
    • Calls from discharged patients should be to an organization that is expecting the calls and able to handle them.  One effective target is the hospital floor where the inpatient bed was.  As long as the floor staff understand that discharged patients are still part of their responsibilities.  These numbers must be given to the patient. 
    • Different owners of discharge in different sites with different resources and expectations. 
    • Indigents with no PCP while discharge process is designed expecting PCP participation in the handover. 
    • Immigrants with cultural disconnects from standard US procedures.  This is a complex area with the potential for many misunderstandings. 
    • No local resource in a poor community to accept discharge but hospital needs to proceed with discharge.  BOOST argues to design for this issue setting up for support from a partner area with resources!
    • Replace emergency room one day hospital admittance with observation which is lower cost and will avoid possible reimbursement refusals. 
    and hot spot strategies is a highly connected agent with an outsize influence.  In medicine these are very high cost patients often with very poor personal health care strategies (Sep 2017). The logic of hot spots is reviewed by Atul Gawande.  Glenn Steele & David Feinberg describe how Geisinger has successfully identified and reduced the cost impact of its hot spot patients.  Robert Pearl argues the strategy has limited applicability in the current health care network.  He asserts a revolution can/must happen that will help this strategy to become broadly applicable.  Ezekiel Emanuel asserts practice transformations have allowed chronic care operations: CareMore; to identify and support hotspot patients in the community.   exemplified by the special care center of AtlantiCare Medical Center that what would be effective needs to take into account the specific situation of the patient.  But that is a much harder problem for technology to solve.  Instead resources will be used to lock in on the certification capabilities.  (Dallas Parkland Health's Mobile clinics may help hospitals manage these costs May 2016).  Just as when the Federal government helped the consolidation of AT&T and IBM it seems likely that the EHR vendors will gain fat profits and can be expected to consolidate the market using classic IBM strategies and tactics.  It is reported that Epic is avoiding HIE integration.  Does the HIE have an effective security architecture?  KLAS respondents weren't convinced. 

    An equally difficult challenge is the representation of inaccurate data within the EHR.  Laguna Honda illustrates how medication and diagnosis notes can become invalid.  So EHR data quality is hard to ensure and sustain. 

    The architecture of the certified EHR network is a highly distributed network of EHRs.  The effective coordination of workflows in such a distributed environment with shared state is typically quite challenging.  For example when a patient provides updates about their current status (insurance details, medication changes etc.) does the network aim to update all copies of the information? 

    This suggests there is a significant risk that the federal government will suck capital is the sum total nonhuman assets that can be owned and exchanged on some market according to Piketty.  Capital includes: real property, financial capital and professional capital.  It is not immutable instead depending on the state of the society within which it exists.  It can be owned by governments (public capital) and private individuals (private capital).  , or momentum, out of progressive HCIT is health care information technology.  The AHRQ argues HCIT consists of a complex set of technologies, policies, standards and user sets.  Technically they represent it as a set of layers: Application: CPOE, CDS, e-prescribing, eMAR, Results reporting, Electronic documentation, Interface engines, etc.; Communication: Messaging standards (HL7, ADT, NCPDP, X12, DICOM, ASTM, etc,) Coding standards (LOINC, ICD10, CPT, NDC, RxNorm, SNOMED CT, etc.), Process: HIE, MPI, HIPAA security & privacy, etc.; Device: Tablet and PC, ASP, PDAs, Bar Coding, etc.; 
    projects and starve the HCIT industry of emergent opportunities.  KLAS post-acute care perceptions 2013 confirms this worry

    SMART on FHIR
    The Federal government responded to this challenge by sponsoring an application development environment for developing applets that can operate on distributed sets of EHRs, HIE a Health Information Exchange is responsible for the transmission of health care-related data among facilities, health information organizations and government agencies according to national standards.  They are designed to address legal, organizational and technical challenges that would otherwise impede the sustainability of health information interchange.  An HIE is a component of the HIT.  It must enable reliable and secure transfer of data among diverse systems and facilitate access and retrieval.  The two main types are private and public exchanges.  Private exchanges may be able to leverage homogeneous IT infrastructure to facilitate data sharing.  Public exchanges are likely to be heterogeneous.  RHIO provide the regional organizations to support such HIE.  They are there to ensure that infrastructure amplification initiates.  The government will ensure that low healthcare density areas are served by public HIE infrastructure.  Both centralized and federated technical solutions were initially considered for implementation by the RHIOs for deploying HIE as specified in the Markle Foundation's NHIN common framework.  Common framework clients such as appropriately architected HIE use SOAP messaging to interact with their local SNO's ISB and RLS.  The HIE SOAP query transactions follow the HL7 Query Model.  Alternatively some HIE's are now using direct messaging to support interoperation.  HIE deployment goals have been phased (1 - supporting care transitions, 2 - Quality and care management, 3 - Population health).  Some HIEs will support "EHR-lite" as part of their functionality.  HIE does not yet solve some difficult challenges:
    • Safeguarding the security of health information.  Currently HIEs conforming to the common framework only provide locations of clinical data held remotely.  
    • Providing effective life cycle management.  The HIE is dependent on the local set of entities to provide updates that match the current state of the entity data. 
    s and other HIT the health information technology infrastructure.
    • The HIT strategic plan includes 5 goals:
      1. Achieve adoption and Information Exchange through Meaningful Use of health IT.  ONC and AHRQ identified best practices will be distributed by HITRC and REC to providers in the community.  HITECH Beacon community grants have created 17 demonstration communities using HIT.  CMMI will test innovative payment and service delivery models.  There are 3 objectives:
        1. Accelerate adoption of EHRs.  Incentives for Meaningful use.  Provide implementation help. Train an implementation workforce.  Add meaningful use to professional certification.  Certify EHR technology that supports meaningful use.  Promote the benefits.  Align federal programs.  Encourage private payers to align. 
        2. Facilitate information exchange to support meaningful use of electronic health records.  Support exchange based business models.  Fill gaps in provider options.  Develop standards. 
        3. Support heath IT adoption and information exchange for public health and populations with unique needs.  Ensure public health agencies can exchange EHRs.  Track health disparities and promote HIT that reduces them.  Support HIT adoption in post-acute, behavioral health and ER. 
      2. Improve Care, Improve Population Health, and Reduce Health Care Costs through the Use of Health IT.  There are 4 objectives:
        1. Support more sophisticated uses of EHRs (viewed as a necessary step to the three aims) and other health IT to improve health system performance.  ICD-10 migration is viewed as necessary to obtain fine granularity of health care treatments, outcomes and costs.  Enrollment in federal health programs will be improved by development of interoperable and secure standards and protocols for enrollment. 
        2. Better manage care, efficiency, and population health through EHR-generated reporting measures.  HHS National Quality Strategy has 6 priorities which will be the focus of measures.  These will then be incorporated in EHR. 
        3. Demonstrate health IT-enabled reform of payment structures, clinical practices, and population health management.  Beacon demonstrator best practices will be replicated into the community.  Payment reforms were also piloted (bundled payments, medical home).  CMS will translate the best practices into policy. 
        4. Support new approaches to the use of health IT in research, public and population health, and national health security.  CDC is encouraging deployment of Health IT and communications infrastructure at public health departments. 
      3. Inspire Confidence and Trust in Health IT.  There are 3 objectives:
        1. Protect confidentiality, integrity, and availability of health information.  HIPAA is being strengthened by the OCR to match HITECH.  EHRs must be encrypted, with access controls, audit logs, and login timeouts.  EHRs will be made granular so certain aspects can be withheld from sharing (substance abuse notes for example).  Assess security vulnerabilities of EHR systems.  Identify privacy/security requirements and best practices and communicate them. 
        2. Inform individuals of their rights and increase transparency regarding the uses of protected health information.  Transparent policy making and explanations of rights. 
        3. Improve safety and effectiveness of health IT.  Safety concerns of patients researched and monitored. 
      4. Empower Individuals with Health IT to Improve their Health and the Health Care System.  There are 3 objectives:
        1. Engage individuals with health IT.  Most individuals don't use EHR.  HIT argues if they did their health data could become centered on them and enable Tele-health including local sensors reporting back to the HIT infrastructure and applications providing [social] support and advice.  It is also presumed it would enable new classes of health care market.  HIT hopes that involving individuals in the policy making through participation via HITPC and HITSC will increase confidence in EHR.  Ensuring individuals are aware of the benefits of HIPAA privacy and that EHR supports HIPAA may build confidence and use of EHR.  HIT also promotes generating AIDA via social networks and social media. 
        2. Accelerate individual and caregiver access to their electronic health information in a format they can use and reuse.  HIT is using Medicare and Medicaid EHR incentives to encourage providers to give individuals and caregivers access to EHRs as PHRs and secure m-Health applications.  Blue Button presents a use case. 
        3. Integrate patient-generated health information and consumer health IT with clinical applications to support patient-centered care.  ONC will use device certification to enable the integration of consumer health device data with the individuals EHRs.  HHS is studying how to enable the integration of patient generated insights from blog entries, health journals etc.  Diabetes management is being used to identify tools for benefiting from EHR data. 
      5. Achieve Rapid Learning and Technological Advancement.  There are 2 objectives:
        1. Lead the creation of a learning health system to support quality, research, and public and population health.  HIT conjectures that electronic records will provide a foundation for learning about the population's health.  Examples include tracking and managing epidemics (CDC) and improving quality and efficiency of prevention and care (FDA sentinel).  New standards (spearheaded by IOM) will be developed for technologies supporting de-identification, aggregation, querying and analysis of population health data.  Individuals and providers will be encouraged to share information with the learning health infrastructure users. 
        2. Broaden the capacity of health IT through innovation and research.  CHDI is making many large data sets and tools to analyze them available.  The best practices from SHARP funded (NIH and AHRQ) research programs will be promoted into the practice of medicine.  The focus topics are: usability of EHRs, clinical decision support, consumer health IT, HIEs and Tele-health.  NITRD is developing the programs and strategic plans that HITECH requires to coordinate research and development relating to Heath IT.  VA, DOD and CMS are acting as test beds for Health IT.  
    s.  This has developed into SMART is substitutable medical applications and reusable technology from SMART Health IT. 
    on FHIR is fast healthcare interoperability resources (fire) an HL7 standard defining a set of 'resources' that represent granular clinical concepts.  The items include:
    • Clinical
      • General: AdverseReaction, AlergyIntolerance, CarePlan, Condition, Family/History, Procedure, Questionnaire,
      • Medications: Medication, MedicationPrescription, Medication/Administration, MedicationDispense, MedicationStatement, Immunization, ImmunizationRecommendation
      • Diagnostics: Observation, DiagnosticReport, DiagnosticOrder, ImagingStudy, Specimen
      • Device Interactions: DeviceObservationreport
    • Administrative
      • Attribution: Patient, RelatedPerson, Practitioner, Organization
      • Entities: Device, Location, Substance, Group
      • Workflow Management: Encounter, Alert, Supply, Order, Order/Response
      • Financial:
    • Infrastructure
      • Support: List, Media, Other, Provenance, SecurityEvent, (Binary)
      • Document Handling: Composition, DocumentReference, DocumentManifest
      • Exchange: MessageHeader, OperationOutcome, Query
      • Conformance: Conformance, Profile, ValueSet, ConceptMap (informative)






    The publishing of EHR refers to electronic health records which are a synonym of EMR.  EHR analysis suggests strengths and weaknesses:
    • The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
    • The EHR does not necessarily reflect the patient's situation accurately. 
    • The EHR often acts as a catch-all.  There is often little time for a doctor, newly attending the patient, to review and validate the historic details. 
    • The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patient setting. 
    • As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient.  Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes.  With the EHR 12 minutes may be required to update the record!
    data is architected to be facilitated through RHIO is regional health information Organization facilitates the HIE transfer of health information electronically across organizations.  There are four components to an RHIO: convenor, transactor, grid, and last mile.  RHIOs are viewed as key components of the NHIN.  Two technological architectures are used to implement the HIEs: (1) Data warehouses and (2) federated database systems.  This results in two RHIO architectures:
    1. Centralized - where local nodes data is extracted, transformed and then loaded into the central warehouse.  Technically this suffers from central data being out of date by the time between batch updates generated by the distributed extract and transform processes. 
    2. Federated - where record locators are stored in data bases at each RHIO node linking to the actual data.  There were no protocols defined and standardized initially for supporting the operation of the federation.  INPC and IHIE are examples of operational federated RHIOs.  
    agents via health information exchange a Health Information Exchange is responsible for the transmission of health care-related data among facilities, health information organizations and government agencies according to national standards.  They are designed to address legal, organizational and technical challenges that would otherwise impede the sustainability of health information interchange.  An HIE is a component of the HIT.  It must enable reliable and secure transfer of data among diverse systems and facilitate access and retrieval.  The two main types are private and public exchanges.  Private exchanges may be able to leverage homogeneous IT infrastructure to facilitate data sharing.  Public exchanges are likely to be heterogeneous.  RHIO provide the regional organizations to support such HIE.  They are there to ensure that infrastructure amplification initiates.  The government will ensure that low healthcare density areas are served by public HIE infrastructure.  Both centralized and federated technical solutions were initially considered for implementation by the RHIOs for deploying HIE as specified in the Markle Foundation's NHIN common framework.  Common framework clients such as appropriately architected HIE use SOAP messaging to interact with their local SNO's ISB and RLS.  The HIE SOAP query transactions follow the HL7 Query Model.  Alternatively some HIE's are now using direct messaging to support interoperation.  HIE deployment goals have been phased (1 - supporting care transitions, 2 - Quality and care management, 3 - Population health).  Some HIEs will support "EHR-lite" as part of their functionality.  HIE does not yet solve some difficult challenges:
    • Safeguarding the security of health information.  Currently HIEs conforming to the common framework only provide locations of clinical data held remotely.  
    • Providing effective life cycle management.  The HIE is dependent on the local set of entities to provide updates that match the current state of the entity data. 
    infrastructure. 



    RHIO is regional health information Organization facilitates the HIE transfer of health information electronically across organizations.  There are four components to an RHIO: convenor, transactor, grid, and last mile.  RHIOs are viewed as key components of the NHIN.  Two technological architectures are used to implement the HIEs: (1) Data warehouses and (2) federated database systems.  This results in two RHIO architectures:
    1. Centralized - where local nodes data is extracted, transformed and then loaded into the central warehouse.  Technically this suffers from central data being out of date by the time between batch updates generated by the distributed extract and transform processes. 
    2. Federated - where record locators are stored in data bases at each RHIO node linking to the actual data.  There were no protocols defined and standardized initially for supporting the operation of the federation.  INPC and IHIE are examples of operational federated RHIOs.  
    s are organizational emergent agents which are structured to enhance the funding, deployment and effective use of EHR refers to electronic health records which are a synonym of EMR.  EHR analysis suggests strengths and weaknesses:
    • The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
    • The EHR does not necessarily reflect the patient's situation accurately. 
    • The EHR often acts as a catch-all.  There is often little time for a doctor, newly attending the patient, to review and validate the historic details. 
    • The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patient setting. 
    • As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient.  Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes.  With the EHR 12 minutes may be required to update the record!
    and HIE a Health Information Exchange is responsible for the transmission of health care-related data among facilities, health information organizations and government agencies according to national standards.  They are designed to address legal, organizational and technical challenges that would otherwise impede the sustainability of health information interchange.  An HIE is a component of the HIT.  It must enable reliable and secure transfer of data among diverse systems and facilitate access and retrieval.  The two main types are private and public exchanges.  Private exchanges may be able to leverage homogeneous IT infrastructure to facilitate data sharing.  Public exchanges are likely to be heterogeneous.  RHIO provide the regional organizations to support such HIE.  They are there to ensure that infrastructure amplification initiates.  The government will ensure that low healthcare density areas are served by public HIE infrastructure.  Both centralized and federated technical solutions were initially considered for implementation by the RHIOs for deploying HIE as specified in the Markle Foundation's NHIN common framework.  Common framework clients such as appropriately architected HIE use SOAP messaging to interact with their local SNO's ISB and RLS.  The HIE SOAP query transactions follow the HL7 Query Model.  Alternatively some HIE's are now using direct messaging to support interoperation.  HIE deployment goals have been phased (1 - supporting care transitions, 2 - Quality and care management, 3 - Population health).  Some HIEs will support "EHR-lite" as part of their functionality.  HIE does not yet solve some difficult challenges:
    • Safeguarding the security of health information.  Currently HIEs conforming to the common framework only provide locations of clinical data held remotely.  
    • Providing effective life cycle management.  The HIE is dependent on the local set of entities to provide updates that match the current state of the entity data. 
    .  It was argued that they should be formed from the collaboration of RHIO convenors is an organization that brings together RHIO stakeholders.  , transactors provides community-wide exchange of healthcare administrative data.  , grids supplies the clinical exchange network.  and last miles ensures that RHIO services can connect to provider offices through EHR systems.  .  That logic is followed in the case of the Massachusetts's virtual RHIO

    The HIE infrastructure has been implemented using both centralized and federated technologies. 

    The complexity of HIE information security and privacy prompted the office of the National Coordinator for Health IT at HHS is the U.S. Department of Health and Human Services.  , AHRQ is the Agency for Healthcare Research and Quality.  It provided the definition of a medical home (PCMH) as both a place and a model of the organization of primary care that delivers core functions of primary health care. 
    and the National Governors Association to sponsor the Health Information Security and Privacy Collaborative (HISPC is a project of the AHRQ to address privacy and security policy issues affecting interoperable HIE.  It is managed by RTI, the NGA, AHRQ, and HHS Office of the National Coordinator for health IT.  It aims to identify variation among states on privacy and security practices and laws, to propose solutions to address challenges, and to increase expertise about health information privacy and security protection.  Phase I of the project resulted in the identification of four key public policy concerns: patient consent to the use of HIE networks, use and disclosure of sensitive medical information, implementation of access controls, and application of community standards. 
    ). 





    Health Information Exchanges (HIE a Health Information Exchange is responsible for the transmission of health care-related data among facilities, health information organizations and government agencies according to national standards.  They are designed to address legal, organizational and technical challenges that would otherwise impede the sustainability of health information interchange.  An HIE is a component of the HIT.  It must enable reliable and secure transfer of data among diverse systems and facilitate access and retrieval.  The two main types are private and public exchanges.  Private exchanges may be able to leverage homogeneous IT infrastructure to facilitate data sharing.  Public exchanges are likely to be heterogeneous.  RHIO provide the regional organizations to support such HIE.  They are there to ensure that infrastructure amplification initiates.  The government will ensure that low healthcare density areas are served by public HIE infrastructure.  Both centralized and federated technical solutions were initially considered for implementation by the RHIOs for deploying HIE as specified in the Markle Foundation's NHIN common framework.  Common framework clients such as appropriately architected HIE use SOAP messaging to interact with their local SNO's ISB and RLS.  The HIE SOAP query transactions follow the HL7 Query Model.  Alternatively some HIE's are now using direct messaging to support interoperation.  HIE deployment goals have been phased (1 - supporting care transitions, 2 - Quality and care management, 3 - Population health).  Some HIEs will support "EHR-lite" as part of their functionality.  HIE does not yet solve some difficult challenges:
    • Safeguarding the security of health information.  Currently HIEs conforming to the common framework only provide locations of clinical data held remotely.  
    • Providing effective life cycle management.  The HIE is dependent on the local set of entities to provide updates that match the current state of the entity data. 
    ) can be viewed as schematically generated phenotypic infrastructure for supporting the signal and sensor deployment necessary for the interaction of complex adaptive system (CAS) agents within the health care provider network is the owned health system and its extended network of partners.  
    HIE Core Services:
    The Markle Foundation has been a significant influence on the early approaches taken to HIE architecture and deployment. 

    It is suggested that HIE automatic reporting will reduce labor costs. 

    The current nature of the foundation's common framework is the Markle common Framework used by connecting for health.  The common framework provides information about setting up the agents of a CAS based electronic health network that allows emergence of the NHIN.  It includes:
    • Policy guides for how information is protected
      • The architecture for privacy in a networked information environment
      • Model privacy policies and procedures for health information exchange
      • Notification and consent when using a record locator service
      • Correctly matching patients and their records
      • Authentication of system users
      • Patients access to their own health information
      • Auditing access to and use of a health information exchange
      • Breaches of confidential health information
      • A common framework for networked personal health information
    • Technical guides for how information is exchanged
      • Technical issues and requirements for common framework implementation. 
        • There is an architected hierarchy.  The NHIN is viewed as a network of SNOs - while entities within an SNO are free to communicate directly with other entities in the SNO, inter SNO communications is required to go via an ISB so that all flows between SNOs can be observed. 
      • HIE architecture implementation guide
      • Medication history standards
      • Laboratory results standards
      • Background issues on data quality
      • Technical background of record locator service
      • Consumer authentication for networked personal health information
    • Model contractual language
    signal generation mechanism seems remarkably indirect.  Markle's approach to external standards resulted in common framework based systems being complicated and acts as a barrier (due to high development costs and limited value of the initial emergent entities) to emergence of networks (NHIN) based on such systems.  As ONC funding in 2012-13 has dried up the various state HIEs have been collapsing. 

    Some exchanges, such as Tennessee's have been terminated in favor of use of the Direct Project at ONC specifies (2) a simple, secure, scalable, standards-based way for participants to send via email authenticated, encrypted health information directly to known, trusted recipients over the Internet.  The email addresses are trusted having been issued by ONC.   which they concluded is simpler.  KLAS sees rising dissatisfaction with the HIE approach.  Dissatisfaction has increased over time. 

    Deployment of HIE has been slow.  This has been attributed to:
    However, as providers have worked with HIE, failure to scale appears to be the major issue with HIE based solutions.  With the requirement to construct the query results each time and then resolve the associated data with networked gets this is no surprise.  (recall RPC - 'its like a procedure call only slower'!)  In comparison Epic Care Everywhere is viewed by the customer base very positively.  KLAS is a healthcare technology rating organization.   also promote athenaHealth's strategy as an attractive alternative. 

    Providing filters which remove sensitive information is only a partial solution to the privacy and security constraints.  Medication information that is withheld may be important to know to effectively prescribe new treatments and medications. 

    Can CAS architectures effectively represent individual agents (patients)?  Typically they use ubiquitous equivalence to support flows. 




    Evolved amplifiers


    Evolved amplifiers support high margins in US is the United States of America.   health care.  They promote the selection of expensive treatments, price opacity, and cost management constraints. 
    The screening, diagnosis and treatment of colorectal cancer is a major hereditary cancer also called colorectal cancer.  It:
    • Follows a slow, many yearlong, progression from a benign polyp to a localized cancer to an invasive one.  Two bacteria: Bacteroides fragilis, Escherichia coli variant; from the gut microbiome have been implicated in the early stages of tumor induction (Feb 2018).  It
    • Is often associated with Ras mutations and the high risk allele TCF7L2.  30 to 50% of colon cancers have KRAS mutations.  Intensive medical surveillance and removal of polyps can be lifesaving for those at high risk.  Types of colon cancer include the single gene mutation hereditary: FAP, HNPCC; 
    • Is linked to obesity. 
    provide an illustrative case.  Patients with little impact from prices are encouraged to get screened. CMS is the centers for Medicare and Medicaid services.   reimbursement is the payment process for much of US health care.  Reimbursement is the centralizing mechanism in the US Health care network.  It associates reward flows with central planning requirements such as HITECH.  Different payment methods apportion risk differently between the payer and the provider.  The payment methods include:
    • Fee-for-service,
    • Per Diem,
    • Episode of Care Payment, 
    • Multi-provider bundled EPC,
    • Condition-specific capitation,
    • Full capitation.  
    price controls, and lobbying by medical guilds, supported by the risk of litigation encourages the amplifying development of fat margins for overelaborate procedures that benefit all the participants financed from taxes and insurance fees. 


    The screening decision has become important to Americans and shaped by powerful actors: 
    Price not a constraint: Screening process via colonoscopy enables high charges.  In approving the sedative Propofol is an intravenous sedative that takes effect quickly and wears off within minutes.  When Propofol won the approval of the FDA in 1989 as an anesthesia drug, it carried a label advising that it "should be administered only by those who are trained in the administration of general anesthesia" because of concerns that too high a dose could depress breathing and blood pressure to a point of requiring resuscitation. 
    the FDA Food and Drug Administration.   advised it should only be administered by a trained anesthesiologist is a physician who has completed an accredited residency program in anesthesiology and is trained in anesthesia and perioperative medicine. 
    .  With lobbying from the American Society of Anesthesiologists the FDA has so far declined to rescind the advisory for low doses required for sedation is the inducement of a relaxed state with a Valium-like drug (a benzodiazepine) or a low dose of Propofol.  In most countries sedative mixes are administered in offices and hospitals by a wide range of doctor and nurses unlike general anesthesia which typically requires a specialist.  Sedation in traumatic situations such as are typical in ICUs has been correlated with subsequent PTSD. 
    .  In 2007 Aetna tried to disallow payments for anesthesiologists delivering Propofol for colonoscopy sedation but backed off after heavy criticism from anesthesiologists and endoscopy groups. 

    Reimbursement is the payment process for much of US health care.  Reimbursement is the centralizing mechanism in the US Health care network.  It associates reward flows with central planning requirements such as HITECH.  Different payment methods apportion risk differently between the payer and the provider.  The payment methods include:
    • Fee-for-service,
    • Per Diem,
    • Episode of Care Payment, 
    • Multi-provider bundled EPC,
    • Condition-specific capitation,
    • Full capitation.  
    :
    Long term learning:
    • Many patients forgo necessary treatments due to high out-of-pocket expenses.  This has the effect of undermining preventative care strategies (which may not help with cost constraints anyway), while potentially inducing complex problems later in life that are well suited to general hospital diagnosis and treatment. 




    Aligned federal policy, and industry practice and rewards can generate powerful cascades:



    Tax and budget policy have setup a powerful evolutionary amplifier for health care.  It will strengthen strategies for health care cost control and or rationing. 

  • Tax bill written by Kevin Brady, passes Senate 51-48 allowing House to vote to send it to President Trump's Desk.  The bill sets up an evolved amplifier.  It contains: Removal of ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care).  In part it is designed to make the health care system costs grow slower.  It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s.  It funds these changes with increased taxes on the wealthy.  It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew.  The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO).  The ACA did not include a Medicare buy in (May 2016).  The law includes:
    • Alterations, in title I, to how health care is paid for and who is covered.  This has been altered to ensure
      • Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
      • That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).  
      • Children, allowed to, stay on their parents insurance until 26 years of age. 
    • Medicare solvency improvements. 
    • Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision. 
    • Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.  
    • Medical home models.  
    • Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health. 
    • Qualifications for ACOs.  Organizations must:
      • Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers. 
      • Participate in the MSSP for three or more years. 
      • Have a management structure. 
      • Have clinical and administrative systems. 
      • Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO. 
      • Be accountable for the quality and cost of care provided to the Medicare FFS patient population. 
      • Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care; 
      • Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.  
    • CMMI Medicare payment experimentation.  
    • Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act). 
    • A requirement that chain restaurants must report calorie counts on their menus. 
    individual mandate pushing insurers out of the markets as risk pools collapse, Opening of the Arctic Wildlife Refuge for oil & gas drilling, $1.5 trillion allowed deficit justifying Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS.  Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage.  It includes:
    • Benefits
      • Part A: Hospital inpatient insurance.  As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization.  Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital. 
      • Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
      • Part C: Medicare Advantage 
      • Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices. 
    • Eligibility
      • All persons 65 years of age or older who are legal residents for at least 5 years.  If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived.  Medicare is legislated to become the primary health plan. 
      • Persons under 65 with disabilities who receive SSDI. 
      • Persons with specific medical conditions:
        • Have end stage renal disease or need a kidney transplant. 
        • They have ALS. 
      • Some beneficiaries are dual eligible. 
      • Part A requires the person has been admitted as an inpatient at a hospital.  This is constrained by a rule that they stay for three days after admission.  
    • Sign-up
      • Part A has automatic sign-up if the person is drawing social security.  Otherwise the person must sign-up for Part A and Part B. 
      • Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office.  But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July.  Incremental yearly 10% penalties apply for not signing up at 65.  These penalties apply to all subsequent premiums. 
    • Premiums
      • Part A premium
      • Part B insurance premium
      • Part C & D premiums are set by the commercial insurer.  
    & Medicaid is the state-federal program for the poor.  Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state.  Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program.  Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem.  The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states.  As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year.  In 2017 it pays for 40% of new US births. 
    defunding, limits to state & local tax deductions impacting large Democratic states: California, New York, New Jersey; of $10,000, Top corporate tax rate reduced from 35% to 21%, Individual rates reduced from 39.6% to 37% but with sunsets in 2025, Inheritances of $22 million shielded from tax, Pass-through businesses able to deduct 20% of their business income (Dec 2017)

  • Budget deal (BBA is the Bipartisan Budget Act of 2018, increasing spending caps imposed by the BCA of 2011, and including as part 3, the CHRONIC care act. 
    ) expanding military & nonmilitary spending by $300 billion signed by President Trump (Feb 2018)




  • Dialysis provides another powerful evolved amplifier for hospitals. 

    The 2013 value delivery system for dialysis treatment is over stocked with clinics relative to potential demand.  This has occured because of the opportunity to capture revenue from Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS.  Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage.  It includes:
    • Benefits
      • Part A: Hospital inpatient insurance.  As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization.  Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital. 
      • Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
      • Part C: Medicare Advantage 
      • Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices. 
    • Eligibility
      • All persons 65 years of age or older who are legal residents for at least 5 years.  If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived.  Medicare is legislated to become the primary health plan. 
      • Persons under 65 with disabilities who receive SSDI. 
      • Persons with specific medical conditions:
        • Have end stage renal disease or need a kidney transplant. 
        • They have ALS. 
      • Some beneficiaries are dual eligible. 
      • Part A requires the person has been admitted as an inpatient at a hospital.  This is constrained by a rule that they stay for three days after admission.  
    • Sign-up
      • Part A has automatic sign-up if the person is drawing social security.  Otherwise the person must sign-up for Part A and Part B. 
      • Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office.  But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July.  Incremental yearly 10% penalties apply for not signing up at 65.  These penalties apply to all subsequent premiums. 
    • Premiums
      • Part A premium
      • Part B insurance premium
      • Part C & D premiums are set by the commercial insurer.  
    reimbursement is the payment process for much of US health care.  Reimbursement is the centralizing mechanism in the US Health care network.  It associates reward flows with central planning requirements such as HITECH.  Different payment methods apportion risk differently between the payer and the provider.  The payment methods include:
    • Fee-for-service,
    • Per Diem,
    • Episode of Care Payment, 
    • Multi-provider bundled EPC,
    • Condition-specific capitation,
    • Full capitation.  
    of ESRD is end-stage renal disease.  This is the last stage of CKD.  It is associated with adolescents who have hypertension.  There are more than 200,000 cases a year in the U.S.  Richard Nixon encouraged and signed Social Security amendments that provided Medicare for anyone suffering from ESRD.  There are two main treatment strategies:
    1. Kidney transplants allow recovery from the disease but are limited by the availability of matching donated kidneys, enabled by UNOS, and the patient's awareness of the option to have a transplant.  
    2. Kidney dialysis performed at a dialysis center. 
    (Aug 2013). 

    Until 2011 the government paid clinics for each dosage of an anti-anemia is a decrease in the number of red blood cells or the amount of hemoglobin in the blood.  There are various types: Fanconia anemia, Iron-deficiency anemia, Pernicious anemia, Sickle-cell anemia;
    drug Epogen administered with FFS is fee-for-service payment.  For health care providers the high profits were made in hospitalizations, imaging and surgery.  Due to its inducing excessive treatment activity it may be replaced by FFV bundled payment.  .  The potential over-purscription issue was compounded by research which suggested the drug caused health issues. 
    In 2011 the government switched to a flat fee for dialysis.  In response the use of the drug Epogen plunged more than the federal government expected when it designed its flat fee bundle, while the dialysis companies' margins consequently rose.  The industry has collected an extra $530 - 880 million a year in federal payments since 2011. 
    In Jan 2013 Congress responded by ordering a cut in the drug fee. 
    Companies have enlisted patients and members of congress to protect the payments.  The companies argue that the funding is used to support other costs not covered by the federal government.  Without the payments they argue they will have to cut services - to clinics in rural areas and in poor areas of major cities which have the lowest profit margins. 





    ED is emergency department.  Pain is the main reason (75%) patients go to an E.D.  It has traditionally been part of an acute care hospital but recently is being deployed standalone as a catchment funnel to the owning hospital.  The EMTALA legislation requires E.D. treatment to stabilize every person seeking treatment by most hospitals.  Unreimbursed care is supported from federal government funds.  E. D. profitability has been helped by hospitals contracting with 3rd party companies who are able to improve margins through surprise billing.  The standalone E.D. competes with the positioning and brand power of lower cost urgent care clinics.  Commercial nature of care requires walk-ins to register to gain access to care.  With the focus on treatment of pain, E.D.s are a major distributor of opioids (5% of opioid prescriptions) and a major starting point of addiction in patients but are cutting back (Jun 2016). 
    referral links a doctors patient to an additional service as part of a treatment proposal.  The regulations are state based so the mechanism is geography dependent.  Referral services will be key to providers managing their revenue base.  
    incentives are problematic for hospitals. 



    2012 HMA ED incentives
    Having to contest an expanding Government investigation with associated legal costs 2013.  (Includes a 60 minute expose.)  Alleged improper coding as short-stay inpatient stays for Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS.  Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage.  It includes:
    • Benefits
      • Part A: Hospital inpatient insurance.  As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization.  Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital. 
      • Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
      • Part C: Medicare Advantage 
      • Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices. 
    • Eligibility
      • All persons 65 years of age or older who are legal residents for at least 5 years.  If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived.  Medicare is legislated to become the primary health plan. 
      • Persons under 65 with disabilities who receive SSDI. 
      • Persons with specific medical conditions:
        • Have end stage renal disease or need a kidney transplant. 
        • They have ALS. 
      • Some beneficiaries are dual eligible. 
      • Part A requires the person has been admitted as an inpatient at a hospital.  This is constrained by a rule that they stay for three days after admission.  
    • Sign-up
      • Part A has automatic sign-up if the person is drawing social security.  Otherwise the person must sign-up for Part A and Part B. 
      • Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office.  But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July.  Incremental yearly 10% penalties apply for not signing up at 65.  These penalties apply to all subsequent premiums. 
    • Premiums
      • Part A premium
      • Part B insurance premium
      • Part C & D premiums are set by the commercial insurer.  
    patients that were more appropriately classified as outpatient observation stays.  Maximum exposure estimated at $50 - 100 Million. 

    Jan 2014 NYT Hospital Chain Said to Scheme to Inflate Bills
    ED is emergency department.  Pain is the main reason (75%) patients go to an E.D.  It has traditionally been part of an acute care hospital but recently is being deployed standalone as a catchment funnel to the owning hospital.  The EMTALA legislation requires E.D. treatment to stabilize every person seeking treatment by most hospitals.  Unreimbursed care is supported from federal government funds.  E. D. profitability has been helped by hospitals contracting with 3rd party companies who are able to improve margins through surprise billing.  The standalone E.D. competes with the positioning and brand power of lower cost urgent care clinics.  Commercial nature of care requires walk-ins to register to gain access to care.  With the focus on treatment of pain, E.D.s are a major distributor of opioids (5% of opioid prescriptions) and a major starting point of addiction in patients but are cutting back (Jun 2016). 
    staff were presented with scorecards.  Physicians hitting the admission targets: admitting at least half of the patients aged 65 or over; were coded green.  Failing to hit the targets was coded red. 
    According to a whistleblower law suite there were many more ways that HMA kept tabs on an internal strategy that regulators argue was intended to increase admissions, regardless of if the patient needed hospital care. 
    This month the Justice Department joined eight separate whistle-blower lawsuites against HMA in six states.  That is unfortunate timing for HMA who's board recently approved the CYH takeoverCYH is also accused by the government of inappropriately increasing admissions.  Still the stock hardly moved with investors viewing the issues as a cost of doing business with typical penalties being only in the tens of millions. 

    The law suites (including qui tam litigation) brought by physicians, adminstrators and compliance staff, describe a wide range of strategies leveraging sophisticated software, financial incentives and threats to inflate the companies fees from Medicare and Medicaid is the state-federal program for the poor.  Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state.  Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program.  Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem.  The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states.  As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year.  In 2017 it pays for 40% of new US births. 
    :
    The accusations reach all the way to the former CEO, Gary Newsome, who many of the whistle-blowers claim drove the strategy.  They contend that shortly after joining HMA Newsom travelled to North Carolyna and informed local hospital officials that he was having customized software installed that would drive admissions.  When Michael Cowling the CEO of the H.M.A. hospital in NC raised physician concerns that the new protocols were clinically inappropriate and would result in unnecessary tests and admissions and said his doctors won't do it Newsome responded "Do it anyway" according to the lawsuit.  HMA commented "H.M.A associates and physicians who practice at our facilities are focused on providing the highest-quality patient care in all our hospitals." 





    Patient advocates for drugs (Sep 2016) enable an evolved amplifier framed by Thomas Donahoe for USCC is the United States Chamber of Commerce
    lobbying:
    • Patient advocate associations -> foot solders helping patients get access to drugs
    • Pharmaceutical companies -> funding of the advocate associations
    • Health care suppliers, doctors and hospitals leverage the margin on the high priced drugs


    Donohhue successfully pushed large companies for funding arguing that the small members would provide the foot soldiers, and often the political cover, for issues big companies want pursued.  Generally the chamber now gets more than $150 million in revenue a year.  Affiliates bring in additional funding. 






    Hedge funds is an investment fund that accepts investments from a limited number of accredited individual or institutional investors.  Hedge funds are able to use investment methods that are not allowed for other types of fund. 
    , private equity is the pooling of commitments from fund investors, to: buy assets that are not publicly traded: companies, real estate, and debt; improve their acquisition's value and sell them again, returning the sale cash to the fund investors.  Private equity companies gain competitive advantage from being lightly regulated, and wealth from the fees and special tax privileges.  Private equity companies were initially corporate raiders. 
    & banks collaborate with lawyers and surgeons to enable an evolved amplifier in medical device litigation:





























































    .