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Universal Internet Connectivity

Posted Aug 25 2008 4:12pm
Today AT&T announced a major program with the State of Tennessee.

Pertinent links:

Here's a portion what the AT&T press release said:

AT&T is actively engaged with the state and health care providers statewide in building the eHealth Exchange Zone. Plans call for eHealth applications to be phased in as participation by health care providers grows.

The AT&T solution features a secure online collaboration center — a Virtual Private Network (VPN)-based portal — designed to safely and securely enable such applications as:

  • Prescribing pharmaceuticals online (also known as "ePrescribing").
  • Securing clinical messaging among the state's health care providers.
  • Sharing high-density images, including X-rays, MRIs and CT scans.
  • Exchanging patient information via portable health records, which provides patient profiles, medical history, prescriptions, etc.
  • Delivering telemedicine applications for remote diagnostics and care.
  • Accessing Tennessee Department of Health applications, including the immunization registry, disease registries, death certificate applications and processing and medical license renewal.
  • Accessing other health care applications and systems, including laboratory systems.
The network has an added component especially for protecting health information provided by the Covisint OnDemand Platform. The platform is a hosted solution that provides dual-factor authentication of health care providers using the VPN-based portal, which supports HIPAA privacy requirements. It also centralizes, automates and streamlines the access to information across health care communities statewide by giving physicians the ability to use many health-information applications with a single sign-on. The platform from Covisint, a division of Compuware Corporation (NASDAQ: CPWR), provides an on-demand, industry-leading infrastructure for secure collaboration and interoperability among health care providers.

Reading carefully, the AT&T announcement does not declare an intention to become the "exchange zone," to provide health care applications, or do more than two very important things: 1.) establish Internet connectivity for providers who do not have this capabilities because of locale; 2.) work with Covisint to provide dual-factor authentication - a critical aspect of any future health care application (don't you want to be sure that clinicians accessing your personal health information are who they say they are?) Covisint has been active in this area. See, for example, the testimony of their Chief Security officer to the U.S. Senate Judiciary Committee on the Future of e-Prescribing of Controlled Substances .

Reading carefully, the AT&T announcement does not seem to be exclusive, but potential grants from the state may be available to those who wish to use this network or switch to AT&T from their current means of Internet access.

According to the TN eHealth Council physician connectivity grant Web site , the State of Tennessee will distribute through intermediary organizations connectivity grants designed to "offset the costs offset the costs of connecting health care providers to Tennessee eHealth resources" including "hardware, software, peripherals, broadband connectivity, and HIPAA compliant authentication." The grant contract funding includes $3,500 per actively practicing physician as well as $6,000 per site.

This is a boon especially to rural practitioners who at this date do not have access to high-speed internet services in their community. It is not clear how much practitioners will be charged for this connectivity, nor is it clear how the Covisint authentication will work, but both seem to be good ideas in selected circumstances.

But what are the requirements?

Excerpting from the sample grant contract at the TN eHealth site one notes the following conditions:

  • A.3.d Grantee agrees, for a period of two (2) years, to actively participate in electronic prescribing (ePrescribing) and capturing prescription information to populate a patient’s medication history as directed by the eHealth Council. Grantee should use a software application with SureScripts and/or RxHub certifications.
  • A.3.d.1. Electronic prescribing, as defined by the National Council for Prescription Drug Programs (NCPDP), is two way [electronic] communication between physicians and pharmacies involving new prescriptions, refill authorizations, change requests, cancel prescriptions, and prescription fill messages to track patient compliance. Electronic prescribing is not Faxing or printing paper prescriptions. ePrescribing also includes the potential for information sharing with other health are partners including eligibility/formulary information and medication history.
  • A.3.e. Grantee agrees to participate in discussions with any health information exchange “HIE” or regional health information organization “RHIO” operating in that geographic area.
  • A.4. Grantees, who are TennCare providers, must adopt the health information technology in accordance with TennCare metrics. When serving TennCare patients, Grantee agrees to use an electronic medical record to document and track pertinent preventive health services (e.g. immunizations, pap smears, mammograms) and/or access and populate (as appropriate) a claims-based electronic health record for the same purpose.
What are the implications of these provisions? Here's one person's guess:


This measure will ensure that e-prescribing is adopted in a way that ensures security and authentication. This measure will place practitioners ahead of the curve - particularly if controlled substances and stronger authentication are required. One problem with the current system: It is not clear how many rural pharmacies are ready to accept e-prescriptions. Progress in the chains is striking and growth of adoption in independent pharmacies is rapid, but some communities may have to await new initiatives by independent pharmacists to achieve Internet connectivity and upgrade their systems.

E-prescribing brings new opportunities to communities. Because the linkages are between the prescriber and the pharmacy (with eligibility checks via RxHub or SureScripts in some instances), there is the potential for a leaner system and new methods of ensuring better compliance with needed medications. Remember, the real "quick win" with e-prescribing may be simplifying refills and ensuring that patients take the meds required to avoid long-term complications.

One unknown: it is not clear what "population of a medication history" means. This will be resolved. But clearly both providers with e-prescribing and plans have these data and additional overhead does not seem warranted.


This caveat seems to urge collaboration but does not impose additional burdens on practitioners. It is not clear which "RHIOs" are really valid here - and which are even exchanging data. It is assumed that the list includes initiatives in Memphis, Knoxville, the Tri-Cities area, and the Shared Health Initiative.


This clause focuses on TennCare. It is not clear what "TennCare metrics" are, but the need to document care for these patients is acute. One requirement is that for TennCare patients, providers must " use an electronic medical record to document and track pertinent preventive health services (e.g. immunizations, pap smears, mammograms) and/or access and populate (as appropriate) a claims-based electronic health record for the same purpose. "

Optimists can read this as a means of enabling choice among ambulatory care systems, although it's not clear how such systems will transmit "TennCare metrics" to the State. The only "claims-based electronic health record" available is Shared Health. Cynics can argue that such a requirement limits choice. In reality, it all depends on the extent to which the state encourages open choices among exchanges. The objective - improving the care of TennCare patients - seems a good one.

The Suggestion of a Framework

There are several different components that are alluded to in these documents:

  • The "back end" - a database that TennCare uses to document care and quality
  • One or more "health information exchanges" - the means by which health care providers (and someday consumers) communicate their information among authorized parties
  • Authentication mechanisms - means by which one can be sure of valid communications
  • Authorization - means by which policies and technologies ensure that the person authenticated is authorized to transmit or receive information
  • The "front end" - the means by which data are captured by clinicians, consumers, and fiscal intermediaries

Aligning all of these moving parts is complex and involves assuring that components at each layer are able to communicate with others. Such "interoprability" is important so that each consumer and provider can chose systems best suited for these needs. (Example: as much as we Tennesseans like Nissan, I don't think we all want to drive a Tundra, nor do we want excessing intrusion into our auto purchasing decisions.)

Unanswered Questions

This program seems worthy of strong consideration by practitioners who do not at present have access to the Internet. Among the unanswered questions are:

  • Internet connectivity is essential to health care delivery. But what of those who already have such access by some other means? In essence, receiving grant funding would require them to change carriers to AT&T. And what about pharmacies, nursing homes, and other essential care sites? Ultimately, every care provider is going to have to pay their way, so understanding the total cost of participation - over a 5 year period - would be valuable.

  • Authentication is a vital service. Can a physician gain access to these services without using AT&T? Is there any grant funding for this? Will other means of authentication be developed over time, or is Covisint the only authorized authentication broker?

  • Choice is important. Many practices are adopting comprehensive electronic medical record systems? How will these systems interact with the authentication mechanisms proposed? How will exchanges collaborate? How will the public's concerns over privacy and confidentiality be addressed?
Each of these topics has been the matter of hard work and collaboration. It may take time for answers to emerge.

This announcement should be viewed as a part of a broader framework enabling better care. Putting the pieces together will be somewhat a process of trial and error; that's the price a state pays for staying ahead of the curve.

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