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Meaningful Use and the
Electronic Health Record
The five underlying principles that drive
meaningful use are defined as:
1.
Improving
quality, safety and efficiency of healthcare
2.
Engaging patients
in their care
3.
Increasing
coordination of care
4.
Improving the
health status of the population, and
5.
Ensuring privacy
and security of health information
What is meaningful use? Meaningful Use was established by the
ARRA legislation, also known as the American Reinvestment and Recovery Act, that
passed in 2009. The intention of
this legislation was that providers and hospitals not only implement certified
electronic health records but also make meaningful use of those systems and the
data contained in them. Incentive
payments through Centers for Medicare and Medicaid Services (CMS) will be used
to ensure that this occurs. The
expectation is that electronic health records and health information technology
are implemented in a manner in which achievement of goals that support the five
underlying principles are directly measured and demonstrated.
There has been a very compressed timeline on
which the meaningful use of a certified EHR has moved forward.
The initial proposals defining meaningful use
and defining the standards for certification of the EHR were published in the
Federal Register on January 13, 2010 by CMS and ONC (Office of the National
Coordinator) respectively.
The Final Rule report entitled “Health
Information Technology: Initial Set of Standards, Implementation Specifications,
and Certification Criteria for Electronic Health Record Technology was published
in the Federal Register on July 13, 2010.
Also on July 13, 2010, CMS published in the
Federal Register, its paper defining the meaningful use metrics and schedules
for incentive payments to eligible professionals (EPs) and eligible hospitals
(EHs) that implement a certified EHR and meet the meaningful use criteria.
Collectively, this legislation establishes
criteria for EHR certification, the metrics for meaningful use of a certified
EHR, and a timeline for incentive payments that will begin in 2011.
Requirements for the meaningful use of the EHR
will be implemented in three stages.
In stage 1 the eligible providers (EPs) and eligible hospitals (EHs) will
collect and share patient data.
Stage 1 conditions will be described in more detail in this presentation.
In stage 2 it is expected meaningful use
requirements will include rigorous
expectations for health information exchange,
include more demanding requirements for e-prescribing and incorporating
structured laboratory results and the expectation that providers will
electronically transmit patient care summaries to support transitions in care
across unaffiliated providers, settings and EHR systems.
Increasingly robust expectations for health
information exchange in stage two and stage three will support and make real the
goal that information follows the patient. Stage 2 will build upon Stage 1 by
altering the expectations of the functionalities in Stage 1 and adding new
functionalities which are not yet ready for inclusion in Stage 1, but whose
provision is necessary to maximize the potential of EHR technology.
The goals for the Stage 3 meaningful use
criteria are to focus on promoting improvements in quality, safety and
efficiency leading to improved health outcomes, focusing on decision support for
national high priority conditions, patient access to self management tools,
access to comprehensive patient data through robust, patient-centered health
information exchange and improving
population health.
Slide 6:
This slide provides a chart that shows the year
that incentive payments will begin for each stage based on when a provider or
hospital begins participating. A
major change from the implementation timeline published earlier is that stage 3,
which was to begin in 2015, is now left undetermined. The new schedule describes a more
relaxed implementation plan than the one originally envisioned.
Slide 7:
As can be seen from this slide, the
implementation of payment incentives to eligible hospitals uses a complex
formula. To understand this fully, it is best to study the detailed explanation
of the EH schedule of incentives and requirements as published in the CMS
document which is included as a resource to this module.
Slide 8:
As we begin the examination of the meaningful
use criteria for stage 1, it is important to note the general organization of
the metrics. There are 15 core
metrics for meaningful use of a certified EHR that must be met by EPs and EHs in
order to meet stage 1 implementation requirements. All of the guiding principles
have core metrics associated with them except for "improving the health status
of the population.' In addition, EPs
and EHs must choose another five measurable outcomes from an additional menu of
metrics. Of these five, at least two
must support the public health goal of improving the health status of the
population.
Slide 9:
Stage 1 meaningful use metrics that map to data
collection requirements include the following core metrics:
•
More than 80% of all
unique patients seen by the EP or admitted to the EH have at least one entry or
an indication of none recorded as structured data. Essentially, an up-to-date problem list
of current and active diagnoses based on ICD-9 CM or SNOMED CT must be
maintained.
•
More than 80% of all
unique patients seen by the EP or admitted to the EH have at least one entry (or
an indication of none if the patient is not currently prescribed) recorded as
structured data. It is suggested
that RxNorm is used as the nomenclature system.
RxNorm is a standardized nomenclature for clinical drugs and drug
delivery devices produced by the National Library of Medicine. In RxNorm, the
name of a clinical drug combines its ingredients, strengths, and/or form.
•
More than 80% of all
unique patients seen by the EP or admitted to the EH have at least one entry (or
an indication of none if the patient has no medication allergies) recorded as
structured data. (Unique ingredient identifiers (UNIIs) are used to identify and
code for substances in drugs, biologics, foods, and devices.)
•
More than 50% of all
unique patients seen by the EP or admitted to the EH have demographics recorded
as structured data. The minimum demographics required for Stage 1 are language,
gender, race, ethnicity, and date of birth; plus date and cause of death in the
event of mortality for EHs.
•
At least 50% of all
unique patients age 2 and over seen by the EP or admitted to the EH, record
blood pressure, height and weight (BMI calculated from height and weight);
additionally plot growth chart for children age 2 – 20.
•
More than 50% of all
unique patients age 13 and over seen by the EP or admitted to the EH, have
“smoking status” recorded.
An additional meaningful use metric that is
included in the menu for selection is that:
•
At least 40% of all
clinical lab tests ordered whose results are in a positive/negative or numerical
format are incorporated in certified EHR technology as structured data. LOINC®
is recommended for the coding and stands for Logical Observation Identifiers
Names and Codes. The purpose
of LOINC® is to facilitate the exchange and pooling of clinical results for
clinical care, outcomes management, and research by providing a set of universal
codes and names to identify laboratory and other clinical observations. The
Regenstrief Institute, Inc, an internationally renowned healthcare and
informatics research organization, maintains the LOINC database and supporting
documentation.
Slide 10:
The certified EHR is expected to perform a
number of functions. The meaningful
use metrics for stage 1 include the following core requirements:
•
The EP/EH has enabled
all drug-drug and drug-allergy
checks that are available through the EHR.
•
Implement one clinical
decision support rule relevant to specialty or high clinical priority (or
related to a high priority hospital condition), along with the ability to track
compliance with that rule.
•
Performs medication
reconciliations for at least 50% of relevant encounters and transitions of care.
•
Provide 50% of all
patients who request an electronic copy of their health information (including
diagnostic tests results, problem list, medication list, allergies (discharge
summary, procedures for EHs) within 3 business days. Both the Continuity of Care
Record (CCR) and the Continuity of Care Document (CCD) are designed as ways of
passing information between entities. For example, when a patient leaves the
hospital, information can be passed to their primary care physician through one
of these types.
•
Clinical Summaries
provided for at least 50% of all office visits within 3days
•
At least 50% of all
patients who are discharged from an EH and who request an electronic copy of
their discharge instructions and procedures are provided it.
Slide 11:
We now continue with Stage 1 functions metrics
and turn to the ones from the menu selection:
•
More than 20% of all
unique patients 65 years or older or 5 years old or younger were sent an
appropriate reminder during the EHR reporting period. These reminders are sent
according to the patient preference such as mail, email, phone or PHR.
•
At least 10% of all
unique patients seen by the EP are provided timely electronic access to their
health information (including lab results, problem list, medication lists,
allergies) within 4 days of the information being available to the EP.
•
The EP or EH who
transitions their patient to another setting of care or provider of care or
refers their patient to another provider of care should provide a summary of
care record for more than 50% of transitions of care and referrals
•
The ability to generate
lists of patients by specific conditions to use for quality improvement,
reduction of disparities and outreach and must produce at least one report for a
specific condition.
•
The EP/eligible
hospital/CAH has enabled drug formulary checking and has access to at least one
internal or external drug formulary for the entire EHR reporting period.
•
More than 50% of all
unique patients 65 years or older admitted to the EH's inpatient department have
an indication of an advance directive status recorded (EH only).
•
More than 10% of all
unique patients seen by the EP or admitted to the eligible hospital's inpatient
or emergency department are provided patient-specific education resources
There is an underlying expectation that the
information provided to patients will be communicated in form and manner that is
understandable to them.
Slide 12:
One of the main goals for meaningful use of a
certified electronic health record is to use CPOE for medication orders directly
entered by any licensed healthcare professional who can enter orders into the
medical record per state, local and professional guidelines. The associated meaningful use metric is
that:
•
More than 30% of unique
patients with at least one medication in their medication list seen by the EP or
admitted to the EH's inpatient or emergency department have at least one medication order
entered using CPOE
•
At least 40% of all
permissible prescriptions written by the EP are transmitted electronically using
certified EHR technology. NCPDP (for National Council for Prescription Drug
Programs) SCRIPT 8.1 or NCPDP SCRIPT 8.1 and 10.6. SCRIPT 8.1 is the current standard
adopted by HHS for specified transactions involving the communication of a
prescription or prescription-related information between prescribers and
dispensers.
Slide 13:
The Health Information Exchange (HIE) core metric requires that there is:
•
Capability to exchange
key clinical information (for example, problem list, medication list, allergies,
diagnostic test results) among providers of care and patient authorized entities
electronically.
Stage1 Public Health Metrics – these are all
non-core menu items but at least 2 must be chosen as part of the 5 meaningful
use metrics that are optional.
•
Capability to provide
electronic syndromic surveillance data to public health agencies and actual
transmission according to applicable law and practice. (Syndromic surveillance systems monitor
data from school absenteeism logs, emergency call systems, hospitals'
over-the-counter drug sale records, Internet searches, and other data sources to
detect unusual patterns. When a spike in activity is seen in any of the
monitored systems, disease epidemiologists and public health professionals are
alerted that there may be an issue.)
•
Capability to submit
electronic data to immunization registries and carry out actual submission where
required and accepted. (At least one test).
•
Capability to provide
electronic submission of reportable lab results (as required by state or law) to
public health agencies and carry out actual submission where it can be received.
(hospitals only).
Slide 14:
There is one metric that relates to security and
health information exchange and that metric is:
•
Protect electronic
health information created or maintained by the certified EHR technology through
the implementation of appropriate technical capabilities. The actual metric for 2011 stage 1 is
to “conduct or review a security risk analysis and implement security updates as
necessary.
Other specifications which are not listed in
terms of meaningful use metrics but are identified as certification requirements
by ONC include:
•
Address the need for
encryption/decryption of electron health information
•
The date, time, patient
identification (name or number), and user identification (name or number) must
be recorded when electronic health information is created, modified, deleted, or
printed. An indication of which action(s) occurred must also be recorded.
•
A secure hashing
algorithm must be used to verify that electronic health information has not been
altered in transit.
•
•
Use of a
cross-enterprise secure transaction that contains sufficient identity
information such that the receiver can make access control decisions and produce
detailed and accurate security audit trails.
•
The date, time, patient
identification (name or number), user identification (name or number), and a
description of the disclosure must be recorded.
Slide 15:
Clinical quality measures consist of measures of
processes, experience, and/or outcomes of patient care, observations or
treatment that relate to one or more quality aims for health care such as
effective, safe, efficient, patient centered, equitable, and timely care.
One metric for clinical quality is:
•
The quality measures
reported must be captured by and reported from a certified EHR system.
•
The quality measures
have been derived using a number of resources:
•
NQF – National Quality
Forum
•
HQA – Hospital Quality
Alliance
•
CMS PQRI – Centers for Medicare and
Medicaid Services Physician Quality Reporting Initiative
•
AQA – formerly known as
the Ambulatory Care Quality Alliance now represents a broader coalition of
interests and is called AQA.
•
Eligible Hospitals and
eligible practitioners must report on a number of specific quality measure, some
of which overlap with the existing RHQDAPU ( Reporting Hospital Quality Data for
Annual Payment Update) list and the Physician Quality Reporting Initiative
(PQRI) list. Clinical quality
measures are covered more thoroughly in Comp 11/unit2c.
Slide 16:
Use of a certified EHR systems is a central
construct in achieving meaningful use along with the constructs of health
information exchange (HIE) and the use of clinical quality measures to achieve
meaningful use goals at each stage of implementation. Certification of an EHR
will be tightly linked to the metrics developed for meaningful use. In fact, some of the meaningful use
metrics such as the ones identified in the security and data collection areas
can almost be viewed as system specifications.
Both health information exchange and clinical quality measures will be
elaborated in the next two modules of this unit.
Slide 17:
The basic benchmark for an EHR considering
application for certification is that it meets the minimum data set requirements
and has the potential to satisfy the requirements used to measure meaningful use
now and in the future. Actual
implementation criteria for a certified EHR will be directly tied to the
meaningful use criteria. Just as
meaningful use criteria will be enhanced over a period of time, it can be expect
that the standards for certification will also be enhanced. The EHR capacity
identified in the slide represents those defined for Stage 1.
Certification can be for an entire EHR system or
it may be for individual modules.
It is presumed that if an EHR is certified that each module in the EHR
would also be considered certified.
Slide 18:
Why certify?
Certification will provide assurance to purchasers and other users that
an EHR system offers the necessary technological capability, functionality, and
security to help them meet the meaningful use criteria established. Providers
and patients must also be confident that the EHR systems they use are secure,
can maintain data confidentiality, and can work with other systems to share
information. Certification of EHR systems is an important step in ensuring
that meaningful use requirements are met and that the benefit of improved
patient care is realized.
As part of the American Reinvestment and
Recovery Act (ARRA), the Health Information Technology for Economic and Clinical
Health (HITECH) Act, $19 billion were allocated in the form of bonuses to
eligible professionals and eligible hospitals to encourage the health care
industry to adopt information technology and that technology must include
certified EHR technology.
These incentives will be administered by CMS (Centers for Medicare and Medicaid
Services) and are tied to meaningful use criteria.
Slide 19:
On January 13, 2010, the Office of the National
Coordinator (ONC) issued an Interim
Final Rule (IFR) on the initial set of standards, implementation specification
and certification criteria for EHR systems. After a commenting period the Final
Rule was published in the Federal Register on July 13, 2010. In this document,
the ONC identifies itself as a the agency that would approve interested
organizations as an ONC Authorized Testing and Certification Body (ONC-ATCB)
In July, 2004, the Certificate Commission for
Health Information Technology (CCHIT) was started as a private-sector led
initiative to certify Health IT products.
They began certifying EHRs in 2006 and claim to have established the
first comprehensive, practical definition of what capabilities were needed in
these systems. The certification criteria were developed through a
voluntary, consensus-based process engaging diverse stakeholders, and the
Certification Commission was officially recognized by the federal government as
a certifying body. CCHIT claimed to have certified 75% of EHR systems on the
market by 2009 and has announced its intention to become an ONC Authorized
Testing and Certification Body as described in the ONC regulations.
With the release of the regulation, ONC has
provided the opportunity for other organizations to become an ONC Authorized
Testing and Certification Body (ONC-ATCB).
At this point, one can only surmise what other organizations may take on
this task.
Slide 20:
Again, it is important to recognize that the
certification criteria are driven at the federal level by the ONC and CMS, but
there has been opportunity for public input which was provided and resulted in
modifications to the document.
It is possible that states may add additional criteria, but the federally based
requirements will represent the minimum requirements for participation in the
ONC sponsored certification process.
Slide 21:
Health Information Technology for Economic and
Clinical Health (HITECH) act ties the standards, implementation specifications,
and certification criteria adopted in the ONC ruling to the incentives under the
Medicare and Medicaid EHR Incentive programs by requiring the meaningful use of
certified EHR technology. The ONC
ruling creates specific standards, beginning 2011, in four areas:
•
Vocabulary Standards -
standardized nomenclatures and code sets used to describe clinical
problems and procedures, medications, and allergies. There is limited adoption of specific
vocabulary standards in this initial set. Vocabulary and code sets have been
limited to those with which the regulated community is already required to
comply.
•
Content Exchange
Standards - standards used to share clinical information such as clinical
summaries, prescriptions, and structured electronic documents.
•
Transport Standards - standards used to establish a common,
predictable, secure communication protocol between systems.
•
Privacy and Security
Standards - authentication, access
control, transmission security; Privacy and security standards relate to, and
span across, all of the other types of standards.
Certified EHR Technology will be tested and
certified as being capable of complying with adopted standards.
Meaningful Use and the
Electronic Health Record
The five underlying principles that drive
meaningful use are defined as:
1.
Improving
quality, safety and efficiency of healthcare
2.
Engaging patients
in their care
3.
Increasing
coordination of care
4.
Improving the
health status of the population, and
5.
Ensuring privacy
and security of health information
What is meaningful use? Meaningful Use was established by the
ARRA legislation, also known as the American Reinvestment and Recovery Act, that
passed in 2009. The intention of
this legislation was that providers and hospitals not only implement certified
electronic health records but also make meaningful use of those systems and the
data contained in them. Incentive
payments through Centers for Medicare and Medicaid Services (CMS) will be used
to ensure that this occurs. The
expectation is that electronic health records and health information technology
are implemented in a manner in which achievement of goals that support the five
underlying principles are directly measured and demonstrated.
There has been a very compressed timeline on
which the meaningful use of a certified EHR has moved forward.
The initial proposals defining meaningful use
and defining the standards for certification of the EHR were published in the
Federal Register on January 13, 2010 by CMS and ONC (Office of the National
Coordinator) respectively.
The Final Rule report entitled “Health
Information Technology: Initial Set of Standards, Implementation Specifications,
and Certification Criteria for Electronic Health Record Technology was published
in the Federal Register on July 13, 2010.
Also on July 13, 2010, CMS published in the
Federal Register, its paper defining the meaningful use metrics and schedules
for incentive payments to eligible professionals (EPs) and eligible hospitals
(EHs) that implement a certified EHR and meet the meaningful use criteria.
Collectively, this legislation establishes
criteria for EHR certification, the metrics for meaningful use of a certified
EHR, and a timeline for incentive payments that will begin in 2011.
Requirements for the meaningful use of the EHR
will be implemented in three stages.
In stage 1 the eligible providers (EPs) and eligible hospitals (EHs) will
collect and share patient data.
Stage 1 conditions will be described in more detail in this presentation.
In stage 2 it is expected meaningful use
requirements will include rigorous
expectations for health information exchange,
include more demanding requirements for e-prescribing and incorporating
structured laboratory results and the expectation that providers will
electronically transmit patient care summaries to support transitions in care
across unaffiliated providers, settings and EHR systems.
Increasingly robust expectations for health
information exchange in stage two and stage three will support and make real the
goal that information follows the patient. Stage 2 will build upon Stage 1 by
altering the expectations of the functionalities in Stage 1 and adding new
functionalities which are not yet ready for inclusion in Stage 1, but whose
provision is necessary to maximize the potential of EHR technology.
The goals for the Stage 3 meaningful use
criteria are to focus on promoting improvements in quality, safety and
efficiency leading to improved health outcomes, focusing on decision support for
national high priority conditions, patient access to self management tools,
access to comprehensive patient data through robust, patient-centered health
information exchange and improving
population health.
Slide 6:
This slide provides a chart that shows the year
that incentive payments will begin for each stage based on when a provider or
hospital begins participating. A
major change from the implementation timeline published earlier is that stage 3,
which was to begin in 2015, is now left undetermined. The new schedule describes a more
relaxed implementation plan than the one originally envisioned.
Slide 7:
As can be seen from this slide, the
implementation of payment incentives to eligible hospitals uses a complex
formula. To understand this fully, it is best to study the detailed explanation
of the EH schedule of incentives and requirements as published in the CMS
document which is included as a resource to this module.
Slide 8:
As we begin the examination of the meaningful
use criteria for stage 1, it is important to note the general organization of
the metrics. There are 15 core
metrics for meaningful use of a certified EHR that must be met by EPs and EHs in
order to meet stage 1 implementation requirements. All of the guiding principles
have core metrics associated with them except for "improving the health status
of the population.' In addition, EPs
and EHs must choose another five measurable outcomes from an additional menu of
metrics. Of these five, at least two
must support the public health goal of improving the health status of the
population.
Slide 9:
Stage 1 meaningful use metrics that map to data
collection requirements include the following core metrics:
•
More than 80% of all
unique patients seen by the EP or admitted to the EH have at least one entry or
an indication of none recorded as structured data. Essentially, an up-to-date problem list
of current and active diagnoses based on ICD-9 CM or SNOMED CT must be
maintained.
•
More than 80% of all
unique patients seen by the EP or admitted to the EH have at least one entry (or
an indication of none if the patient is not currently prescribed) recorded as
structured data. It is suggested
that RxNorm is used as the nomenclature system.
RxNorm is a standardized nomenclature for clinical drugs and drug
delivery devices produced by the National Library of Medicine. In RxNorm, the
name of a clinical drug combines its ingredients, strengths, and/or form.
•
More than 80% of all
unique patients seen by the EP or admitted to the EH have at least one entry (or
an indication of none if the patient has no medication allergies) recorded as
structured data. (Unique ingredient identifiers (UNIIs) are used to identify and
code for substances in drugs, biologics, foods, and devices.)
•
More than 50% of all
unique patients seen by the EP or admitted to the EH have demographics recorded
as structured data. The minimum demographics required for Stage 1 are language,
gender, race, ethnicity, and date of birth; plus date and cause of death in the
event of mortality for EHs.
•
At least 50% of all
unique patients age 2 and over seen by the EP or admitted to the EH, record
blood pressure, height and weight (BMI calculated from height and weight);
additionally plot growth chart for children age 2 – 20.
•
More than 50% of all
unique patients age 13 and over seen by the EP or admitted to the EH, have
“smoking status” recorded.
An additional meaningful use metric that is
included in the menu for selection is that:
•
At least 40% of all
clinical lab tests ordered whose results are in a positive/negative or numerical
format are incorporated in certified EHR technology as structured data. LOINC®
is recommended for the coding and stands for Logical Observation Identifiers
Names and Codes. The purpose
of LOINC® is to facilitate the exchange and pooling of clinical results for
clinical care, outcomes management, and research by providing a set of universal
codes and names to identify laboratory and other clinical observations. The
Regenstrief Institute, Inc, an internationally renowned healthcare and
informatics research organization, maintains the LOINC database and supporting
documentation.
Slide 10:
The certified EHR is expected to perform a
number of functions. The meaningful
use metrics for stage 1 include the following core requirements:
•
The EP/EH has enabled
all drug-drug and drug-allergy
checks that are available through the EHR.
•
Implement one clinical
decision support rule relevant to specialty or high clinical priority (or
related to a high priority hospital condition), along with the ability to track
compliance with that rule.
•
Performs medication
reconciliations for at least 50% of relevant encounters and transitions of care.
•
Provide 50% of all
patients who request an electronic copy of their health information (including
diagnostic tests results, problem list, medication list, allergies (discharge
summary, procedures for EHs) within 3 business days. Both the Continuity of Care
Record (CCR) and the Continuity of Care Document (CCD) are designed as ways of
passing information between entities. For example, when a patient leaves the
hospital, information can be passed to their primary care physician through one
of these types.
•
Clinical Summaries
provided for at least 50% of all office visits within 3days
•
At least 50% of all
patients who are discharged from an EH and who request an electronic copy of
their discharge instructions and procedures are provided it.
Slide 11:
We now continue with Stage 1 functions metrics
and turn to the ones from the menu selection:
•
More than 20% of all
unique patients 65 years or older or 5 years old or younger were sent an
appropriate reminder during the EHR reporting period. These reminders are sent
according to the patient preference such as mail, email, phone or PHR.
•
At least 10% of all
unique patients seen by the EP are provided timely electronic access to their
health information (including lab results, problem list, medication lists,
allergies) within 4 days of the information being available to the EP.
•
The EP or EH who
transitions their patient to another setting of care or provider of care or
refers their patient to another provider of care should provide a summary of
care record for more than 50% of transitions of care and referrals
•
The ability to generate
lists of patients by specific conditions to use for quality improvement,
reduction of disparities and outreach and must produce at least one report for a
specific condition.
•
The EP/eligible
hospital/CAH has enabled drug formulary checking and has access to at least one
internal or external drug formulary for the entire EHR reporting period.
•
More than 50% of all
unique patients 65 years or older admitted to the EH's inpatient department have
an indication of an advance directive status recorded (EH only).
•
More than 10% of all
unique patients seen by the EP or admitted to the eligible hospital's inpatient
or emergency department are provided patient-specific education resources
There is an underlying expectation that the
information provided to patients will be communicated in form and manner that is
understandable to them.
Slide 12:
One of the main goals for meaningful use of a
certified electronic health record is to use CPOE for medication orders directly
entered by any licensed healthcare professional who can enter orders into the
medical record per state, local and professional guidelines. The associated meaningful use metric is
that:
•
More than 30% of unique
patients with at least one medication in their medication list seen by the EP or
admitted to the EH's inpatient or emergency department have at least one medication order
entered using CPOE
•
At least 40% of all
permissible prescriptions written by the EP are transmitted electronically using
certified EHR technology. NCPDP (for National Council for Prescription Drug
Programs) SCRIPT 8.1 or NCPDP SCRIPT 8.1 and 10.6. SCRIPT 8.1 is the current standard
adopted by HHS for specified transactions involving the communication of a
prescription or prescription-related information between prescribers and
dispensers.
Slide 13:
The Health Information Exchange (HIE) core metric requires that there is:
•
Capability to exchange
key clinical information (for example, problem list, medication list, allergies,
diagnostic test results) among providers of care and patient authorized entities
electronically.
Stage1 Public Health Metrics – these are all
non-core menu items but at least 2 must be chosen as part of the 5 meaningful
use metrics that are optional.
•
Capability to provide
electronic syndromic surveillance data to public health agencies and actual
transmission according to applicable law and practice. (Syndromic surveillance systems monitor
data from school absenteeism logs, emergency call systems, hospitals'
over-the-counter drug sale records, Internet searches, and other data sources to
detect unusual patterns. When a spike in activity is seen in any of the
monitored systems, disease epidemiologists and public health professionals are
alerted that there may be an issue.)
•
Capability to submit
electronic data to immunization registries and carry out actual submission where
required and accepted. (At least one test).
•
Capability to provide
electronic submission of reportable lab results (as required by state or law) to
public health agencies and carry out actual submission where it can be received.
(hospitals only).
Slide 14:
There is one metric that relates to security and
health information exchange and that metric is:
•
Protect electronic
health information created or maintained by the certified EHR technology through
the implementation of appropriate technical capabilities. The actual metric for 2011 stage 1 is
to “conduct or review a security risk analysis and implement security updates as
necessary.
Other specifications which are not listed in
terms of meaningful use metrics but are identified as certification requirements
by ONC include:
•
Address the need for
encryption/decryption of electron health information
•
The date, time, patient
identification (name or number), and user identification (name or number) must
be recorded when electronic health information is created, modified, deleted, or
printed. An indication of which action(s) occurred must also be recorded.
•
A secure hashing
algorithm must be used to verify that electronic health information has not been
altered in transit.
•
•
Use of a
cross-enterprise secure transaction that contains sufficient identity
information such that the receiver can make access control decisions and produce
detailed and accurate security audit trails.
•
The date, time, patient
identification (name or number), user identification (name or number), and a
description of the disclosure must be recorded.
Slide 15:
Clinical quality measures consist of measures of
processes, experience, and/or outcomes of patient care, observations or
treatment that relate to one or more quality aims for health care such as
effective, safe, efficient, patient centered, equitable, and timely care.
One metric for clinical quality is:
•
The quality measures
reported must be captured by and reported from a certified EHR system.
•
The quality measures
have been derived using a number of resources:
•
NQF – National Quality
Forum
•
HQA – Hospital Quality
Alliance
•
CMS PQRI – Centers for Medicare and
Medicaid Services Physician Quality Reporting Initiative
•
AQA – formerly known as
the Ambulatory Care Quality Alliance now represents a broader coalition of
interests and is called AQA.
•
Eligible Hospitals and
eligible practitioners must report on a number of specific quality measure, some
of which overlap with the existing RHQDAPU ( Reporting Hospital Quality Data for
Annual Payment Update) list and the Physician Quality Reporting Initiative
(PQRI) list. Clinical quality
measures are covered more thoroughly in Comp 11/unit2c.
Slide 16:
Use of a certified EHR systems is a central
construct in achieving meaningful use along with the constructs of health
information exchange (HIE) and the use of clinical quality measures to achieve
meaningful use goals at each stage of implementation. Certification of an EHR
will be tightly linked to the metrics developed for meaningful use. In fact, some of the meaningful use
metrics such as the ones identified in the security and data collection areas
can almost be viewed as system specifications.
Both health information exchange and clinical quality measures will be
elaborated in the next two modules of this unit.
Slide 17:
The basic benchmark for an EHR considering
application for certification is that it meets the minimum data set requirements
and has the potential to satisfy the requirements used to measure meaningful use
now and in the future. Actual
implementation criteria for a certified EHR will be directly tied to the
meaningful use criteria. Just as
meaningful use criteria will be enhanced over a period of time, it can be expect
that the standards for certification will also be enhanced. The EHR capacity
identified in the slide represents those defined for Stage 1.
Certification can be for an entire EHR system or
it may be for individual modules.
It is presumed that if an EHR is certified that each module in the EHR
would also be considered certified.
Slide 18:
Why certify?
Certification will provide assurance to purchasers and other users that
an EHR system offers the necessary technological capability, functionality, and
security to help them meet the meaningful use criteria established. Providers
and patients must also be confident that the EHR systems they use are secure,
can maintain data confidentiality, and can work with other systems to share
information. Certification of EHR systems is an important step in ensuring
that meaningful use requirements are met and that the benefit of improved
patient care is realized.
As part of the American Reinvestment and
Recovery Act (ARRA), the Health Information Technology for Economic and Clinical
Health (HITECH) Act, $19 billion were allocated in the form of bonuses to
eligible professionals and eligible hospitals to encourage the health care
industry to adopt information technology and that technology must include
certified EHR technology.
These incentives will be administered by CMS (Centers for Medicare and Medicaid
Services) and are tied to meaningful use criteria.
Slide 19:
On January 13, 2010, the Office of the National
Coordinator (ONC) issued an Interim
Final Rule (IFR) on the initial set of standards, implementation specification
and certification criteria for EHR systems. After a commenting period the Final
Rule was published in the Federal Register on July 13, 2010. In this document,
the ONC identifies itself as a the agency that would approve interested
organizations as an ONC Authorized Testing and Certification Body (ONC-ATCB)
In July, 2004, the Certificate Commission for
Health Information Technology (CCHIT) was started as a private-sector led
initiative to certify Health IT products.
They began certifying EHRs in 2006 and claim to have established the
first comprehensive, practical definition of what capabilities were needed in
these systems. The certification criteria were developed through a
voluntary, consensus-based process engaging diverse stakeholders, and the
Certification Commission was officially recognized by the federal government as
a certifying body. CCHIT claimed to have certified 75% of EHR systems on the
market by 2009 and has announced its intention to become an ONC Authorized
Testing and Certification Body as described in the ONC regulations.
With the release of the regulation, ONC has
provided the opportunity for other organizations to become an ONC Authorized
Testing and Certification Body (ONC-ATCB).
At this point, one can only surmise what other organizations may take on
this task.
Slide 20:
Again, it is important to recognize that the
certification criteria are driven at the federal level by the ONC and CMS, but
there has been opportunity for public input which was provided and resulted in
modifications to the document.
It is possible that states may add additional criteria, but the federally based
requirements will represent the minimum requirements for participation in the
ONC sponsored certification process.
Slide 21:
Health Information Technology for Economic and
Clinical Health (HITECH) act ties the standards, implementation specifications,
and certification criteria adopted in the ONC ruling to the incentives under the
Medicare and Medicaid EHR Incentive programs by requiring the meaningful use of
certified EHR technology. The ONC
ruling creates specific standards, beginning 2011, in four areas:
•
Vocabulary Standards -
standardized nomenclatures and code sets used to describe clinical
problems and procedures, medications, and allergies. There is limited adoption of specific
vocabulary standards in this initial set. Vocabulary and code sets have been
limited to those with which the regulated community is already required to
comply.
•
Content Exchange
Standards - standards used to share clinical information such as clinical
summaries, prescriptions, and structured electronic documents.
•
Transport Standards - standards used to establish a common,
predictable, secure communication protocol between systems.
•
Privacy and Security
Standards - authentication, access
control, transmission security; Privacy and security standards relate to, and
span across, all of the other types of standards.
Certified EHR Technology will be tested and
certified as being capable of complying with adopted standards. |
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Meaningful Use and Health
Information Exchange
Component 11/Unit 2b
Slide 1:
Meaningful use and health information exchange - the slides in this module will
define Health Information Exchange (HIE) and provide examples of how the five
guiding principles of meaningful use are supported when HIE is implemented.
Slide 2:
Health information exchange represents the
mobilization of healthcare information electronically. It supports the flow of information
within organizations, between organizations, between different modules of an
EHR, between different EHRs, across regions, between regions or states and
ultimately across the nation. HIE
supports the flow of information to the person and place where it is needed at
the time it is required and in a manner that is secure and preserves patient
privacy. It also means that the
information arrives in a form that is usable by the person needing it.
RHIO – Regional Health Information Organization
NHIN – National Health Information Network
Slide 3:
Interoperability is a property referring to the ability of diverse
systems and organizations to work together (inter-operate). The term is most
often used in a strictly technical sense, but it is also applicable in a broad
sense, taking into account social, political, and organizational factors that
impact the exchange of information between “systems”. HIE and interoperability of Health
Information Systems are virtually synonymous concepts. HIE may even be viewed as the
application of interoperability principles at work in the health care system.
HIE provides interoperability between disparate health
information systems, delivering patient information when and where it is needed.
Consider the situation where one system delivers a file written in Japanese to
another system with an English speaking user, this does not represent true
interoperability. If effective
Japanese-English translation software was included in the systems, then they
could be considered to meet interoperability (HIE) standards for this particular
application. Does that sound slightly familiar to comments by patients when
information is exchanged between provider “information systems” and patient
“information systems”?
Slide 4:
HIE functionality can be achieved in a variety
of ways. Often, the exchange
only needs to be uni-directional.
When HIE only requires information to be sent in one direction, such as the
updating of registries, it is referred to as pushing the data out to the other
application or user. The real power of push technology is the ability to
automatically push critical information quickly out to a large number of users. Uni-directional information flow can
also be the situation where a system has the ability to query a database and
pull down the required information.
This can be automated as well such as automated updates to formulary
information. Most HIEs, however will
require bi-directional communications where the user will need to enter/update
the information as well as query that same information.
Future advances are likely to include
intelligent agents that will be able to anticipate clinicians information
management needs and push information to them based on predefined choices.
Slide 5:
The goals of HITECH are rooted in improving
individual health, health care and public health.
All ITECH rules, regulations,
incentives, programs, etc. are
linked to one of five underlying principles that guide our understanding of
meaningful use.
Lets quickly review the five underlying
principles:
•
Improving quality,
safety and efficiency
•
Engaging patients in
their care
•
Increasing coordination
of care
•
Improving the health
status of the population
•
Ensuring privacy and
security
Slide 6:
HIE improves safety, quality and efficiency,
lets demonstrate this with an example.
Mrs. J. visits her doctor regarding a nagging
and persistent cough. At the end of
the visit Dr. P. advises her that she will transmit a prescription to her
pharmacy electronically and enters the medication choice in the patient’s
medical record which is integrated with a prescription alert system. Dr. P. automatically receives an alert
describing adverse side effects of this medication that patients with similar
conditions have experienced. Dr. P.
is able to substitute an equally effective, alternative prescription without
known side effects. Dr. P’s clinical
practice system automatically reviews the records for all her patients but does
not find any other patients on the medication.
Meanwhile the clinical practice system has received an alert from the
drug manufacturer with updated information on the drug first prescribed. The system then updates its internal
drug review program.
Slide 7:
HIE supports engaging patients in their care and
again lets look at an application scenario:
Mrs. B. is a 43 year old, single mother who runs
a graphic design business from her home.
She also uses her multimedia information center to manage her family’s
health including her aging mother’s for whom she is an authorized personal
health information manager. She
receives automatic alerts and e-mails from her doctor and her daughter’s. The last time her daughter had an
asthma attack, she e-mailed information on her daughter’s condition to the
physician and received advice promptly, avoiding a visit to the emergency room. Mrs. B’s mother lives in another city
and has emphysema, they are both alerted when the air quality index in her
mother’s community reaches a high level of pollution. Her mother also has a medication
reminder service that tells her what medication to take and when. When she takes the medication she
easily confirms that she has taken the medication. The information is all
delivered through an application on her PDA.
The system also tracks the need for refills and automatically sends a
refill request to the mail order prescription service. Mrs. B. can monitor that
her mother is taking her medication as directed.
Slide 8:
Health Information Exchange supports
coordination of care by facilitating scheduling of consultations, diagnostic
tests, or other procedures and allowing multiple caregivers to view the same
information simultaneously.
Ideally, health information exchange would allow a patient’s information to
follow the patient throughout the healthcare system so that health care
providers would have access to the required information regardless of whether
the patient was in his doctor’s office, at his dentist, in an extended care
facility, or unconscious in the emergency room of a hospital.
Slide 9:
Health Information Exchange helps improve the
health status of the population. The
benefits from vaccination records that are also part of the electronic personal
health history and medical record are multifold.
Parents and practitioners can receive automatic reminders when the next
vaccination is due and vaccinations can be tracked over time regardless of where
they were received. Vaccination
reporting systems can aggregate anonymous patient data to show rates at the
local, regional, and national levels and compare those to CDC guidelines. At the local level, rates by practice
group or neighborhood can be used to target areas for outreach. Health
information Exchange enables the flow of information between systems and
facilitates the aggregation of information which may initially exist across
multiple systems.
Slide 10:
Health Information Exchange ensure privacy and
security. Health Information
exchange requires secure transmission of information and builds in precautions
that the information will arrive as it was sent and that privacy of the
information is maintained. Encryption and decryption of information being
transferred provides greater security and privacy than the production and
physical transport of hard copy information.
Encryption can be built into the system and occur automatically. Other
tools such as packet checking also support secure transmission of information
Backing up information in some physical form
(paper) can be costly, difficult, intermittent and subject to ample opportunity
for error, destruction, and loss.
Electronic backups are relatively easy, low cost, not prone to errors,
and can be automated on a frequent schedule.
This responsibility can also be centralized, specialized and scheduled in
a manner that guarantees it is done.
Automated systems allow for very specific
control of access to information through the use of passwords, profiles and
other tools that are support by HIE.
This means that a person using the system remotely will still be subject to the
same levels of authentication as a person using the system directly. A bonus is an automatic audit trail
that can be created identifying who accessed what information and when they did. The log can be reviewed when needed or
random reviews could be implemented as compliance checks.
Component 11/Unit 2c Quality Measure Terminology •NQF – National Quality Forum
•HQA – Hospital Quality
•CMS PQRI – Centers for Medicare & Medicaid Services Physician Quality Reporting Initiative
•AQA – Ambulatory Care
Quality •EH – Eligible Hospitals •RHQDAPU - Reporting Hospital Quality Data for Annual Payment Update •EP – Eligible Professionals Quality Measures Definition •Measures of processes, experience, and/or outcomes of patient care, observations or treatment that relate to one or more quality aims for health care such as effective, safe, efficient, patient-centered, equitable, and timely care.
Stage 1 Meaningful Use •Infrastructure for electronic exchange of structured data not currently available •Low threshold requirements for lab data in structured format •Not anticipated that HHS will have the capability to accept data on quality measures from EHRs for the 2011 payment year 2012 Payment Year •Expected that EPs will be required to submit clinical quality measures electronically •Important to the overall goal of the HITECH Act to improve quality of care
Selection of Quality Measures •HITECH Act required preference given to measures through an organization contracted by HHS and those selected for the RHQDAPU program •HHS awarded contract to NQF •Preference given to quality measures endorsed by NQF –For EPs includes measures previously selected for PQRI program –For EHs includes measures selected for the RHQDAPU program
Clinical Quality Measures •Eligible professionals will need to be comply with 44 clinical quality measures including the PQRI measures beginning in 2011 •Eligible Hospitals will need to comply with 15 clinical quality measures including Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) beginning in 2011
Future Expansion •For 2013 payment year and beyond the measures are expected to rapidly expand •Likely to include: –Pediatric measures –Long-term care measures –Obstetrics measures –Dental care/oral health measures –Mental health and substance abuse measures
Reporting Methods •In 2011 use attestation that the data elements are captured within a certified EHR –Attest to the accuracy and completeness of the numerators, denominators and exclusions •In 2012 submit summary information (not personally identifiable) on the clinical quality measures using certified EHR technology
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