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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.

 

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
Meaningful Use  -  Quality Measures

Quality Measure Terminology

NQF – National Quality Forum

HQA – Hospital Quality Alliance

CMS PQRI – Centers for Medicare & Medicaid Services Physician Quality Reporting Initiative

AQA – Ambulatory Care Quality Alliance

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
2011 payment year

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
EP and EH Compliance

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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