DIVURGENT

In 2010, the transformation of health systems will improve health care quality, efficiency, equity and safety through the use of Health Information Technology (HIT). This will lead to measurable improvement in our nation’s health. The meaningful use of technology is central to the modernization of our health system. In the Interim Final rule (IFR) on Standards and Certification Criteria issued today, the Office of the National Coordinator for Health Information Technology (ONC) has published an initial set of standards, implementation specifications and certification criteria.

In the Notice of Proposed Rulemaking (NPRM), the Centers for Medicare and Medicaid (CMS) outlined provisions governing the Medicare and Medicaid Electronic health record (EHR) incentive programs. These included a proposed definition for the concept of “meaningful use” of EHR technology. It is essential that professionals and hospitals are able to demonstrate meaningful use of a certified EHR system in order to be eligible to receive payments under the incentive program which are provided through the American Recovery and Reinvestment Act (ARRA). Certifications in the IFR are organized into four categories: Content Exchange Standards, Vocabulary Standards, Transport Standards and Privacy and Security Standards. The criteria are designed to be supportive of the staged meaningful use requirements while also laying the foundation for future growth in information exchange and technological innovation. Meaningful use requirements are expected to become more demanding over time as our industry continues to spur adoption through its innovative offerings. An incremental approach to standards adoption requires harmonization with current and future standards to come.

Both the IFR and NPRM can be found at:

http://www.federalregister.gov/inspection.aspx#special

With all of us wondering about meaningful use final objectives and measures, I was surprised to find vendors “guaranteeing” achievement of meaningful use. One such vendor is athenahealth. They say, “We’re so confident that our low-cost, low-risk Web-based EHR service will meet HITECH Act requirements for meaningful use and help you secure your government payments, that we are guaranteeing it and putting our money on the line”. Interesting indeed.

If you haven’t kept up with what the NCQA has been up to in supporting patient centered care initiatives, it’s interesting to look at the program in light of ARRA and the most recent meaningful use definition.

NCQA’s Physician Practice Connections –  The Patient Centered Medical Home (PPC-PCMH) initiative is aimed at recognizing medical practices who are meeting NCQA standards related to providing a patient centric medical home model (for definition, see). This model emphasizes patient centric, holistic care coordinated by a physician.

I have become increasingly concerned lately about the multitude of programs (see my previous post), aimed at improving various components of the healthcare system, due to the amount of confusion it is occurring at the provider level of care. Although all have admirable goals, the lack of coordination may actually freeze the market as providers work to reconcile the various programs and what they must do to receive incentives, achieve meaningful use, obtain NCQA accreditation and so on. What is needed at the Federal and State level is a coordinated effort which aligns these programs and provides clear direction to providers so they can act on implementing strategic and tactical initiatives.

However, it is most interesting how many of these programs/initiatives are aligned in their mission and goals. For example, NCQA’s PCMH “must pass” elements include:

1. Written standards for patient access and patient communication
2. Use of data to show meeting standards
3. Use of paper or electronic based charting tools to organize clinical information
4. Use of data to identify important diagnosis and conditions in practice
5. Adoption and implementation of evidence based guidelines for three conditions
6. Active support of patient self management
7. Tracking system to test and identify abnormal results
8. Tracking referrals with paper based or electronic system
9. Measurement of clinical and/or service performance
10. Performance reporting by physician or across the practice

It is clear that the above elements are largely included in the current definition of meaningful use. In fact, it is virtually impossible to achieve NCQA level 3 recognition without an electronic health record of some sort.

My hope is that providers are able to devote the appropriate resources and develop an overall organizational strategy that will allow them to achieve the greatest success in obtaining incentives, obtaining recognition and of course improving the overall. And most importantly, accomplishing this with the most efficient utilization of resources.

The federal HIT Policy Committee met on Friday, August 14, 2009 in Washington DC to discuss meaningful use. The Committee released a timeline for the next 12 months to finalize a meaningful use definition:

• 3Q09: Develop process for updating meaningful use objectives and measures
– Tag 2011 measures relevant to specialties
• 4Q09: Conduct informational hearings to inform 2013 and 2015 criteria development
• 1Q10: Update 2013 and 2015 criteria
• 2Q10: Work with HIT Standards committee to ascertain availability of relevant standards
• 3Q10: Refine 2013 meaningful use criteria
• 4Q10: Assess industry preparedness for meeting 2011 and initial 2013 meaningful use criteria

The updates on meaningful use are as follows:

• Continue to use National Priorities Partnership (NPP) framework for meaningful use criteria
• Work with NPP and Healthy People programs to identify HIT-sensitive objectives and measures appropriate for meaningful use criteria (exemplars) in 2013 and 2015
• Gather public input on identified gaps in measures needed for MU criteria
– Examples: specialists, smaller practices and hospitals, safety-net providers, patient-supplied information
• Assess industry initial response to 2011 MU program
• Refine 2013 and 2015 MU criteria
• Address barriers to EHR adoption and mitigation strategies

The Committee will hold an informational hearing on ‘meaningful use’ criteria for 2013-15 in October 2009. They will address gaps in appropriate measures for assessing meaningful use, criteria for specialists including: use of measures relevant to specialists, participation in national registries, development of new measures; and feedback & new ideas from provider organizations for meaningful use criteria for 2013& 2015 for the spectrum of physician practices, hospitals, and safety-net providers.

We are looking forward to the upcoming meetings and a final definition on meaningful use.

As I’ve spent more time thinking about the ARRA, I’ve reflected on the multitude of other governmental “stimulus” programs that are available to providers to help improve the quality, safety, and efficiency of healthcare delivery. If providers are unable to navigate the morass of legislation that is the byproduct of all these programs, then it will be increasingly difficult for either the government or the provider community to garner the intended benefits of these programs.

Some of the governmental programs currently in place include: (a) CMS’s Physician Quality Reporting Initiative (PQRI), (b) the e-Prescribing initiative authorized in Section 132 of the Medicare Improvements for Patients and Providers Act of 2008, (c) CMS’ Hospital Compare project, (d) the anti-kickback safe harbors / STARK exceptions for e-prescribing and electronic medical records, and (e) the American Recovery and Reinvestment Act of 2009 (ARRA).

The complexity of these programs has, understandably, caused a significant level of confusion in the healthcare marketplace as providers have struggled with understanding the overall program framework let alone trying to implement strategies that allow them to maximize the benefits and incentives associated with such programs. In short, providers are confused and stymied by the number and complexity of programs available to them in today’s legislative landscape.

Do most providers have the resources in place in order to develop the strategic approaches necessary to leverage the incentives offered in these programs and do it efficiently?

The federal HIT Policy Committee approved revised recommendations for “meaningful use” of electronic health records. The meaningful use workgroup of the HIT Policy Committee met for a second time on July 16, 2009 and has released its newest recommendations. Overall, the committee states that “the focus of meaningful use must be on objectively measurable improvement of health outcomes and actual effective use, not simply to promote the adoption of technology for its own sake.” Meaningful use of HIT is critical to the President’s and Congress’s agenda for health reform, which drives the urgency and the seemingly aggressive nature of the timelines. Thus, the alignment of the planned healthcare reform and meaningful use must be met in order to assure the success of health reform. Although extremely ambitious, the 2015 vision is achievable.

Vision for 2015
• Prevention and management of chronic diseases
o A million heart attacks and strokes prevented
o Heart disease no longer leading cause of death in the US
• Medical Errors
o 50% fewer preventable medication errors
o Health disparities
o The racial/ethnic gad in diabetes control halved
• Care Coordination
o Preventable hospitalizations and re-admissions cut by 50%
• Patients and families
o All patients have access to their own health information
o Patient preferences for end of life care followed more often
• Public Health
o All health departments have real-time situational awareness of outbreaks

Recommendations

Improve Quality, Safety, Efficiency; Reduce Disparities (Timing)
• If an organization cannot meet 2012, the 2013 criteria sets an even higher bar (“rising tide”)
• Recommendation – use of “adoption year” timeframe.
If a provider is not ready by 2011 to meet meaningful use, they can become meaningful users at a later time and still use 2011 criteria as their meaningful use standards for their first adoption year. In other words, a provider’s criteria for meaningful use would be according to adoption year 1 criterion, two years later they would use the 2013 criteria, no matter the start year.

• Computerized physician order entry (CPOE) too fast (primarily hospitals)
– Unintended consequence of trying to implement faster than feasible, considering workflow redesign pre-work
• Recommendation – Establish 10% threshold of CPOE orders for hospitals
• Accommodates pilots, implementations in-progress

• Start clinical decision support earlier
– It’s the payoff (faster)
– Need to implement EHR before turning on rules; also need to populate the database (slower)
• Recommendation – Start with one rule; make it important: “Implement one clinical decision rule relevant to high clinical priority”

Patient and Family Engagement
• Provide access to electronic health information (in addition to electronic copy)
• Included in 2011
• Moved up real-time access to patient information in PHR from 2015 to 2013

Efficiency Measures
• Initial starter set
• % of all medications entered into EHR as generic, when generic options exist in the relevant drug class
• % of orders for high-cost imaging services with specific structured indications recorded
• Claims submitted electronically to both public and private payers
• Eligibility checks performed electronically

Specialists
• General approaches discussed
– “500 criteria” model of something for everyone (yet, very few NQF-endorsed measures)
– “Critical few” model of build and prove out the necessary capabilities using exemplar measures
• Use of exemplar measures that would “exercise” the EHR capabilities and meaningful use of the capabilities to measure and improve care
• Require specialists’ participation in electronic registries (approved by CMS) as relevant and available

Improve Care Coordination
• Need better outcomes measures for care coordination
• NQF has a call for measures in care coordination (NPP priority)
• Propose 2013 measure of 10% reduction in 30-day readmission compared to 2012
• Improvement in NQF-endorsed measures of care coordination

• How to meet health information exchange in 2011 when HIE organizations do not currently exist or do not connect all clinical trading partners
• 2015 should include required participation in nationwide HIE
• Require capability and exchange where possible in 2011
• Defer to HIE workgroup for specific requirements and roadmap

Privacy and Security
• Clarify “under investigation”; could any complaint trigger “investigation”?
– Length of investigation could also potentially cause a missed payment (even if found “not guilty”)
• Intent was to disallow participation in HIT incentives if confirmed HIPAA violation goes unresolved
• Revised wording: “…recommend that CMS withhold meaningful use payment for any entity until any confirmed HIPAA privacy or security violation has been resolved”

• How can federal program “enforce” compliance with state privacy laws?
• Shift to Medicaid section: “…recommend that state Medicaid administrators withhold meaningful use payment for any entity until any confirmed state privacy or security violation has been resolved”

Future Work
• Refine 2015 achievable vision
• Refine 2013 and 2015 meaningful use objectives and measures
• Develop process for ongoing development and refinement of meaningful use objectives and measures
• Review barriers to broad adoption of meaningful use and provide recommendations, to the HIT Policy Committee, for removing barriers

Upcoming HIT Policy Committee Meetings:
• August 12, 2009
• September 18, 2009
• October 27, 2009
• December 15, 2009

Like you, I will be anxiously awaiting the final definition.

The meaningful use workgroup of the HIT Policy Committee has released its initial recommendations for a definition of ‘meaningful use’ of electronic health records. Thanks to Terri Ripley for the notes below from the Committee meeting. I’ll post links to the most valuable information asap.

Vision for 2015

• Prevention and management of chronic diseases
o A million heart attacks and strokes prevented
o Heart disease no longer leading cause of death in the US
• Medical Errors
o 50% fewer preventable medication errors
• Health disparities
o The racial/ethnic gad in diabetes control halved
• Care Coordination
o Preventable hospitalizations and re-admissions cut by 50%
• Patients and families
o All patients have access to their own health information
o Patient preferences for end of life care followed more often
• Public Health
o All health departments have real-time situational awareness of outbreaks

Initial Metrics and Validation
• Provider makes use of, and the patient has access to, clinically relevant electronic information, not just existence of technology
• Achievable whenever possible through automatic reporting from electronic health systems to avoid creating additional unnecessary reporting burden for clinicians
• Verification to be performed by CMS
• Many suitable measures already developed and specified for automated reporting
• Consider use of PQRI HER/ registry receiving capabilities
• Attestation will be necessary for some criteria (at least initially)
• Can use escalation thresholds

Criteria for 2013 and Beyond
• Additional metrics required
o Additional efficiency, “inappropriate use” measures
o Patient Safety
o Care Coordination
• Transition from “pay for reporting” to “pay for outcomes” as per the CMS EHR demonstrations

Improve Quality, Safety, Efficiency 2011 Objectives

• Capture data in coded format
o Maintain current problem list
o Maintain active medication list
o Record vital signs (height, weight, blood pressure)
o Incorporate lab/test results into EHR
o Document key patient characteristics (race, ethnicity, gender, insurance type, primary language)
• Document progress not for each encounter (outpatient only)
• Use CPOE for all order types
o Use electronic prescribing for permissible Rx
o Implement drug-drug, drug-allergy, drug-formulary checks
• Manage populations
o Generate list of patients by specific conditions (outpatient only)
o Send patient reminders per patient preference

2011 Measures
• % Labs incorporated into EHR in coded format
• % CPOE orders entered directly by physician
• Report quality measures using HIT-enabled quality measure (HIT-QM)
o % Diabetics with A1c under control
o % Hypertensives with BP under control
o % LDL under control
o % Smokers offered smoking cessation counseling
o % Patient with recorded BMI
o % Colorectal screening for 50+
o % Mammograms for women 50+
o % Current pneumovax status
o % Annual flu vaccination
o % Aspirin prophylaxis for patients at risk for cardiac event
o % Surgical patients receiving VTE prophylaxis
o Avoidance of high risk medications in elderly
• Quality reports stratified by race, ethnicity, gender, insurance type

2011 Objectives – Engage Patients and Families
• Provide patients with electronic copy of or electronic access to clinical information per patient preference
o Includes labs, problem list, medication list, allergies
• Provide access to patient-specific educational resources
• Provide clinical summaries for patients each encounter

2011 Objectives – Improve Care Coordination
• Exchange key clinical information among providers of care
• Perform medication reconciliation at relevant encounters

Improve Care Coordination – 2011 Measure
• Report 30 day readmission rate
• % Encounters where medication reconciliation performed
• Implemented ability to exchange information with external clinical entities
o Problems, labs, medication lists, care summaries
• % Transitions in care where summary care record is shared (in 2011, could use modality)

2011 Objectives – Improve Population and Public Health
• Submit electronic data to immunization registries where required and can be accepted
• Submit electronic reportable lab results to public health agencies
• Submit electronic syndrome surveillance data to public health agencies according to applicable law and practice

2011 Measures– Improve Population and Public Health
• Report up-to-date status of childhood immunizations
• % Reportable lab results submitted electronically

2011 Objectives– Ensure Privacy and Security Protections
• Compliance with HIPAA Rules and state laws
• Compliance with fair data sharing practices set forth in the National Privacy and Security Framework

2011 Measures– Ensure Privacy and Security Protections
• Full compliance with HIPAA
o Entity under investigation for HIPAA violation cannot achieve meaningful use until entity is cleared
• Conduct or update a security risk assessment and implement security updates as necessary

Looking Forward: 2013 – Objectives

• Improve quality, safety, efficiency
o Evidence based order sets
o Clinical documentation recorded (inpatient)
o Clinical decision support at point of care
o Manage chronic conditions using patient lists and decision support
o Report to external disease registry

• Engage patients and families
o Offer secure patient-provider measuring
o Access to patient specific educational resources
o Record patient preferences
o Documentation of family medical history
o Upload data from home monitoring devices
• Coordinate Care
o Medication reconciliation at each transition of care
o Produce electronic summary of care at each transition
o Retrieve and act on electronic prescription fill data

Looking Forward: 2015 – Objectives
• Improve quality, safety, and efficiency
o Achieve minimal levels of performance on quality, safety, and efficiency measures
o Implement clinical decision support for national high priority conditions
o Achieve medical device interoperability
o Provide multimedia support (e.g., x-rays)
• Engage patients and families
o Provide access for all patients to PHR populated in real time with data from HER
o Provide patients with access to self-management tools
o Capture electronic reporting on experience of care
• Coordinate care
o Access comprehensive patient data from all available sources
• Improve population and public health
o Use epidemiologic data derived from EHRs
o Automate real-time surveillance
o Provide clinical dashboards
o Generate dynamic and ad hoc quality reports
• Ensure privacy and security protection
o Provide patients with accounting of treatment, payment, and health care operations disclosures
o Protect sensitive health information

Click this link to see a detailed matrix:

http://divurgent.com/meaningfuluse.html

Health Data Management has reported that a workgroup of the HIT Policy Committee on June 16 will unveil its recommendations on the definition of “meaningful use” of electronic health records, confirms John Glaser, senior special advisor to the Office of the National Coordinator for Health Information Technology.

“This definition, if approved by the committee, will be forwarded to ONC for consideration,” Glaser said in an e-mail to Health Data Management. The full policy committee also meets on the 16th.

Hospitals and physicians must meaningfully use EHRs to qualify for Medicare and Medicaid incentive payments under the American Recovery and Reinvestment Act. The law requires the Department of Health and Human Services to publish a final rule on the initial definition or definitions of meaningful use by the end of 2009. The definitions likely will expand in subsequent years.

Glaser, vice president and CIO at Partners HealthCare System in Boston, assumed his ONC position in early May to assist National Coordinator David Blumenthal, M.D., for six months.

Since consumers rely on quality and cost information in many other segments of their lives, I believe it is the consumer who will soon begin to drive improvements in quality and price transparency in healthcare. Further, the American Recovery and Reinvestment Act of 2009 will result in the industry’s increased adoption of technologies that are critical to creating the environment of transparency that consumers will demand.

As consumers become more and more involved in their care, they are coming to realize that better information about cost and quality will allow them to make better, more informed choices. Just as they can book hotel rooms anywhere around the world—and find data on cost and quality that is readily available—they will begin to expect the same in healthcare. Providers operating in a competitive environment will be forced to improve the quality and cost of care if they are to compete effectively. In addition, transparency will encourage these consumers to reward high quality/low cost care. Over time, consumers will not tolerate a healthcare system without quality and cost transparency.

Hotels and healthcare

Already, today’s consumers feel that the current state of information is inadequate. They rarely have cost and quality details about healthcare services, and even physicians rarely have comparative information on the quality of their own care or of the care of physicians to whom they refer patients .

Quite unlike decisions about a hotel stay, the unique characteristics of healthcare decision-making includes a high degree of risk and value–both perceived and real. Healthcare decisions therefore necessitate that consumers maintain a high level of involvement in the decision-making process. Unfortunately today, most consumers overall could spend considerable time and effort to uncover a minimal level of information to make their final purchase decision. Further, even though they have researched the service, sometimes the end-user experience differs greatly from what they expected, since the healthcare delivery processes includes many touch points. This variance in the consistency of services and involvement of diverse processes in the system raises additional issues of cost and quality transparency.

Opportunities and solutions

Cost and quality transparency would help patients to make informed choices about their care, encourage private insurers and public programs to reward quality and efficiency, and compel providers to improve services by benchmarking their performance against others . To develop and implement a national strategy for health care quality measurement and reporting, for example, the National Quality Forum (NQF), a private not-for-profit membership organization, was incorporated in 1999. NQF is also involved in standardizing health care performance measurement and reporting. Some of the selected projects include cancer care quality measures, mammography standards for consumers, cardiac surgery performance measures and nursing care performance measures. Some effective state-driven transparency efforts in the US include various programs such as the Pennsylvania Health Care Cost Containment Council, California health care reform, Florida Compare Care and the Massachusetts Health Care Quality and Cost Council.

The demand for details and quality in the form of report cards and rating systems for hospitals has also provided business opportunities for private companies. Some of these report card providers are:
- “Consumers’ CHECKBOOK,” which provides “desirability” ratings for hospitals based on surveys of physicians, risk-adjusted mortality figures, and adverse outcome rates for several surgical procedures
- “Leapfrog Group,” which surveys hospitals on about 30 safety practices and then combines them to provide an overall safety score
- “HealthGrades,” which rates hospitals by individual procedures and conditions .

These report card providers may differ in the methodology of their rating systems, so it’s become important for consumers to have a broad perspective in order simply to evaluate these ratings.

Key conclusions

Going forward, the cost and quality transparency and standardization of services will act as key purchase drivers and contribute to the success of a healthcare system.

Therefore, if stakeholders in the health sector wish to look forward to assured profits from this industry, they have to execute activities such as in-depth planning, deployment, execution, and monitoring of various parameters which can equip them to deal with customer sensitiveness for quality and cost transparency.

What might the role of technology play in this arena?

HHS Announces Members of Committees That Will Advise on Implementation
of Health IT Policy and Standards Committees Will Meet Next Week

The Department of Health and Human Services announced the
appointment of three members to the Health Information Technology (HIT)
Policy Committee as well as members of the HIT Standards Committee. The
two new federal advisory committees were established by the American
Recovery & Reinvestment Act of 2009. The first meeting of the Health IT
Policy Committee will be held on Monday, May 11 in Washington, D. C.

“The Policy and Standards committees bring together a wide diversity of
key stakeholders to help guide the advancement of health IT as an
integral part of health reform,” stated Dr. David Blumenthal, National
Coordinator for Health Information Technology at HHS and Chairman of the
Policy Committee. “It is an honor to lead one of these committees, and
I am confident that these committees will provide valuable insight to
help develop important health IT policy in the next few years.”

The HIT Policy Committee will make recommendations to the National
Coordinator for Health Information Technology on a policy framework for
the development and adoption of a nationwide interoperable health
information infrastructure, including standards for the secure and
private exchange of patient medical information.

The HHS appointees to the Policy Committee are:

David Blumenthal, MD, MPP,
National Coordinator for Health Information Technology, U.S. Department
of Health and Human Services.

Michael J. Klag, MD, MPH
Dean, Johns Hopkins Bloomberg School of Public Health.

Deven C. McGraw, JD, MPH, Director
Health Privacy Project, Center for Democracy & Technology.

An additional 13 members were appointed by the Acting Comptroller
General of the United States, and four members appointed by the Majority
and Minority Leaders of the Senate and the Speaker and Minority Leader
of the House of Representatives. A complete list of the Policy Committee
members and information about the May 11th meeting can be found at
http://healthit.hhs.gov/. The Presidential appointments from relevant
federal agencies are expected to be announced prior to the HIT Policy
Committee’s second meeting in June.

In addition, appointments were made to the HIT Standards Committee, also
a federal advisory body, which is charged with making recommendations to
the National Coordinator on standards, implementation specifications,
and certification criteria for the electronic exchange and use of health
information. The first meeting of this committee is scheduled for
Friday, May 15, 2009.

Members appointed by HHS are:

Jonathan Perlin, MD, Chair
Healthcare Corporation of America

John Halamka, MD. Co-Chair
Harvard Medical School

Dixie Baker, PhD
Science Applications International Corporation

Anne Castro
BlueCross BlueShield of South Carolina

Christopher Chute, MD
Mayo Clinic College of Medicine

Janet Corrigan, PhD
National Quality Forum

John Derr, R.Ph.
Golden Living, LLC

Linda Dillman
Wal-Mart Stores, Inc.

James Ferguson
Kaiser Permanente

Steven Findlay, MPH
Consumers Union

Douglas Fridsma, MD, PhD
Arizona Biomedical Collaborataive 1

C. Martin Harris, MD, MBA
Cleveland Clinic Foundation

Stanley M. Huff, MD
Intermountain Healthcare

Kevin Hutchinson
Prematics, Inc.

Elizabeth O. Johnson, RN
Tenet Health

John Klimek, R.Ph.
National Council for Prescription Drug Programs

David McCallie, Jr., MD
Cerner Corporation

Judy Murphy, RN
Aurora Health Care

J. Marc Overhage, MD, PhD
Regenstrief Institute

Gina Perez, MPA
Delaware Health Information Network

Wes Rishel
Gartner, Inc.

Sharon Terry, MA
Genetic Alliance

James Walker, MD
Geisinger Health System

Representatives from relevant federal agencies will be named separately.
For more information about these committees, meeting dates and
preliminary agendas please visit http://healthit.hhs.gov

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