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 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.