Achieving Meaningful Usefrom Life as a Healthcare CIO by John Halamka
Now that the Interim Final Rule(Initial Set of Standards, Implementation Specifications, andCertification Criteria for Electronic Health Record Technology) and theNotice of Proposed Rulemaking(Medicare and Medicaid Programs Electronic Health Record IncentiveProgram) have been published, we can all finalize our policy andtechnology strategies for achieving Certification and Meaningful Use inour organizations and communities.
It'simportant to use these two documents together to understand what isrequired for Certification and to achieve Meaningful Use stage 1measures (2011) by professionals and hospitals.
Certificationis a guarantee of software capabilities and Meaningful Use describesthe way software features should be implemented in actual workflows.Certification and Meaningful Use are related but different concepts.For example, Certification requires that a complete EHR or EHR modulehave the capability of recording, retrieving, and transmittingimmunization information using HL7 2.3.1 or HL7 2.5.1 with the CVXvocabulary. The Meaningful Use stage 1 measure is to perform at leastone test of the certified EHR technology's capacity to submitelectronic data to immunization registries if local public healthagencies are capable of receiving them. Thus, for 2011, actualsubmission of immunization data is not required, just the capabilityand a single test of that capability. Of course, by Stage 2 (2013), Iexpect that actual data submission will be part of every patientimmunization.
How should you prepare for Meaningful Use in your own organization? I recommending printing 3 tables
1. Certification Criteria - pages 51-61 of the Interim Final Rule
2. Adopted Content Exchange, Vocabulary, and Privacy/Security Standards - pages 79-81 and page 85 of the Interim Final Rule
3. Stage 1 Criteria for Meaningful Use - pages 103-108 from the Notice of Proposed Rulemaking
Usethese three documents to guide all your planning efforts. That's whatI've done and here's a 25 item strawman strategy for BIDMC (which runslargely self built systems) and its affiliated community hospital,BID-Needham (which runs Meditech).
1. Use CPOE
a.For ambulatory settings - support electronic ordering of 80% ofmedications, laboratory, radiology/imaging, and referrals. webOMR (ourself built EHR) or eClinicalworks (eCW) will be implemented based onthe workflow requirements of the practice as it interacts withhospitals, labs, radiology centers, and the community. At BIDMC we willneed to make improvements to our self built lab system to support labdata exchange with sites that use us as reference lab. At BID-Needham,the combination of eClinicalWorks, Quest, and Meditech will meet theneed.
b. For inpatient settings - support electronic orderingof 10% of medications, laboratory, radiology/imaging, blood bank,physical therapy, occupational therapy, respiratory therapy,rehabilitation therapy, dialysis, provider consultants, anddischarge/transfers. At BIDMC, our self built CPOE system already doesthis. At BID-Needham, Meditech version 5.6 is being implemented to dothis.
2. Implement drug-drug, drug-allergy, drug-formulary checks.
a. For ambulatory settings - webOMR or eCW connected to Surescripts will meet the need.
b. For inpatient settings - our self built CPOE system or Meditech will meet the need.
3.Maintain an up to date problem list of current and active diagnoses (atleast one coded entry or "No Problems exist") in ICD9-CM or SNOMED-CTfor at least 80% of all patients
a. For ambulatory settings -webOMR or eCW will meet the need. Note that we have already implementedthe NLM's SNOMED Core vocabulary to map our proprietary vocabularies toSNOMED-CT before we sent them to Google Health or MicrosoftHealthvault, but we will need to create a new problem list picker forwebOMR that uses SNOMED-CT natively. Luckily, we already have aprototype.
b. For inpatient settings - webOMR plus IMDSoft's Metavision for ICUs or Meditech will meet the need.
4.Generate and transmit permissible prescriptions electronically (the DEAdoes not yet allow controlled substances to be e-prescribed) for 75% ofall ambulatory prescriptions. webOMR or eCW connected to Surescripts dothis today.
5. Maintain an active medication list (at least one coded entry or "No Medications taken") for at least 80% of all patients
a.For ambulatory settings - webOMR or eCW will meet the need. We areusing First Data Bank in webOMR and Medispan in eCW. Both qualify asappropriate controlled vocabularies in 2011 because they are includedin RxNorm.
b. For inpatient settings - our self built CPOE system or Meditech will meet the need.
6.Maintain an active allergy list (at least one entry or "No Allergiesreported") for at least 80% of all patients. Note that nocoding/vocabulary is required for 2011
a. For ambulatory settings - webOMR or eCW will meet the need.
b. For inpatient settings - our self built CPOE system or Meditech will meet the need.
7.Record demographics including preferred language, insurance type,gender, race, ethnicity, date of birth, and date of death/cause in theevent of inpatient mortality for 80% of patients.
a. Forambulatory settings - webOMR or eCW will meet the need. Note that wealready do this using controlled vocabularies and report the data tothe Boston Public Health Commission as part of their effort to measuredisparities in healthcare.
b. For inpatient settings - our self built registration/scheduling system called CCC or Meditech will meet the need.
8.Record vital signs including height, weight, blood pressure, Body MassIndex (calculated) and growth charts for children 2-20 years for 80% ofpatients.
a. For ambulatory settings - webOMR or eCW will meet the need.
b. For inpatient settings - webOMR plus Metavision for ICUs or Meditech will meet the need.
9. Record smoking status for 80% of patients 13 years or older
a. For ambulatory settings - webOMR or eCW will meet the need.
b. For inpatient settings - webOMR plus Metavision for ICUs or Meditech will meet the need.
10. Incorporate 50% of clinical lab test results as structured data using LOINC codes
a.For ambulatory settings - webOMR or eCW. At BIDMC we will need to makeimprovements to our self built lab system to support lab data exchangewith sites that use us as reference lab. We already have a single hubfor all eCW/Quest lab data exchange.
b. For inpatient settings - webOMR plus Metavision for ICUs or Meditech will meet the need.
11.Generate a least one report listing patients with a specific condition.The concept is that such reporting can be used for quality improvement,reduction of disparities, and outreach.
a. For ambulatorysettings - webOMR includes numerous data marts that already providesuch reports such as our BIDMC/Joslin diabetes registry. Also our workwith the MAeHC Quality Data Center will support numerous reports for our clinicians using webOMR and eCW data.
b. For inpatient - BIDMC homebuilt systems use our data marts. For Meditech, we'll have to rely on built-in reporting tools.
12. Report aggregate numerator and denominator quality data to CMS in 2011 and exchange it using PQRI XML by 2012
TheMAeHC Quality Data Center project includes the ability to gather alldetailed metrics from home built and eCW systems for reporting to ourclinicians, the state, and CMS using the adopted standards. It will golive for all Beth Israel Deaconess Physician Organization clinicians in2010.
13. Send reminders to at least 50% ofall patients who are 50 years and over for preventative care/followup.The intent is to allow the patient to choose between post card, email,phone reminder, or PHR reminder.
At present, BIDMC has this ability via our tethered PHR, Patientsite.We already send reminder cards via email and make calls via automatedphone systems. Documenting patient preference for which modality to usemay be a challenge.
14. Implement 5 clinicaldecision support rules relevant to the clinical quality metrics (Noticeof Proposed Rulemaking pages 123-138 from ambulatory and pages Page153-160 for inpatient)
We already have implemented numerous decision support rules in BIDMC self built systems.
We'reactivating eCW decision support rules a few weeks after implementingeach practice to enable clinicians to adjust to the EHR beforealerts/reminders start popping up.
15. Check insurance eligibility and submit claims electronically for at least 80% of patients.
Since 1997, the New England Healthcare Exchange Network (NEHEN) has provided this functionality to all the payers and providers in Massachusetts.
16.Provide 80% of patients who request an electronic copy of their healthinformation in the CCD or CCR format within 48 hours of their request
a.For ambulatory settings this will include the problem list, medicationlist, allergies, and diagnostic test results. We do this today viaGoogle Health and Microsoft Healthvault.
b. For inpatientsettings this will include discharge instructions and procedures. We dothis today via a self built discharge application that provides a humanreadable document for the patient and routes a CCD via the NEHENgateway to the primary care provider.
17.Provide 10% of patients with online access to their problem list,medication lists, allergies, lab results within 96 hours of theinformation being available to the clinician.
Today,any patient can get access to their BIDMC records via Patientsite, ourtethered personal health record. For eCW, we'll be implementing the eCWPatient Portal this Spring.
18. Provide aclinical summary for 80% of all office visits (problem lists,medication lists, allergies, immunizations, and diagnostic testresults) in paper or CCD/CCR format
Today, anypatient of BIDMC can receive a CCR via Microsoft Health Vault or GoogleHealth. For eCW, we'll be implementing the eCW Patient Portal thisSpring.
19. At least one test of health information exchange among providers of care and patient authorized entities.
In 2009, we implemented a CCD interface to the Social Security Administration so that we can send complete patient summaries with patient consent to a Federal agency.
20. Perform Medication reconciliation for at least 80% of relevant encounters and transitions of care
We're already at 90% compliance with ambulatory and inpatient medication reconciliation.
21.Provide a summary of care record for at least 80% of transitions ofcare and referrals. This also implies the ability to receive a recordand display it in human readable format
Forambulatory and inpatient settings, the NEHEN network can route datasecurely (in this case CCD) among providers (and payers). We alreadysend ED and Inpatient discharge summaries in CCD format with automatedintegration into EHRs such as eClinicalWorks. We have not added theability to receive a CCD into our home built EHR, webOMR, since so fewcommercial EHRs are capable of sending a summary in any format. We willneed to add CCD and CCR receiving ability and we'll display them ashuman readable notes in webOMR.
22. Perform at least one test of the EHR capacity to submit electronic data to immunization registries.
Sincethe Boston Public Health Commission is joining NEHEN so that it canreceive disparity and surveillance data via one secure gateway, it is alogical choice as our immunization pilot.
23. Perform at least one test of the EHR's capacity to submit electronic lab results to public health agencies.
As above, the NEHEN gateway connected to the Boston Public Health Commission is the solution.
24. Perform at least one test of the EHR's capacity to submit syndromic surveillance data to public health agencies.
Wealready submit 4000 data elements every day to the CDC and send EDutilization data to Boston Public Health Commission using proprietaryapproaches. Converting these to the GIPSE standard and routing them through the NEHEN gateway is a local approach.
25. Conduct or review a security risk analysis and implement updates as necessary
Inthe past, we've had Third Brigade (now a part of TrendMicro) do whitehat hacking penetration testing and risk analysis. My security teamplus external partners will ensure we have the right policies andtechnologies in place. For example, we're currently evaluating Imperva products to protect all our externally available websites as part of layered defense approach to security.
These25 steps to meaningful use may seem like a tall order. However, we canleverage numerous projects already in process including our communityHIE initiatives, RHITEC plans, Beacon Community planning, and hostedEHR rollouts to accomplish them. Many will feel stressed by meaningfuluse. My advice is to approach it stepwise, breaking it down intodiscrete projects which are doable. That way, the 25 step plan abovewill not lead to a 12-step program for your staff! |
发表于 2010-1-13 09:13:53