The much-anticipated proposals of meaningful use criteria by the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) covering EHR technology capabilities and how providers must utilize it to qualify for ARRA incentives were jointly released late Wednesday afternoon.
It’s clear from their reading that the two dominate themes and goals of the proposed rules are standardization and interoperability, all toward the eventuality of a National Health Information Network.
Meaningful use is “based on currently available technological capabilities and providers’ practice experience,” according to the documents, which also state that “the standards adopted in the rule are consistent with current industry standards.”
That means that basic incentive funding for Medicare and Medicaid pathways - along with the majority of the specific clinical meaningful use functionality EHRs must provide - has not changed from preliminary requirements published earlier in 2009.
What’s new is that the proposals outline a manageable 3-step phasing in of criteria goals beginning in 2011. The first phase focuses on the tracking and exchange of clinical summaries and prescriptions, lab tests and medication information using standard exchange language
Phase 2 expands the standard functionality to include disease management, quality reporting and information exchange with public health agencies, and Phase 3 moves those functions to high priority national healthcare issues.
Also new in the proposals is the announcement that EHRs will be certified specific to meaningful use functionality in 2010, the same year that CMS and ONC expect these proposals to become a final regulation.
The broad goals in front of eligible professional (EP) providers are to improve quality, safety and efficiency, reduce outcome disparities, engage patients, improve coordination of care and ensure privacy.
For EHRs, the proposals focus on securely exchanging information using standard data language for clinical summaries, medical descriptions and test results, for example.
The proposals state that the criteria largely drew on recommendations already compiled from the National Committee on Vital and Health Statistics, which Greenway testified before last April, the Health IT Policy Committee and the Health IT Standards Committee.
Similarly, the provider incentive payment schedule and amounts remain largely the same as earlier recommended. For example within the Medicare incentive pathway, EPs can qualify for the first-year maximum $18,000 incentive whether their first year of meaningful use is 2011 or 2012. A new provision that should further motivate EPs to adopt EHRs is that to qualify for meaningful use incentives, reporting only has to take place for 90 continuous days that first year. Then in following years the reporting period would be the entire year.
These proposals offer a 60-day period for public comment, and Greenway is currently formulating its response. Below are links to the proposals as outlined in Wednesday’s announcement, and to a recent article by ONC Director Blumenthal that appeared in the New England Journal of Medicine.
Medicare Incentive Fact Sheet
Medicaid Incentive Fact Sheet
EHR Meaningful Use Fact Sheet
Launching HITECH by David Blumenthal, M.D., M.P.P.
Tuesday, January 5, 2010
Sunday, November 22, 2009
The high road of HITECH
Electronic health records and industry vendors took center stage throughout the 4th annual Healthcare Trade Faire & Regional Conference November 19 in downtown Atlanta.
Sponsored by the Georgia chapter of the Healthcare Information and Management Systems Society (HIMSS), the healthcare-wide and impending EHR-focused issues of HITECH stimulus funding, meaningful use and implementation drew a record attendance of 500 healthcare professionals, according to chapter President Don Kinser.
Greenway Medical Technologies Vice President of Marketing, Corporate Development and Government Affairs Justin Barnes debuted the conference as keynote speaker. In his capacity as chairman of the HIMSS Electronic Health Records Association, Barnes detailed the stimulus incentives of EHR adoption in his presentation “ARRA-HITECH: Understanding & Optimizing the EHR Incentives for Georgia Healthcare Providers – Perspectives for all size Hospitals and Physician Practices.”
“The goal of the HITECH Act is a systemic interoperability across the country, reaching three hundred to three hundred and fifty thousand providers nationwide. It’s about managing the heartbeat of your practice,” said Barnes. While he diagrammed the high-profile Medicaid and Medicare EHR adoption incentives offered during coming years, Barnes also revealed less well known but sizable incentives also available for Health Information Exchanges, Regional Extension Centers, Federal Qualified Health Centers and the undertaking of broadband capabilities, all while noting, for example, the $1.5 billion alone that is available from the Health Resources and Services Administration
When practices review EHR vendors for stimulus implementation, he advised attendees to cross reference a system’s certification, KLAS scores and HIMSS Davies Awards among other criteria. And incentives don’t stop with implementation. “Only five percent of practices undertake clinical trials,” he noted. “Trials and research are a source of ROI and income per patient. Think of the clinical trials and research you could do.”
Barnes’ keynote dovetailed into conference sessions such as EHR rollout, eMAR in 90 days, the medical home and “liberating data.” At an overflow CIO roundtable session, panelists grappled with the conflicting objectives of data security and the exchange of patient records. Attendees agreed that systems need sustainable IT funding like that found in other industries, and pointed to the adoption of mobile banking models, both in technical terms and as an analogous strategy, to assure stakeholders of the stability of healthcare technology.
“This is a good time to have a good relationship with your vendor,” recommended panelist Ron Strachan, CIO of Wellstar Health Systems. “Should you make diagnostics from the view of an iPhone? No, that’s not meaningful use. Just because you can doesn’t mean you should.”
A discussion of meaningful use capped the conference, as attendees were given a preview of the critical components of CPOE, e-prescribing, standardized information exchange, quality reporting and other tenets of EHR adoption to procure incentive funds. But, like in the other major sessions, attendees were urged to consider the idealistic and attainable goals of the HITECH Act.
“Meaningful use is understanding what an EHR is and should do,” said presenter Donna Schmidt, chief nursing officer of CSC Healthcare Group. “Meaningful use takes the ambiguity away and allows for prioritizing.”
Echoed presenter David Stewart, GAHIMSS board member, “Meaningful use is the enabler to define quality care and to survive and achieve under any healthcare reform scenario.”
Sponsored by the Georgia chapter of the Healthcare Information and Management Systems Society (HIMSS), the healthcare-wide and impending EHR-focused issues of HITECH stimulus funding, meaningful use and implementation drew a record attendance of 500 healthcare professionals, according to chapter President Don Kinser.
Greenway Medical Technologies Vice President of Marketing, Corporate Development and Government Affairs Justin Barnes debuted the conference as keynote speaker. In his capacity as chairman of the HIMSS Electronic Health Records Association, Barnes detailed the stimulus incentives of EHR adoption in his presentation “ARRA-HITECH: Understanding & Optimizing the EHR Incentives for Georgia Healthcare Providers – Perspectives for all size Hospitals and Physician Practices.”
“The goal of the HITECH Act is a systemic interoperability across the country, reaching three hundred to three hundred and fifty thousand providers nationwide. It’s about managing the heartbeat of your practice,” said Barnes. While he diagrammed the high-profile Medicaid and Medicare EHR adoption incentives offered during coming years, Barnes also revealed less well known but sizable incentives also available for Health Information Exchanges, Regional Extension Centers, Federal Qualified Health Centers and the undertaking of broadband capabilities, all while noting, for example, the $1.5 billion alone that is available from the Health Resources and Services Administration
When practices review EHR vendors for stimulus implementation, he advised attendees to cross reference a system’s certification, KLAS scores and HIMSS Davies Awards among other criteria. And incentives don’t stop with implementation. “Only five percent of practices undertake clinical trials,” he noted. “Trials and research are a source of ROI and income per patient. Think of the clinical trials and research you could do.”
Barnes’ keynote dovetailed into conference sessions such as EHR rollout, eMAR in 90 days, the medical home and “liberating data.” At an overflow CIO roundtable session, panelists grappled with the conflicting objectives of data security and the exchange of patient records. Attendees agreed that systems need sustainable IT funding like that found in other industries, and pointed to the adoption of mobile banking models, both in technical terms and as an analogous strategy, to assure stakeholders of the stability of healthcare technology.
“This is a good time to have a good relationship with your vendor,” recommended panelist Ron Strachan, CIO of Wellstar Health Systems. “Should you make diagnostics from the view of an iPhone? No, that’s not meaningful use. Just because you can doesn’t mean you should.”
A discussion of meaningful use capped the conference, as attendees were given a preview of the critical components of CPOE, e-prescribing, standardized information exchange, quality reporting and other tenets of EHR adoption to procure incentive funds. But, like in the other major sessions, attendees were urged to consider the idealistic and attainable goals of the HITECH Act.
“Meaningful use is understanding what an EHR is and should do,” said presenter Donna Schmidt, chief nursing officer of CSC Healthcare Group. “Meaningful use takes the ambiguity away and allows for prioritizing.”
Echoed presenter David Stewart, GAHIMSS board member, “Meaningful use is the enabler to define quality care and to survive and achieve under any healthcare reform scenario.”
Thursday, November 19, 2009
Greenway sponsors Vision 2020 HIT symposium
Greenway Medical Technologies’ areas of expertise were on full display November 10 at the Woodruff Arts Center in downtown Atlanta during a special symposium on healthcare technology.
Health data exchange, EHR capabilities, meaningful use, sustainability and regional extension centers were just some of the topics that dominated panel discussions during “Vision 2020.” Hosted by the Technology Association of Georgia, panelists from academic, governmental and private industry healthcare pursuits led an audience of approximately 300 through the critical challenges the year 2020 foreshadows.
As a gold sponsor of the event, Greenway’s presence was also on display in program materials and through a sponsor’s reception the night of November 9. Greenway business partner Intel Health was also a sponsor of the event.
Moderated by CNN Senior Medical Correspondent Elizabeth Cohen and Wayne Oliver, vice president of the Center for Health Transformation, itself a strategic legislative partner of Greenway Medical, panelists ranged from the Georgia Department of Community Health and the Grady Health System to the Health Services Research Institute at Georgia State University, to Cisco Systems, Verizon Wireless and the National Health Museum, recently located to Atlanta from its origins in Washington, D.C.
One theme during the day was linking as divergent a state as Georgia, with its mix of rural and urban health systems and infrastructure matched by socioeconomic challenges. David Hartnett, vice president of technology industry expansion for the Metro Atlanta Chamber, advocated a shared service model toward implementation costs for small or rural practices outside of major infrastructure, while panelists agreed there are resources available to expand it.
Recently in Georgia, for example, only 20 of 150 available broadband grants have been funded, meaning untapped means of HIT expansion are available, but to indefinitely sustain a national network “levels of one to three percent of all healthcare spending devoted to IT is not enough,” said Hal Scott, vice president of Information Systems and CIO of MCG Health System, “especially in the face of uncertain declines in reimbursement. There are going to be enormous demands put on the systems through the collection of data. Right now we’re very euphoric about available resources, but what happens when we get what we ask for?”
By 2020, panelists agreed, what will happen is the realization of a shared vision of a healthcare system that knows few boundaries.
Health data exchange, EHR capabilities, meaningful use, sustainability and regional extension centers were just some of the topics that dominated panel discussions during “Vision 2020.” Hosted by the Technology Association of Georgia, panelists from academic, governmental and private industry healthcare pursuits led an audience of approximately 300 through the critical challenges the year 2020 foreshadows.
As a gold sponsor of the event, Greenway’s presence was also on display in program materials and through a sponsor’s reception the night of November 9. Greenway business partner Intel Health was also a sponsor of the event.
Moderated by CNN Senior Medical Correspondent Elizabeth Cohen and Wayne Oliver, vice president of the Center for Health Transformation, itself a strategic legislative partner of Greenway Medical, panelists ranged from the Georgia Department of Community Health and the Grady Health System to the Health Services Research Institute at Georgia State University, to Cisco Systems, Verizon Wireless and the National Health Museum, recently located to Atlanta from its origins in Washington, D.C.
One theme during the day was linking as divergent a state as Georgia, with its mix of rural and urban health systems and infrastructure matched by socioeconomic challenges. David Hartnett, vice president of technology industry expansion for the Metro Atlanta Chamber, advocated a shared service model toward implementation costs for small or rural practices outside of major infrastructure, while panelists agreed there are resources available to expand it.
Recently in Georgia, for example, only 20 of 150 available broadband grants have been funded, meaning untapped means of HIT expansion are available, but to indefinitely sustain a national network “levels of one to three percent of all healthcare spending devoted to IT is not enough,” said Hal Scott, vice president of Information Systems and CIO of MCG Health System, “especially in the face of uncertain declines in reimbursement. There are going to be enormous demands put on the systems through the collection of data. Right now we’re very euphoric about available resources, but what happens when we get what we ask for?”
By 2020, panelists agreed, what will happen is the realization of a shared vision of a healthcare system that knows few boundaries.
Wednesday, August 19, 2009
Thursday, July 23, 2009
Monday, July 6, 2009
Meaningful Use Criteria Comments for Review
Greenway Medical Technologies HITPC Meaningful Use Comments Regarding Inpatient, Ambulatory and Interoperability.
Priority 1: Improve quality, safety, efficiency, and reduce health disparities
Greenway Medical Technologies (Greenway) supports the use of comprehensive EHRs to attain meaningful use (MU) starting in 2011. Initial MU criteria should promote achievable objectives to promote as much adoption as possible.
· 2011 objectives should be based on software and standards that are currently deployed and implemented. Advancement towards 2013 and 2015 objectives will evolve naturally once adoption occurs.
· We support MU criteria based on CCHIT inpatient 2007 functionality including CPOE, clinical decision support and closed-loop medication administration. This approach meets the majority of the 2011 objectives including adoption of CPOE (measured as a percent of all physicians) and electronic medication administration (EMAR) with bar-coding in later years.
Functional objectives beyond this scope should not be considered for implementation in 2011. In order for the appropriate measures to be supported, there must be correlation between objectives, measures and underlying technology to make this possible.
· CPOE use will be aided by EMAR and evidence–based order sets. Selecting a few evidence-based order sets for chronic diseases (e.g., diabetes and cardiovascular disease) for CPOE implementation will support desired outcomes for overall improvement in healthcare delivery.
· Measures as described may require extensive manual data collection from electronic and paper sources to determine percentages. Reporting quality measures must initially be simple, neutral and based on accepted and readily usable standards. Quality reporting will expand with the addition of clinical documentation, incorporation of data sets or applicable standards. Reporting should allow submission of either patient-level data or population-level computed measures so long as the process for such computation is sufficiently specified and validated, and the underlying data comes from EHRs.
· Consideration should be given to the volume of information that will be reported once mandatory programs exist and organizations are able to receive this information. Quality reporting should be tied to MU objectives and outcomes while remaining independent of healthcare reform mandates for pay-for-performance programs.
· In addition to quality reporting, starting in 2011, there should be objective measures to evaluate the use of quality measures for patient care management.
· We support the inclusion in 2011 criteria of the forthcoming HITSP C/106 guidance on the ability for EHRs to consume quality measures in electronic format. This is an important keystone to the required decision support and quality reporting infrastructure.
· The HITSP-recommended Quality Reporting standards support for 2011 is extremely aggressive for the EHR community. The RHQDAPU program is well-established for hospital baseline comparative data with extensive measure definition from reputable clinical groups. Any quality reporting components should be considered relative to established baselines for hospitals and clinical outcome benefits for patients with consideration for ability to electronically gather the data.
Challenges to physician practices in achieving this priority include capturing codified clinical data, reporting quality measures and using data to track clinical conditions and chronic diseases. Greenway recommends reconsideration of requiring competence in all three areas for 2011.
In studying EHR adoption, many have reported low EHR usage among small practices (less than 25%, according to an April 2009 article in The Wall Street Journal, with use of comprehensive ambulatory EHRs is reported between 4% and 13% as cited in a 2008 New England Journal of Medicine article. We believe that the most successful approach to achieving MU, especially for the majority of physicians who practice in small groups, is through deployment of a comprehensive EHR certified to meet all aspects of MU.
· Consideration must be given to specialists vs. family or general practitioners in developing MU criteria relative to this priority.
Another strategy that addresses implementation challenges for practices of all sizes, yet achieves improved healthcare outcomes and system performance through HIT adoption, is to limit the type of reporting required in 2011.
· There is precedent in the existing CMS PQRI program, as well as in the NCQA Medical Home recognition program, to allow practices to select three measures that are “important” to their patient population.
· Based on comments to NeHC by the ACP (June 2, 2009), we support the concept that HIT adoption and MU will be more easily achieved if practices focus initially on the goals of data collection and use of data to care for patients and families rather than broader population health management.
· We further recommend that criteria for reporting be scoped to demonstrated ability to report rather than reaching any particular measurement threshold. Moreover, as part of the foundation-building for quality reporting based on clinical data, we recommend that data from EHRs be used for this reporting rather than billing and claims data.
Two 2011 objectives require clarification in order to avoid ambiguity in terms of interoperability:
· “Send reminders to patients per patient preference for preventive /follow up care [OP, IP]”. Patient preference should not be open-ended regarding technological methods used, but within the technologies available to providers (e.g., phone, mail). If reminders are to be generated from an EHR and if security is required, HITSP-recommended specifications should be used
· “Incorporate lab test results into EHR [OP, IP]”. Is this about results (1) from a lab system in response to orders, or (2) about accessing shared historical lab tests (either in a separate report, or included in a CCD summary)? We suggest the use of option (1) and encourage access of lab results in a CCD for consistency with the sharing results with patients.
For 2011 and 2013, on the interoperability associated with NQF quality measures we suggest alignment on the single set of standards harmonized by HITSP
Priority 2: Engage patients and families
Careful consideration of the differences between patient engagement in ambulatory and inpatient settings is important. Patient preferences for access to personal health information via portals or other electronic means, as well as personal health record (PHR) preferences, may not be generally available in inpatient systems to meet 2011 objectives. Educational resources such as drug information monographs and clinical summaries are available and could be a significant starting point to engage patients.
Patient-centered care delivery requires engagement not only of patients and families, but also of designated caregivers. This can be facilitated through access to patients’ healthcare data as well as educational tools to help manage health status.
· Many ambulatory EHRs today provide patient education materials at the point of care. The “stretch goal” of providing remote electronic access to such resources adds another layer of complexity to physicians’ practices that may not have access to adequate IT resources.
· Our experience with customers is that implementation of patient-centered connectivity is just beginning to be adopted among small and solo practices because of the amount of setup and maintenance required. This should be later in the MU timeline.
Two 2011 objectives require clarification in order to avoid ambiguity in term of interoperability:
· “Provide patients with electronic copy of/or electronic access to clinical information (including lab results, problem list, medication lists, allergies) per patient preference (e.g., through PHR) [OP, IP]”. The information “transport” method or medium requires clarification. Likewise the need to provide “access to clinical information” may be interpreted as a tethered PHR or as a network interfacing to a PHR. Furthermore the statement “per patient preference” implies that every provider would have to support all of the above. It is strongly recommended that sharing with PHRs uses the same transport, standards and terminologies as sharing among disparate EHRs.
· “Provide clinical summaries for patients for each encounter [OP, IP]”. Additional clarity is needed. Is this on paper, in electronic form? Clarity is also needed re content. Is it providing discharge instructions such as for IP, or a visit summary for OP?
Priority 3: Improve care coordination
The medication reconciliation process is still largely manual with many independent workflows often determined by hospital policies and procedures. The availability of an automated, electronic process for medication reconciliation in the inpatient setting will be best accomplished beyond 2011.
· Alignment with the electronic prescribing process, including medication history query, will further automate the process. Exchange of clinical summary information should be evaluated and hospitals should be encouraged to use standards-based data exchange from the outset.
· Interoperability standards for document exchange with a health information exchange (HIE) are best accomplished with a certified HIE using HITSP-recommended standards. There are also opportunities for standards-based exchange among hospitals and their community physicians.
It is also essential to balance the need for accelerated adoption of interoperable, comprehensive EHRs with the need for clinicians and hospitals to implement these in a careful and non-disruptive fashion.
· The requirement to provide patients with access to clinical information via PHRs should draw on both ambulatory and inpatient commercial systems’ abilities to utilize the same protocols for data sharing among disparate EHRs. This would support faster adoption and deployment of either tethered or non-tethered PHRs.
Greenway emphasizes existing HITSP-recommended standards for exchange of information. The underlying best practices reflected in these standards are supported and tested by our industry and adherence to these as national standards is, we believe, critical for all systems.
· Our companies currently participate in several regional HIEs so we can attest to the variety of interfacing standards we must support to meet each HIEs requirements. This is a costly and inefficient way to exchange healthcare information. We ask the Committee to support continued use of HITSP-recommended standards.
Two 2011 objectives require clarification in order to avoid ambiguity in term of interoperability:
· “Exchange key clinical information among providers of care (e.g., problems, medications, allergies, test results) [OP, IP]”. This should be HITSP standards-based information to ensure effective re-use.
· For the measure “% of transitions in care for which summary care record is shared”, we would like to see a baseline percentage (low, 5-10%) with an associated threshold. To account for the ramp-up of connected peers.
When combining the 2013 objective: “Produce and share an electronic summary care record for every transition in care [OP, IP]” and the objective for medication reconciliation for each transition of care, this would imply discrete data import for medications.
Priority 4: Improve population and public health
The process for reporting public health surveillance and receiving alerts will require standards development in order to meet the defined objectives.
· Communication with registries requires consideration of standards and processes involving the exchange of data.
· Reportable lab results are a requirement of laboratories and should not be a MU requirement for inpatient EHRs.
Greenway supports the CDC standard to report immunizations to public health registries; however, we remain concerned about the ability of these registries to accept a dramatic increase in data feeds should this requirement be retained for 2011.
· Issues of volume in reporting already exist. We have already seen how registries were not able to accept the volume of EHR-based PQRI reporting and CMS is still working through these issues with several ambulatory EHR vendors.
· Immunization reporting is another process like quality reporting that requires workflow analyses for successful implementation. Our experience is that such quality-enabling activities can only take place once a practice is comfortable with the new electronic workflow. We recommend that this criterion be tiered for practices that are current EHR users.
Greenway suggests that submitting electronic data to immunization registries be ambulatory-only for 2011 with limited reporting for inpatient systems (e.g., tetanus, hepatitis B on all babies). To achieve this consistently, the HITSP-recommended standards (including HL7V2 transport) should be used.
The objective to receive immunization histories and recommendations from immunization registries should be qualified by “where required and accepted” since not all states may support immunization registries by 2013.
Priority 5- Ensure adequate privacy and security protections for personal health information
Whether any entity is under investigation for HIPAA or security violations should not be considered when evaluating their compliance with MU criteria.
Greenway recommends compliance with privacy requirements that are understandable by consumers and effective. Privacy standards harmonized by HITSP should be leveraged.
Priority 1: Improve quality, safety, efficiency, and reduce health disparities
Greenway Medical Technologies (Greenway) supports the use of comprehensive EHRs to attain meaningful use (MU) starting in 2011. Initial MU criteria should promote achievable objectives to promote as much adoption as possible.
· 2011 objectives should be based on software and standards that are currently deployed and implemented. Advancement towards 2013 and 2015 objectives will evolve naturally once adoption occurs.
· We support MU criteria based on CCHIT inpatient 2007 functionality including CPOE, clinical decision support and closed-loop medication administration. This approach meets the majority of the 2011 objectives including adoption of CPOE (measured as a percent of all physicians) and electronic medication administration (EMAR) with bar-coding in later years.
Functional objectives beyond this scope should not be considered for implementation in 2011. In order for the appropriate measures to be supported, there must be correlation between objectives, measures and underlying technology to make this possible.
· CPOE use will be aided by EMAR and evidence–based order sets. Selecting a few evidence-based order sets for chronic diseases (e.g., diabetes and cardiovascular disease) for CPOE implementation will support desired outcomes for overall improvement in healthcare delivery.
· Measures as described may require extensive manual data collection from electronic and paper sources to determine percentages. Reporting quality measures must initially be simple, neutral and based on accepted and readily usable standards. Quality reporting will expand with the addition of clinical documentation, incorporation of data sets or applicable standards. Reporting should allow submission of either patient-level data or population-level computed measures so long as the process for such computation is sufficiently specified and validated, and the underlying data comes from EHRs.
· Consideration should be given to the volume of information that will be reported once mandatory programs exist and organizations are able to receive this information. Quality reporting should be tied to MU objectives and outcomes while remaining independent of healthcare reform mandates for pay-for-performance programs.
· In addition to quality reporting, starting in 2011, there should be objective measures to evaluate the use of quality measures for patient care management.
· We support the inclusion in 2011 criteria of the forthcoming HITSP C/106 guidance on the ability for EHRs to consume quality measures in electronic format. This is an important keystone to the required decision support and quality reporting infrastructure.
· The HITSP-recommended Quality Reporting standards support for 2011 is extremely aggressive for the EHR community. The RHQDAPU program is well-established for hospital baseline comparative data with extensive measure definition from reputable clinical groups. Any quality reporting components should be considered relative to established baselines for hospitals and clinical outcome benefits for patients with consideration for ability to electronically gather the data.
Challenges to physician practices in achieving this priority include capturing codified clinical data, reporting quality measures and using data to track clinical conditions and chronic diseases. Greenway recommends reconsideration of requiring competence in all three areas for 2011.
In studying EHR adoption, many have reported low EHR usage among small practices (less than 25%, according to an April 2009 article in The Wall Street Journal, with use of comprehensive ambulatory EHRs is reported between 4% and 13% as cited in a 2008 New England Journal of Medicine article. We believe that the most successful approach to achieving MU, especially for the majority of physicians who practice in small groups, is through deployment of a comprehensive EHR certified to meet all aspects of MU.
· Consideration must be given to specialists vs. family or general practitioners in developing MU criteria relative to this priority.
Another strategy that addresses implementation challenges for practices of all sizes, yet achieves improved healthcare outcomes and system performance through HIT adoption, is to limit the type of reporting required in 2011.
· There is precedent in the existing CMS PQRI program, as well as in the NCQA Medical Home recognition program, to allow practices to select three measures that are “important” to their patient population.
· Based on comments to NeHC by the ACP (June 2, 2009), we support the concept that HIT adoption and MU will be more easily achieved if practices focus initially on the goals of data collection and use of data to care for patients and families rather than broader population health management.
· We further recommend that criteria for reporting be scoped to demonstrated ability to report rather than reaching any particular measurement threshold. Moreover, as part of the foundation-building for quality reporting based on clinical data, we recommend that data from EHRs be used for this reporting rather than billing and claims data.
Two 2011 objectives require clarification in order to avoid ambiguity in terms of interoperability:
· “Send reminders to patients per patient preference for preventive /follow up care [OP, IP]”. Patient preference should not be open-ended regarding technological methods used, but within the technologies available to providers (e.g., phone, mail). If reminders are to be generated from an EHR and if security is required, HITSP-recommended specifications should be used
· “Incorporate lab test results into EHR [OP, IP]”. Is this about results (1) from a lab system in response to orders, or (2) about accessing shared historical lab tests (either in a separate report, or included in a CCD summary)? We suggest the use of option (1) and encourage access of lab results in a CCD for consistency with the sharing results with patients.
For 2011 and 2013, on the interoperability associated with NQF quality measures we suggest alignment on the single set of standards harmonized by HITSP
Priority 2: Engage patients and families
Careful consideration of the differences between patient engagement in ambulatory and inpatient settings is important. Patient preferences for access to personal health information via portals or other electronic means, as well as personal health record (PHR) preferences, may not be generally available in inpatient systems to meet 2011 objectives. Educational resources such as drug information monographs and clinical summaries are available and could be a significant starting point to engage patients.
Patient-centered care delivery requires engagement not only of patients and families, but also of designated caregivers. This can be facilitated through access to patients’ healthcare data as well as educational tools to help manage health status.
· Many ambulatory EHRs today provide patient education materials at the point of care. The “stretch goal” of providing remote electronic access to such resources adds another layer of complexity to physicians’ practices that may not have access to adequate IT resources.
· Our experience with customers is that implementation of patient-centered connectivity is just beginning to be adopted among small and solo practices because of the amount of setup and maintenance required. This should be later in the MU timeline.
Two 2011 objectives require clarification in order to avoid ambiguity in term of interoperability:
· “Provide patients with electronic copy of/or electronic access to clinical information (including lab results, problem list, medication lists, allergies) per patient preference (e.g., through PHR) [OP, IP]”. The information “transport” method or medium requires clarification. Likewise the need to provide “access to clinical information” may be interpreted as a tethered PHR or as a network interfacing to a PHR. Furthermore the statement “per patient preference” implies that every provider would have to support all of the above. It is strongly recommended that sharing with PHRs uses the same transport, standards and terminologies as sharing among disparate EHRs.
· “Provide clinical summaries for patients for each encounter [OP, IP]”. Additional clarity is needed. Is this on paper, in electronic form? Clarity is also needed re content. Is it providing discharge instructions such as for IP, or a visit summary for OP?
Priority 3: Improve care coordination
The medication reconciliation process is still largely manual with many independent workflows often determined by hospital policies and procedures. The availability of an automated, electronic process for medication reconciliation in the inpatient setting will be best accomplished beyond 2011.
· Alignment with the electronic prescribing process, including medication history query, will further automate the process. Exchange of clinical summary information should be evaluated and hospitals should be encouraged to use standards-based data exchange from the outset.
· Interoperability standards for document exchange with a health information exchange (HIE) are best accomplished with a certified HIE using HITSP-recommended standards. There are also opportunities for standards-based exchange among hospitals and their community physicians.
It is also essential to balance the need for accelerated adoption of interoperable, comprehensive EHRs with the need for clinicians and hospitals to implement these in a careful and non-disruptive fashion.
· The requirement to provide patients with access to clinical information via PHRs should draw on both ambulatory and inpatient commercial systems’ abilities to utilize the same protocols for data sharing among disparate EHRs. This would support faster adoption and deployment of either tethered or non-tethered PHRs.
Greenway emphasizes existing HITSP-recommended standards for exchange of information. The underlying best practices reflected in these standards are supported and tested by our industry and adherence to these as national standards is, we believe, critical for all systems.
· Our companies currently participate in several regional HIEs so we can attest to the variety of interfacing standards we must support to meet each HIEs requirements. This is a costly and inefficient way to exchange healthcare information. We ask the Committee to support continued use of HITSP-recommended standards.
Two 2011 objectives require clarification in order to avoid ambiguity in term of interoperability:
· “Exchange key clinical information among providers of care (e.g., problems, medications, allergies, test results) [OP, IP]”. This should be HITSP standards-based information to ensure effective re-use.
· For the measure “% of transitions in care for which summary care record is shared”, we would like to see a baseline percentage (low, 5-10%) with an associated threshold. To account for the ramp-up of connected peers.
When combining the 2013 objective: “Produce and share an electronic summary care record for every transition in care [OP, IP]” and the objective for medication reconciliation for each transition of care, this would imply discrete data import for medications.
Priority 4: Improve population and public health
The process for reporting public health surveillance and receiving alerts will require standards development in order to meet the defined objectives.
· Communication with registries requires consideration of standards and processes involving the exchange of data.
· Reportable lab results are a requirement of laboratories and should not be a MU requirement for inpatient EHRs.
Greenway supports the CDC standard to report immunizations to public health registries; however, we remain concerned about the ability of these registries to accept a dramatic increase in data feeds should this requirement be retained for 2011.
· Issues of volume in reporting already exist. We have already seen how registries were not able to accept the volume of EHR-based PQRI reporting and CMS is still working through these issues with several ambulatory EHR vendors.
· Immunization reporting is another process like quality reporting that requires workflow analyses for successful implementation. Our experience is that such quality-enabling activities can only take place once a practice is comfortable with the new electronic workflow. We recommend that this criterion be tiered for practices that are current EHR users.
Greenway suggests that submitting electronic data to immunization registries be ambulatory-only for 2011 with limited reporting for inpatient systems (e.g., tetanus, hepatitis B on all babies). To achieve this consistently, the HITSP-recommended standards (including HL7V2 transport) should be used.
The objective to receive immunization histories and recommendations from immunization registries should be qualified by “where required and accepted” since not all states may support immunization registries by 2013.
Priority 5- Ensure adequate privacy and security protections for personal health information
Whether any entity is under investigation for HIPAA or security violations should not be considered when evaluating their compliance with MU criteria.
Greenway recommends compliance with privacy requirements that are understandable by consumers and effective. Privacy standards harmonized by HITSP should be leveraged.
Monday, June 1, 2009
HIMSS Electronic Health Record Association on “Meaningful Use” of Certified EHRs
The Electronic Health Records Association (EHR Association) seeks broad stakeholder consensus on the American Recovery and Reinvestment Act of 2009 (ARRA) as well as specific recommendations for the definition of “meaningful use” of certified EHRs, which will be used to determine eligibility for the over $36B in healthcare IT stimulus incentives for physicians and hospitals.
“I’ve been pleased to have the opportunities to speak and collaborate on behalf of the Association with healthcare executives and clinicians around the country on the ARRA term “meaningful use” of certified EHRs,” said Justin Barnes, EHR Association Chairman. “I believe that our unique, collective experience as developers, implementers and providers of EHRs is being recognized as we strive to strike the right balance between practical application of these comprehensive EHR solutions and real results that support more effective, efficient care delivery.”
http://www.himssehra.org/docs/20090520_EHRA_meaningfulUsePR.pdf
“I’ve been pleased to have the opportunities to speak and collaborate on behalf of the Association with healthcare executives and clinicians around the country on the ARRA term “meaningful use” of certified EHRs,” said Justin Barnes, EHR Association Chairman. “I believe that our unique, collective experience as developers, implementers and providers of EHRs is being recognized as we strive to strike the right balance between practical application of these comprehensive EHR solutions and real results that support more effective, efficient care delivery.”
http://www.himssehra.org/docs/20090520_EHRA_meaningfulUsePR.pdf
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