State of the Industry

Putting the “Me” in Meaningful Use

By Judy Murphy, RN, FACMI, FHIMSS

It is hard to pick up a healthcare magazine or attend a healthcare conference today without hearing about meaningful use and the federal incentives for clinician adoption of electronic health records (EHRs) with the passage of the American Recovery and Reinvestment Act (ARRA) and its key Health Information Technology for Economic and Clinical Health Act (HITECH) in early 2009. Many healthcare organizations are scrambling to select, implement, enhance or measure the care impact of EHRs in order to achieve the meaningful use criteria and qualify for the CMS incentive payments.

At the core of the new reform initiatives, the incentivized adoption of EHRs will improve care quality and better manage care costs, meeting clinical and business needs by capturing, storing, and displaying clinical information when and where it is needed to improve individual patient care and to provide aggregated, cross-patient data analysis.  EHRs will manage healthcare data and information in ways that are patient-centered and information-rich. Improved information access and availability will increasingly enable both the provider and the patient to better manage each patient’s health by using capabilities provided by enhanced clinical decision support and customized education materials.

But what about the “me” in meaningful use? What is the impact to clinicians, and what can clinicians expect to get out of this major transformation of the healthcare industry?  Two significant facts come to mind when considering the relationship of meaningful use to clinicians: first, EHR implementation is the enabler for the necessary clinical practice changes needed for healthcare reform; and, second, the transportability and interoperability of EHRs will finally create a truly patient-centric record.

EHR as Enabler for Clinical Practice Change
In the implementations of information systems for nurses and physicians, the importance of planning and executing the project as a practice change that is being facilitated by technology can never be over-emphasized. The technology change needs to take a supportive role to the people/process/practice change being enabled by the technology.  Thus, it is important to ensure EHR implementation is seen as the means to an end, and not as an end unto itself. It is not about the EHR implementation, but is about the way the clinicians’ practice changes through the use of the technology. This leads directly into ensuring there is clarity around the purpose of the EHR, as demonstrated by the meaningful use objectives and quality outcome measures.

David Blumenthal, MD, national coordinator of health IT, emphasized this point during the National HIPAA Summit in Washington, DC on Sept. 16, 2009, when he said “Health IT is the means, but not the end. Getting an EHR up and running in healthcare is not the main objective behind the incentives provided by the federal government under ARRA. Improving health is. Promoting healthcare reform is.”

EHR Facilitates a Patient-Centric Record
A second point is the clear focus on the patient and patient-centered care. The currently-proposed meaningful use criteria highlight this focus in several ways: patient participation with a personal health record (PHR), interoperability and portability of electronic records, customizing the delivery of information to the patient, improving care coordination, improving population and public health; and reducing disparities. 

Being able to share and compare data between healthcare organizations and across time is the right thing to do for patients – both for the individual patient’s quality of care and for the secondary use of analyzing the data across patients to study the efficacy of clinical practice and how it contributes to patient outcomes.

As the final meaningful use criteria come out this month and the EHR implementation work consumes the lives of IT staff and clinical staff, it will be important to remember the “me” in meaningful use and keep in mind why we are doing what we’re doing.  This is not about the technology. It is about the clinical practice change and it is about the patient care impact.

Judy Murphy, RN, FACMI, FHIMSS, is vice president of information services at Aurora Health Care in Milwaukee, Wis.; a member of the HIMSS Board of Directors; and a member of the federal Health IT Standards Committee.

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A Clinician’s Perspective on Meaningful Use

Jon Feeney, MD, Colorado Mountain Medical

Dr. Feeney is the president and one of 24 primary care physicians, specialists and other practitioners at Colorado Mountain Medical (Eagle County, Colo.). He has extensive experience taking care of an assortment of healthcare issues—from the very young to mature adults, including women's health issues. Dr. Feeney has a special interest in multiple sclerosis and is the medical director of the Heuga Center for the Physically Challenged. He is certified in Basic Life Support and Advanced Cardiac Life Support. He is a member of the American Academy of Family Physicians and the Colorado Medical Society. Clinical Informatics Insights recently spoke with Dr. Feeney to get his perspective on meaningful use.

Where is your facility on the track to implementing meaningful use?
We are currently grappling with “what constitutes meaningful use and meaningful technology?” We have had an EHR since 1998 and we see 40,000-plus patients a year; so, we have a lot of electronic data stored. Our current EHR will not meet meaningful use criteria primarily because it does not include e-prescribing and, therefore, we need to update our EHR. We assessed upgrading our current EHR versus transitioning to a new EHR (the hospital wanted us to transition to its EHR vendor); however, in the end, we decided to upgrade our current EHR. The hospital’s vendor couldn’t transfer any of our old data to the new EHR: It could only provide PDFs of patients’ data, which is useless for providers. It would be like sifting through a big stack of papers to find a piece of data—a complete waste of time. Our current vendor guaranteed we will meet the meaningful use criteria once the upgrade is complete. We, surely like many other providers, are heavily relying on vendors to help us understand the meaningful criteria and ensure the EHR meets the criteria.

What’s the biggest hurdle to implementing meaningful technology?
It boils down to a combination of money (what it costs), the time it takes to implement it and a sense of faith. Every American knows where our economy is right now; who’s to say Congress won’t be able to afford it and not pay? Hopefully it will. A multi-specialty practice, like ours, is fortunate because an upgrade isn’t as expensive as starting from scratch. It would cost a practice like ours about $500,000 to start from scratch. That is a lot of money to front on the faith the government is going to pay you back. If you look at the actual dollars, a practice won’t get all $500,000 back. It may get half of it back. We are fortunate we already have an EHR; so, we should get the money we are putting in for the upgrade back. Although, it doesn’t include the $750,000 we spent to get to where we already are today.

Another problem is we feel like we are spending money on an Olympic sprinter but in reality we get a running toddler. The technology is just not there yet. It isn’t fast enough, it isn’t facile enough, and it isn’t flexible enough. The reality of technology hasn’t caught up to promise of the technology and the costs are horrendous. One of my partners said, “Here I sit broken hearted. I wanted to see patients but all I did was charted.” Another colleague who I trained said, “You know what we had before we had EHRs? We had weekends.” She said this while we were both sitting in front of computers on a Sunday afternoon working on charts from the previous week. To say we are faster or it is easier is not true. Providers have become transcriptionists. EHRs don’t necessarily make patient care any easier or better.

What sort of impact do you foresee the implementation of meaningful technology at your facility will have on patient care?
Our hope is the new EHR is significantly better than our five-year-old technology. And it looks like that will be the case as illustrated in a demonstration; however, a demonstration is very different than real life. And if all goes well it will be faster and better. I think the new EHR will result in better care for patients because the data is consolidated (it is in one place); data has tabs to find it easily, and so on. Hopefully the new technology will also help us maintain quality service but reduce the intensive charting workload for providers. Additionally, I am very much excited about the e-prescribing, which will eliminate a lot of duplicated work (i.e., lost prescriptions and/or requests for refills).

If you could have one question answered by the ONC, in relation to, meaningful use and/or certification criteria what would it be?
Make it easy and don’t make too many rules or paper work. There are so many rules and paper work out there today. The KISS (Keep It Simple Stupid) principle needs to be there number one priority.

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Strategies for Success

Meeting Meaningful Use and User Compliance

By Rene Jackson, RN

Has your organization begun analyzing and assessing the projects needed to meet meaningful use? While you surely have or will identify many technology projects, you are not finished until the human factors of meaningful use are considered. Implementation of software is more than turning on some new functionality; it is looking at how users are performing and how compliant they are with the use of the systems.

The University of Illinois Medical Center performed a meaningful use gap analysis with just that in mind. We reviewed the objectives and measures for meeting proposed meaningful use Stage 1 requirements, and placed them into three categories: “fully implemented,” “implemented but need to consider compliance” and “not implemented.”

As the information systems training and development team coordinator, my focus is to understand and analyze “implemented but need to consider compliance.” As an example, our EMR was built to support the entry of data but we have struggled with getting providers to understand the value and importance of entering the data. We have identified a project for compliance of EMR entry with a focus on the following items:

• Maintain an active medication allergy list,
• Maintain an up-to-date problem list,
• Record smoking status for patients 13 years old and older,
• Maintain an active medication list
• Enter a note for each encounter. *Note, a lesson learned was the lack of an adequate definition for encounter.

One of the objectives for meeting meaningful use of an EMR Stage 1 is to maintain an active medication allergy list.¹ Our EMR utilizes decision support to force the entry of allergy information for hospitalized and emergency department patients with a 100 percent adoption rate. However, we are not able to accurately capture this information in our ambulatory facilities due to many variables including workflow (e.g. prescription refills without contact with patients). Additionally, the following variables need to be measured and understood: Do we really know the current state—who, when and how allergy information is obtained and documented? Do we create reports to identify patients seen with and without entry of allergy information? How should we define the numerator and denominator? Do we need to modify our current policies that state the clinicians have until a specific visit to document this information along with other yet to be decided core elements to the EMR? If they are not prescribing medications, do they really need allergy information at this visit? As you can see, these unforeseen variables can become quite overwhelming. 

The next step will be to form a Project Steering Committee and a User Task Force to assist in workflow assessment, future state of workflow, development of report specifications, and an analysis of any institution policies (with modification and development as needed). We believe strong leadership and education are required to ensure data is captured electronically in a timely fashion. 

Reference

1. Meaningful Use Proposed Rules. Federal Register. Wednesday, Jan. 13, 2010; Vol. 75, No. 8.

Rene Jackson, RN, is the information systems training and development team coordinator at the University of Illinois Medical Center. She has worked there for over 25 years—working her way up the professional development ladder from clinical nurse to administrative nurse to assistant director of nursing to clinical analyst/project lead/project management for meds process.

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Resource in Practice

Regional Extension Centers – A New Partner in EHR Adoption and Meaningful Use

By David Groves, MBA

It’s summer and the rich green fields of the Ohio Valley remind me of my father’s beautiful and productive gardens from my childhood. At this time of year, our dinner table was always brimming with fresh vegetables and corn. One of the resources my father frequently called on was the county agricultural extension office. It provided farmers and family gardeners the best science-based advice available on all agricultural and horticultural issues. Forty years later it still does and, in fact, the US Agricultural Extension has been improving the productivity of farming for nearly 100 years by bringing science to farmers and rural families.

This concept of extension has now been introduced to our world of health IT. Since February, the Department of Health and Human Services (HHS) has awarded competitive grants to 60 organizations nationwide to establish Regional Extension Centers (RECs) for health IT. Each has a principal mission of supporting priority primary care providers (PPCPs) in the selection, implementation and meaningful use of EHR systems in their practices. While the final standards for meaningful use are yet to be released by HHS, the bar is high and will require not just the use of an EHR system within the practice but also the ability to report on quality and exchange clinical information with providers outside the practice as well as with immunization registries and public health agencies.

RECs will provide significant new services and capacity to the health IT landscape and, with federal subsidies over the next two years, will be equipped to focus on parts of our provider market often overlooked and underserved by EHR vendors and traditional commercial consulting firms; rural, independent and small provider group practices. A HealthBridge survey of providers in the 69 Ohio, Indiana and Kentucky counties surrounding Cincinnati indicates as few as 6 percent of these providers have adopted EHR systems. The Tri-State Regional Extension Center has set a goal of assisting over 1,700 or 60 percent of primary care providers in the region to adopt EHR systems and achieve meaningful use by 2012.

RECs will provide a range of market-driven services and, with facilitation by the Office of the National Coordinator (ONC) and the Health IT Research Center (HITRC), will continuously share best practices and lessons learned across regions. Most RECs will provide EHR selection support, EHR group purchasing discounts for a panel of selected EHR solutions, EHR project planning and project management, meaningful use consultation, HIE connectivity and integration services, and quality reporting support. Additionally, RECs will frequently offer education and training on topics of meaningful use incentive programs, privacy and security practices, e-prescribing, clinical documentation and coding, clinical decision support, practice workflow, quality metrics and more.

Core benefits of engaging the REC in an EHR adoption effort should be a reduction of risk of project failure, shortening of the schedule to achieve EHR implementation and meaningful use, and reduction of the total investment cost by making use of the federal subsidy granted to RECs for providing services. Through group purchasing and preferred vendor relationships RECs will be able to establish stronger vendor accountability and cooperation than might be possible by a small provider practice alone. RECs will work closely and collaboratively with vendors and in doing so will extend the vendors’ reach and capacity in a time of significantly compressed demand. As my father would say, “it’s a tough row to hoe” but providers can be successful and the REC is there to help.

David Groves, MBA, is a health informaticist and executive director of the HealthBridge Tri-State Regional Extension Center serving a tri-state area that includes Southwest Ohio, Northern Kentucky and Southern Indiana. View the HealthBridge Tri-State Regional Extension Center Fact Sheet.

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HIMSS News

HIMSS Announces New Board of Directors and Call for Nominations

Heading up the HIMSS Board of Directors, four officers and four board members began their newly appointed posts earlier this month. Of note, the board now includes several representatives from the clinician perspective. Learn more.

Nominations are now being accepted for positions on the HIMSS Board of Directors and the Nominating Committee. Nominees must be a Regular or Life Member or the senior executive representative of an Organizational Member who has achieved and maintained advanced membership status. Nominations must be received by Aug. 1. Please send all nominations and questions to H. Stephen Lieber, President/CEO, HIMSS, 230 East Ohio Street, Suite 500, Chicago, IL 60611-3269.

HHS Awards $96 Million to Train Health Professionals

HHS Secretary Kathleen Sebelius recently announced the awarding of $96 million in grants to increase diversity in the health professions workforce and encourage nurses to choose careers as nurse educators. The grants will go to schools to give scholarships to students from disadvantaged backgrounds with financial need--many  of whom are underrepresented minorities. Funds will also provide low-interest loans to nurse faculty students—students who want to teach nursing—as incentive for nurses to select careers as nurse educators. Of these funds, $27 million is part of the $200 million appropriated to HHS' Health Resources and Services Administration (HRSA) under the American Recovery and Reinvestment Act of 2009 to build the nation's health care workforce.

"The health professions workforce in the United States does not reflect the population it serves," said Secretary Sebelius. "These funds will help support the education of disadvantaged students who are more likely to go on to serve in underserved areas, and will expand the training of nurse faculty in exchange for their service." Get more information on ARRA funding for health professions.

HHS Announces Notice of Proposed Rule Making to Modify Privacy Rule of HIPAA

The Health and Human Services (HHS) Office of Civil Rights (OCR) has released a new Notice of Proposed Rulemaking (NPRM) designed to significantly modify the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy, Security and Enforcement rules. In addition, it provides resources to strengthen the privacy of health information and to help Americans understand their rights and services available to safeguard their personal health information. In a press conference HHS hosted on Thursday, July 8, National Coordinator David Blumenthal stated, “Today we begin to make real the terms ‘private and secure’” for exchange of health information.

The Society will be developing analysis of the final rule, which will be posted at www.himss.org/economicstimulus, HIMSS offers many tools within the Privacy & Security Topic Area, including the highly rated Privacy & Security Toolkit.

OCR also announced the launch of a redesigned Health Information Brief Notification website. The site, which the American Reinvestment and Recovery Act (ARRA) mandated must display public information on any breaches of healthcare information, has been redesigned to provide better search capabilities and better transparency, according to Georgina Verdugo, director, OCR.

Stay Up to Date with Latest Changes on Meaningful Use

As of July 9, 2010 the Centers for Medicare and Medicaid Services (CMS) has moved one step closer to releasing a final rule for The Electronic Health Record Incentive Program (Meaningful Use) when they submitted the final rule for review to the Office of Management and Budget (OMB). When the final rule is published in the Federal Register, the Soceity will update membership and provide the latest analysis on the HIMSS Meaningful Use website. Also, be sure to subscribe to the HIMSS Health IT Policy Update, which is packed with detailed analysis of the latest news surrounding the economic recovery bill; healthcare reform; initiatives and announcements from federal departments; and the Society’s role in transforming the healthcare industry.

 

 

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Tool Box Picks

Office of the National Coordinator for Health IT Meaningful Use Website
Learn more about the Notice of Proposed Rulemaking (NPRM) to implement provisions of the Recovery Act that provide incentive payments for the meaningful use of certified EHR technology. Access CMS fact sheets and other meaningful use documents from ONC, CMS, NCVHS, and HIT Standards and Policy Committees.

HITECH Programs
Check out the HITECH Programs to assist and provide technical support to providers, enable coordination and alignment within and among states, establish connectivity to the public health community in case of emergencies, and assure the workforce is properly trained and equipped to be meaningful users of EHRs.

HIMSS Meaningful Use Website
Visit this website for the latest updates and analysis of all aspects of healthcare reform—including ARRA, meaningful use, certification requirements and more. Valuable resources include an Overview of EHR Incentives; Meaningful Use Stage 1 Hospital Self Assessment; Hospital Meaningful Use Eligibility Criteria; HIMSS Synopsis on Meaningful Use, Standards and Certification Criteria; and HIMSS Analysis of American Recovery and Reinvestment Act.

HIMSS ARRA Webinar Series on Meaningful Use and Certification Criteria
Start the journey for achieving meaningful use with the most up-to-date information. Archived webinars cover health IT workforce development initiatives, latest privacy and security developments, Medicare and Medicaid payments, quality metrics requirements, and more.

HITECH Act Resource Guide and HITECH Act Toolkit
Developed by the American Health Lawyers Association, this new publication is an in-depth guide and toolkit to the HITECH Act. This resource contains in-depth analysis, practice tips and a large collection of sample tools, including policies, procedures and notices to facilitate compliance with this new law.

HIMSS10 Keynote with Dr. Blumenthal
On March 10, 2010David Blumenthal, MD, National Coordinator for Health IT, surprised a packed hall of attendees Tuesday afternoon at HIMSS10 with the release of the notice of proposed rulemaking on certification. Watch his speech on YouTube.

Join the Discussion

Check out these discussions on the HIMSS Group on LinkedIn; you have to be a member of the group to comment and read the discussions.

Top 10 reasons why your EMR/EHR implementation is successful

Where is your facility on the track to implementing “meaningful use”?

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