EMR & EHR Blog for Physicians

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I cam across an interesting article on a very important topic that is very relevant in the light of recent discussion and legislation on 'meaningful use' of Electronic Medical Records (aka Electronic Health Records).

It was a survey that involved sixty respondents, including 52 physicians or staff from 26 practices with commercial ambulatory care EMRs in place for at least 2 years, chief medical officers at four EMR vendors, and four national thought leaders. There were 6 major findings:

1. EMRs facilitate within-office care coordination, chiefly by providing access to data during patient encounters and through electronic messaging;
2. EMRs are less able to support coordination between clinicians and settings, in part due to their design and a lack of standardization of key data elements required for information exchange;
3. Managing information overflow from EMRs is a challenge for clinicians;
4. Clinicians believe current EMRs cannot adequately capture the medical decision-making process and future care plans to support coordination;
5. Realizing EMRs' potential for facilitating coordination requires evolution of practice operational processes;
6. Current fee-for-service reimbursement encourages EMR use for documentation of billable events (office visits, procedures) and not of care coordination (which is not a billable activity).

The third goal of 'meaningful use' focuses on improving care coordination by enabling exchange of meaningful clinical information among professional health care team by requiring the EHR to possess the following capabilities and functions:

1. Capability to exchange key clinical information (for example, problem list, medication list, allergies, and diagnostic test results), among providers of care and patient authorized entities electronically.
2. Perform medication reconciliation at relevant encounters and each transition of care.
3. Provide summary care record for each transition of care or referral.

Given the survey findings listed in the earlier part of this blog, I am personally skeptical how many of the current versions of EHR Software solutions can pass the three capability tests (as above). The jury is out and we will better know which EMR / EHR Solutions will effectively meet the goal as far as co-ordination of care is concerned in the next few months.

If any EMR / EHR vendors or current users of EMR / EHR solutions would like to share their understanding, knowledge or perspective on this topic, please feel free to leave a comment.

We will continue exploring different aspects of 'meaningful use' over the next several weeks.

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RevenueXL Inc. assists medical practices in the assessment, selection and implementation of Medical Software including EMR Software (also called EHR Software), Patient Portal, and Practice Management or Medical Billing software. RevenueXL offers a free consultation session to review your current challenges and answer open questions revolving around EMR and revenue cycle.

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Now that the HHS has issued two sets of long-awaited and much-anticipated federal regulations on list of "meaningful use" criteria that healthcare providers must meet to qualify for federal IT subsidies and the standards and certification criteria that those EHRs must meet for their users to receive the EMR incentives, one is left wondering what is the real value of CCHIT certification and do those EMR vendors who went in for CCHIT certification and spent over $40000 each for the certification without waiting for the meaningful use get any headstart?

Here is a summary of an article that was published by Modern Healthcare today:

CCHIT may have had close ties to HHS in the past but that is history. David Blumenthal, the current head of the ONC, in a meeting was responding to a question about existing CCHIT certifications of Electronic Health Records and HHS' prior recognition of CCHIT as a certifying body.

Blumenthal mentioned that to qualify to receive incentive payments, the EHR would have to be certified by a body certified by the Office of the National Coordinator and that ONC is working towards creating a process to recognize that body.
Blumenthal mentioned that even though CCHIT was recognized in the past as a certifying body, its future status will be governed by the regulatory process that is ongoing right now. He termed as premature the talk about the implications of any particular set of certification criteria that CCHIT or anybody else has put forward or will put forward.

Mark Segal, Vice Chairman of the Electronic Health Record Association of HIMSS said the stimulus law, gives the ONC the authority to go ahead and retroactively accept any EHR systems certified under the old CCHIT process as certified under the new stimulus law provisions.

The ONC rule-makers explained the rationale behind this decision to scrap the previously accepted certification criteria and process. HHS, they wrote, decided not to accept CCHIT certification criteria due to "our approach of aligning adopted certification criteria with the proposed definition of meaningful use."

Segal said there still are "a reasonable expectation that CCHIT will be one of those" organizations that will again be recognized by the ONC. He also mentioned that CCHIT certification criteria come quite close to matching those new criteria being developed by the ONC. As a result, if an EHR is already certified up until now means it already has a lot of the functionality in place.

I do believe that the EMR Vendors who spent the time and financial resources in advance of the recent formal release of regulations, they are at an advantage as compared to a large number of vendors who do not have any certification, whatsoever. A number of smaller EMR vendors got certified in 2006, but as the competition is heating up, are already on the way to getting their EHR certified under the CCHIT 2011 Certification Program.

As I have earlier mentioned in another blog of mine, just because a Physician implements a Certified EMR does not mean that it is used in a meaningful manner, one of the EHR selection criteria must therefore include the ease with which the EHR allows demonstration of meaningful use to CMS.

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RevenueXL Inc. assists medical practices in the assessment, selection and implementation of Medical Software including EMR Software (also called EHR Software), Patient Portal, and Practice Management or Medical Billing software. RevenueXL offers a free consultation session to review your current challenges and answer open questions revolving around EMR and revenue cycle.

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1. List of "meaningful use" criteria that healthcare providers must meet to qualify for federal IT subsidies based on how they use their electronic health records. 
2. The standards and certification criteria that those EHRs must meet for their users to collect the money.

Phased Approach to Meaningful Use

What has been proposed is a phased approach that encompasses reasonable criteria for meaningful use based on currently available technology capabilities and provider practice experience, and builds up to a more robust definition of meaningful use, based on anticipated technology and capabilities development.

Under this phased approach to meaningful use, the criteria of meaningful use would get updated through future rulemaking. The initial meaningful use criteria have been referred to as "Stage 1."

(Stage 2 criteria are expected to be proposed by the end of 2011 and the Stage 3 definition may be proposed by the end of 2013.)

Stage 1 Meaningful Use Criteria

The Stage 1 meaningful use criteria focuses on electronically capturing health information in a coded format; using that information to track key clinical conditions and communicating that information for care coordination purposes (whether that information is structured or unstructured, but in structured format whenever feasible); consistent with other provisions of Medicare and Medicaid law, implementing clinical decision support tools to facilitate disease and medication management; and reporting clinical quality measures and public health information.

Stage 2 and Stage 3 Meaningful Use Criteria

Stage 2 meaningful use criteria shall expand upon the Stage 1 criteria to encourage the use of health IT for continuous quality improvement at the point of care and the exchange of information in the most structured format possible, such as the electronic transmission of orders entered using computerized provider order entry (CPOE) and the electronic transmission of diagnostic test results (such as blood tests, microbiology, urinalysis, pathology tests, radiology, cardiac imaging, nuclear medicine tests, pulmonary function tests and other such data needed to diagnose and treat disease).

Stage 3 meaningful use criteria shall focus on promoting improvements in quality, safety and efficiency, focusing on decision support for national high priority conditions, patient access to self management tools, access to comprehensive patient data and improving population health.

Stage 1 Meaningful Use Defined in Detail

Goal 1: To further the care goal of improving quality, safety, efficiency and reducing health disparities.

1. Use CPOE (which entails the provider's use of computer assistance to directly enter medical orders (for example, medications, consultations with other providers, laboratory services, imaging studies, and other auxiliary services) from a computer or mobile device. The order is also documented or captured in a digital, structured, and computable format for use in improving safety and organization. For Stage 1 criteria, it will not include the electronic transmittal of that order to the pharmacy, laboratory, or diagnostic imaging center)
2. Implement drug-drug, drug-allergy, drug-formulary checks.
3. Maintain an up-to-date problem list of current and active diagnoses based on ICD-9-CM or SNOMED CT®. It also includes past diagnoses relevant to the current care of the patient.
4. Generate and transmit permissible prescriptions electronically (eRx).
5. Maintain active medication list.
6. Maintain active medication allergy list.
7. Record the following demographics: preferred language, insurance type, gender, race and ethnicity, and date of birth.
8. Record and chart changes in the following vital signs: height, weight and blood pressure and calculate and display body mass index (BMI) for ages 2 and over; plot and display growth charts for children 2 - 20 years, including BMI.
9. Record smoking status for patients 13 years old or older.
10. Incorporate clinical lab-test results into EHR as structured data.
11. Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, and outreach.
12. Report ambulatory quality measures to CMS (or, for EPs seeking the Medicaid incentive payment, the States).
13. Send reminders to patients per patient preference for preventive/follow-up care. Patient preference refers to the patient's choice of delivery method between internet based delivery or delivery not requiring internet access.
14. Implement five clinical decision support rules relevant to specialty or high clinical priority, including for diagnostic test ordering, along with the ability to track compliance with those rules.
15. Check insurance eligibility electronically from public and private payers.
16. 16. Submit claims electronically to public and private payers.

Goal 2: Provide patients and families with timely access to data, knowledge, and tools to make informed decisions and to manage their health

1. Provide patients with an electronic copy of their health information (including diagnostics test results, problem list, medication lists, allergies) upon request. Electronic copies may be provided through a number of secure electronic methods (for example, personal health record (PHR), patient portal, CD, USB drive).
2. Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, allergies) within 96 hours of the information being available to the EP. Electronic access may be provided by a number of secure electronic methods (for example, PHR, patient portal, CD, USB drive). Timely is defined as within 96 hours of the information being available to the EP either through the receipt of final lab results or a patient interaction that updates the EP's knowledge of the patient's health. 
3. Provide clinical summaries for patients for each office visit.

Goal 3: To improve care coordination by enabling exchange of meaningful clinical information among professional health care team.

1. Capability to exchange key clinical information (for example, problem list, medication list, allergies, and diagnostic test results), among providers of care and patient authorized entities electronically.
2. Perform medication reconciliation at relevant encounters and each transition of care.
3. Provide summary care record for each transition of care or referral.

Goal 4: To improve population and public health by having the patient's health care team communicate with public health agencies.

1. Capability to submit electronic data to immunization registries and actual submission where possible and accepted.
2. Capability to provide electronic syndromic surveillance data to public health agencies and actual transmission according to applicable law and practice.

Goal 5: To ensure adequate privacy and security protections for confidential information through operating policies, procedures, and technologies and compliance with applicable law and provide transparency of data sharing to patient.

1. Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities.

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RevenueXL Inc. assists medical practices in the assessment, selection and implementation of Medical Software including EMR Software (also called EHR Software), Patient Portal, and Practice Management or Medical Billing software. RevenueXL offers a free consultation session to review your current challenges and answer open questions revolving around EMR and revenue cycle.

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Electronic Health Records - Meaningful use is phased out

The definition of ‘Meaningful use of Electronic Health Records' has undergone a vast change since it was first mooted. With 2011 fast approaching, the authorities have obviously found it hard to reconcile the views of different parties - legislators, vendors, physicians and consultants. So what are the authorities doing? Phasing out the requirements and getting started with basic criteria to be met for satisfying meaningful use paradigm.

According to David Hunt, M.D., Chief Medical Officer in the Office of the National Coordinator for Health Information Technology (ONCHIT), the federal government now intends to implement a basic level of initial 2011 criteria for meaningful use of electronic health records systems to determine who will receive Medicare and Medicaid incentives under the American Recovery and Reinvestment Act (ARRA).

The government's meaningful use definition will probably focus on goals that hospitals and physicians can achieve quickly and reasonably. Thus, the Centers for Medicare and Medicaid Services will primarily be seeking evidence in 2011 that providers have purchased and are using EHRs. This may simply mean that you have to be able to send data and CMS has to be able to receive it.

Meaningful use of EHR to get tougher in 2013

The meaningful use criteria are expected to get progressively tougher in 2013 and 2015. The current thinking is to spread the meaningful use criteria for EHRs over three major phases: 2011 as a period of "structure," 2013 a period of "process" and 2015 a period of "outcomes."

• Meaningful use criteria in 2013 will focus on process measures to demonstrate providers have started to meaningfully use EHRs

• Meaningful use criteria in 2015 will be heavily outcomes-oriented with eventual efforts to measure the actual impact EHRs have on the quality of care.

It is expected that CMS will publish proposed rules in December governing meaningful use incentives and certification of EHRs for meeting meaningful use criteria and collect public comment for a period of 60 days.

Certification Agency for EHRs

It is also expected that the Certification Commission for Health Information Technology (CCHIT) will be one of the many entities that will certify EHRs as meeting meaningful use criteria.

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RevenueXL Inc. assists medical practices in the assessment, selection and implementation of Medical Software including EMR Software (also called EHR Software), Patient Portal, and Practice Management or Medical Billing software. RevenueXL offers a free consultation session to review your current challenges and answer open questions revolving around EMR and revenue cycle.

If you like this post, please subscribe to our Email Subscription to read our new posts in your email.

One question that has not yet been answered is - what constitutes "meaningful use" of an EMR or EHR. Of late, this is becoming more relevant since the physicians who intend to implement EMR in their medical clinics are adopting a wait and watch approach until it becomes clear as to which EMR Software products conform to "meaningful use" definition which allows them to get the Medicare or Medicaid incentives.

On April 27, 2009, the Healthcare Information Management and Systems Society (HIMSS) released two definitions for "meaningful use" of certified electronic health records technology. The definitions cover meaningful use in hospitals and physician practices. In both definitions, HIMSS recommended adopting the CCHIT as the certifying body for electronic health records and recommended three phases of definitions, for a minimum of two years each, starting in fiscal year 2011. At the time of writing this note, it has not been decided if CCHIT will become the certification agency that qualifies an EMR / EHR software product from ARRA incentives perspective, but it seems very likely that this may indeed be so.

On 16 June 2009, the U.S. Office of the National Coordinator for Health Information Technology (ONC) published draft criteria for meaningful use of electronic health records. Comments are due by 26 June 2009. The draft includes a limited set of criteria that the CMS can incorporate into its regulation for incentives for using EHRs. It provides base criteria for fiscal years 2011-2012, and more aggressive sets of criteria to be phased in for 2013-2014, 2015 and beyond. The draft proposes many metrics in three broad categories:

• Quality, safety, disparities in care and patient engagement
• How well an EHR is being used?
• Privacy and security

The draft does not specify if it is sufficient to simply report a value in 2011 or if it will be necessary to report certain minimum levels of compliance. In subsequent years, the criteria will include rising levels of compliance for physician order entry, documented encounters and other measures.

The definition of "meaningful use" will continue to evolve with in the boundaries of what is reasonably possible using technology available today. Both ONC and CMS realize that with the extent of fragmentation in the EMR and EHR market, achieving meaningful use will not be easy. However, it is something that needs to happen if improvement in patient care is the over-riding objective of healthcare reform. The onus will be on the vendors of EMR / EHR products to ensure that their products can be "meaningfully used" by the users in line with what is finally included by CMS in its regulation guiding the incentive payment.

Physicians who are in the process of selecting and implementing EHR / EMR software in the interim period (until the definition of "meaningful use" is clarified) would be advised to include in their contracts that the vendor's product would not only be qualified but the vendor would incorporate features that will make it possible for them to demonstrate "meaningful use". Even after that, it may not be enough to install and implement a qualified EMR / EHR system, the burden of demonstrating that the system is being put to "meaningful use" will be on the physician. The vendor must however make that process easier.

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RevenueXL Inc. assists medical practices in the assessment, selection and implementation of Medical Software including EMR Software (also called EHR Software), Patient Portal, and Practice Management or Medical Billing software. RevenueXL offers a free consultation session to review your current challenges and answer open questions revolving around EMR and revenue cycle.