Hospital Information Systems
How do we get to Meaningful Use Part 2
It's like the old joke: "Meaningful use? You can't get there from here."
For our May issue, HMT put together a roundup on "Implementing Meaningful Use Objectives," asking selected industry experts for their input.
Editor's note: This is part two of a two-part series; part one appeared in HMT's April issue.
MU aims to connect providers, not pharmacists
By John Klimek R.Ph., senior VP, industry information technology,
NCPDP (National Council for Prescription Drug Programs)
No matter what your position on meaningful-use requirements — whether you view the final rule as too lenient or too stringent — one thing is undeniable: We have missed the mark in capturing the full opportunity to transform healthcare. While we do believe the requirements of Stage 1 and subsequent stages will improve healthcare, we remain concerned that pharmacists are still relegated to effectively care for the patient on the periphery.
Pharmacists are an important part of the interdisciplinary team that is critical in the management of a patient's well-being. They are involved in many aspects of patient care and are uniquely positioned to contribute substantially in all settings and throughout the continuum of care. In fact, in the academic medical care setting, pharmacists and physicians do rounds together to optimize medication therapies for patients with the benefit of having a full view of the patient's medical situation. And the payoffs from this collaboration are well documented in terms of improved patient outcomes and reduced costs.
ePrescribing, a core requirement of MU, establishes a point of real-time communication between physicians and pharmacists that will go a long way toward improving patient safety and reducing costs, medication errors, drug-drug interactions, fraud and more. But ePrescribing should only be the beginning. Although it didn't take an act of Congress for the pharmacy industry to achieve the high level of automation that is taken for granted today, it may take just that to embed pharmacists into the patient care team to optimize collaboration among all care providers and have the most profound impact on improving health outcomes and reducing healthcare costs.
Preserve the patient-record narrative
By Nick van Terheyden,
A crucial element of the meaningful-use objectives is maintaining an active patient problem list, which is often found in the unstructured, narrative portion of the record. To meet the objectives, clinicians must capture clinical information in a structured form. While most electronic medical record systems offer pick-lists for physicians to create and manage patient problems, the process can be highly inefficient. The challenge then becomes how clinicians can create a structured record without labor-intensive, manual data-entry tasks.
In addition to workflow disruption, oftentimes problem lists fail to capture the detailed and expressive descriptions of patients' unique health stories, which continue to be a major concern. In fact, the majority of clinicians believe the narrative must be preserved, as it is the best way to present and share a complete clinical case and its associated diagnostic reasoning.
Implementing meaningful use as part of clinicians' workflow is complex. Healthcare IT has already become an enabler of meaningful use, and through strategic collaboration between industry HIT leaders the delivery of new innovation will continue. During this transformative time, a focus on improving medical intelligence through innovation is critical.
CPOEs should put physicians first
By Paul Brient, CEO,
Virtually every hospital that PatientKeeper works with says its biggest concern regarding meaningful use is physician adoption of CPOE and, perhaps even more so, physician documentation. These two have been the "third rail" applications of healthcare IT. It has been 40 years since the first CPOE system was installed and we're at less than 10 percent adoption. Adoption of electronic physician documentation in the inpatient setting is even lower. Given that the vast majority of this adoption has been at academic medical centers with residents, it is no wonder that community hospitals are concerned about whether traditional approaches will work for them.
What's needed is an approach to CPOE that puts physicians first and creates an automated environment for physicians that saves them time and helps them do their job. After all, isn't that what technology has done for the rest of the world? If the iPad was hard to use and didn't help anyone do anything better or faster, do you think Apple would have sold 15 million of them?
CPOE has been, by far, the most difficult challenge PatientKeeper has undertaken because there are so many ways to make it wrong for physicians. It is still early, but we're making some great strides.
Using NLP technologies to achieve meaningful use
By Cheryl Servais, MPH, RHIA,
VP of compliance and privacy officer,
Many Stage 1 requirements can be addressed through the use of advanced natural language processing (NLP) technologies available today.
While problem list creation is just one of many Stage 1 criteria, it need not be a major obstacle to early Stage 1 qualification.
By implementing a sophisticated NLP framework capability as an adjunct to the EMR/EHR system, providers can create active problem lists based on either SNOMED-CT concepts or ICD-9-CM concepts or both. The inputted data sources can range from structured transcribed documents to OCR scanned data. Once the NLP engine is programmed to search the data to identify the patient's various diagnoses and conditions, it will electronically return data to the target EMR/EHR application for view by caregivers in a process requiring no additional physician, nursing or clerical time. Furthermore, through the NLP engine, the data for the problem list can become an automatic byproduct of the transcription system.
Integration vendor can help achieve meaningful use
By Ellen Bellini,
product marketing manager,
When it comes to meaningful-use certification, hospitals are finding that they need to look beyond their core EHR systems when tackling public health objectives.
Doylestown Hospital of Doylestown, Pa., needed a meaningful-use-certified interface capable of functioning with the Pennsylvania Department of Health for their immunization data requirements. Summit Healthcare was chosen to work with Doylestown Hospital to accomplish this.
In order to ensure that its interface received the government's meaningful-use stamp of approval, Doylestown and Summit Healthcare went through the Drummond Group's ONC-ATCB program. The Drummond Group employed its sophisticated software-testing services to determine that the immunization registry interface met the meaningful-use standards required by the Secretary of Health and Human Services. As a result, Doylestown Hospital became eligible to receive federal stimulus dollars as stipulated under the American Recovery and Reinvestment Act (ARRA).
The certification shows how an integration vendor can help hospitals take part in the electronic revolution that is reverberating across the healthcare industry. Healthcare providers are able to leverage technology to not only make significant improvements to their HIT systems, but also achieve meaningful use and qualify for incentive funds.
Meaningful-use criteria could unintentionally hurt EDs
By Robert Hitchcock, M.D., F.A.C.E.P., CMIO,
Although the emergency department (ED) generates 70 percent of hospital volume, government regulations downplay the ED's role in meaningful use. To the extent that they touch on the ED, the rules are confusing and, in some cases, inappropriate. As a result, hospitals burden their EDs with poorly designed, low-performing information systems that are part of enterprise systems. Hospital leaders choosing this path do so because they mistakenly believe that single, integrated applications provide an easier strategy to achieve meaningful use.
One reason for this belief is that the Stage 1 regulations tilt toward enterprise systems rather than best-of-breed systems. For example, the meaningful-use criteria for exchange of clinical data apply only to interchanges with providers outside the facility. Data exchange between hospital and ED systems doesn't qualify, even if those applications come from different vendors. A similar bias exists in the requirements for quality reporting: The need for data reconciliation favors single, enterprise systems.
Therefore, some hospitals are purchasing a single HIS product or turning on the ED module of their current enterprise system — even if ED physicians won't use it. The hospitals can demand that nurses use it, regardless of the negative impact on operational efficiency or patient safety of using paper and electronic systems simultaneously.
In short, the meaningful-use rules are hampering efforts to collect accurate and robust data and improve the quality, safety and efficiency of care in our nation's EDs. These unintended consequences stand in contrast to the admirable goals of meaningful-use legislation.
Clinicians need tools they can use
By Laurens van der Tang, CEO,
There are many barriers to EHR adoption for small practices, but one of the most significant barriers is the ease of deployment and use of EHR solutions. With limited or no IT resources, small practices appreciate the easy accessibility of cloud-based SaaS (Software as a Service) solutions. At the same time, they need a solution that supports and enables their small practice workflow, avoiding the pitfalls of excessive complexity.
Today, many organizations are wisely looking beyond MU to understand if they have an EHR that is usable and desirable for a physician to use, so that they can achieve their ultimate goal of improvements to quality, efficiency and information sharing. When we partnered with Mayo Clinic to do primary research on the EHR needs of small practices, we shadowed clinicians and administrators in a variety of small practices.
Customization and flexibility in both software and device options are critical to ensuring the EHR complements, rather than disrupts, the highly varied work styles of small practices.
Everyone in healthcare facing the challenge of meaningful use needs to look to the greater challenges of sustained efficiency and quality improvement. Bending arms and offering financial incentives can only work for so long. We all need to work toward giving clinicians tools that they want to use; tools they will pick up every day because they help them save time and deliver better care.
Communications enable meaningful use
By Bruce Wallace, group leader,
A key area of focus needs to be making EMR systems more attractive to clinicians so meaningful use can be driven up. One way of achieving this is to build communications into the EMR system.
Take the scenario of a doctor looking at a patient's X-ray and wanting to talk to the radiologist. A doctor could simply click on the radiologist information in the EMR system, determine availability and then click to start communicating with the radiologist. The two doctors could look at the X-ray together on the video call and collaborate on a diagnosis.
A key requirement of Stage 1 meaningful use is patient and family outreach: the ability to contact the patient to remind them about appointments and follow-up care. Solutions link into the EMR system that can reach out to patients via preferred mechanism of contact (phone, e-mail, etc.), provide them the information in language of choice and also get interactive responses from patients that can be used for post-care follow up.
It's about the network, not the app
By Jonathan Hare, chairman and founder,
Resilient Network Systems
One of the primary goals of HITECH's meaningful-use incentives was to motivate providers to go beyond simply adopting EHRs and connect them to a network capable of sharing and coordinating with other providers and the patient.
In spite of this, the final rule adopted for Stage 1 meaningful use required only minimal "push" connectivity — basically the electronic equivalent of faxing a record to a patient or other provider. The only requirement for "pulling" records is a single test of the ability to generate an electronic document that can be uploaded by another EHR. Moreover, this can be performed using a "fictitious patient and fake data" to "avoid security and privacy concerns." In other words, you don't actually need to be connected. Think of it as a halfway house to real meaningful use.
This watered-down requirement was not what CMS or the ONC wanted. The rationale was that no one had demonstrated a way of overcoming the legal, technical and privacy obstacles to exchanging data at scale. As Dr. Blumenthal testified at a Congressional hearing, "we live in a world with virtually no information exchange going on at all."
At the same time, Dr. Blumenthal put industry on notice that the Stage 2 requirement beginning in 2013 would require much more robust exchange. More recently, the President's Council of Advisors on Science and Technology (PCAST) turned up the heat by releasing a provocative report on health IT. The PCAST report makes a compelling case that traditional HIT — both existing EHRs and mechanisms for enabling exchange — is fundamentally incapable of supporting healthcare transformation. They call for a network-centric approach organized around patient data, with mechanisms for rigorously enforcing security and privacy linked to the data itself.
I believe the PCAST report should not be ignored. It's time to stop dodging the obstacles that have prevented patients from benefiting from the IT revolution. We need innovation that enables what healthcare transformation requires, instead of limiting ourselves to what traditional approaches can deliver.
A proactive plan for showing meaningful use
By Rod Walker, interim CIO of Forrest General Hospital, Hattiesburg, Miss.; principal, consulting firm of Negley, Ott & Associates Inc.
Forrest General Hospital, which has had a computerized patient record from QuadraMed since 1996, is leveraging a dual path to meaningful use rather than the single path many other hospitals are taking. Prior to receiving the ONC-ATB-certified version of our EHR, we started using our EHR to develop our meaningful-use capabilities.
For example, one of the largest challenges for any hospital is getting the medical staff to use the newly required problem list. This is due to each practitioner having his or her own approach to diagnosis and terminology. We pulled together people from across Forrest General and worked with them to gain consensus on the problem-list design.
By emulating what we believe the new version of the EHR will support, we've been able to educate our staff and prepare them for the changes that will occur with the certified version of the EHR. Now that we have received the certified EHR, we're confident that we'll have the relevant parts of the workflow ready to go, thus requiring less effort for clinical adoption of practice changes. If we had not done this, we would not be able to anticipate achieving meaningful use as soon as we are.
To take advantage of the functionality we already have established with our EHR, we are working with QuadraMed on developing interfaces with the state public health department so we can report lab results for meaningful-use compliance. And to provide patients with electronic copies of their records, we've given our medical records department preliminary capability to generate electronic files containing EHR data. The staff can now save files — such as H&Ps or discharge summaries — to flash drives or burn them to CDs, and they will use the same methods to provide clinical care summaries generated by our new EHR once we move the certified EHR to production.
Reduce readmissions and improve outcomes
By Laurie Eldridge-Shanaman, healthcare market development consultant, managed enterprise solutions, imaging and printing group, HP
Amidst rising hospital readmission rates, it's vital that patients understand discharge summaries and transition-care instructions for medications, follow-up appointments and post-care directions. Providers can significantly reduce hospital readmissions and improve patient outcomes with clear, easy-to-understand transition-care instructions and discharge plans.
Solutions can help healthcare organizations meet several Stage 1 meaningful-use criteria, including "improving quality, safety, efficiency and reducing health disparities," "engaging patients and families in their health care," and "improving care coordination." Patients' communication preferences can be captured at admission and discharge, allowing automated appointment reminders to be sent.
From an interface, hospital staff can produce discharge documents comprising relevant patient health information from existing systems and databases. These discharge documents summarize care and help patients and caretakers continue the post-care regimen. Discharge documents can be automatically populated with a list of medications with pictures, what to expect during the healing process, who to contact with concerns or questions, and detailed instructions based on that specific patient's demographics, diagnosis and circumstances.
Push toward EHRs will leverage the stages of meaningful use
By Todd Kelly, director, healthcare solutions,
Washington Consulting (a wholly owned subsidiary of Alion Science and Technology)
In the healthcare-reform arena, the three stages of meaningful use are often viewed as bureaucratic hoops practitioners must jump through with no real purpose behind them. In reality, the push toward EHRs will leverage the stages of meaningful use as platforms to build momentum, improve reimbursement and ultimately advance quality of care.
Urging providers to get on board at Stage 1 is critical to demonstrating that practitioners are using EHRs effectively and that functional and interoperability measures and clinical quality measures are being tied to EHR use. This stage will also demonstrate the ability to share information electronically about patient care among providers of care and patient authorized entities, advancing the interoperability requirements for health information.
Stages 2 and 3 of meaningful use (beginning in 2013 and 2015, respectively) will encompass more stringent eligibility requirements to demonstrate meaningful use, including large amounts of data and a gargantuan leap forward in the intricacy of data required from practitioners themselves. Fundamental to making the value proposition easily digestible for healthcare providers is involvement in Stage 1 meaningful use. If provider organizations are utilizing vital outreach and training tools to accomplish Stage 1, however, the subsequent stages will not leave them staring into the abyss. Waiting until 2013 to begin the transition will make already intransigent practitioners even more disillusioned with the process. This type of passive involvement could negatively impact the momentum that is required to unleash innovation with the EHRs, improve patient outcomes and reduce costs.