How to Approach Meeting Meaningful Use June, 2011

Insight Article
How to Approach Meeting Meaningful Use
By Janice Ahlstrom, RN, BSN, CPHIMS, FHIMSS
June, 2011
* This is the third in a series of “Meaningful Use” articles by Wipfli
LLP
Overview
In July 2010 the Department of Healthcare Human Services (DHHS)
released the American Recovery and Reinvestment Act (ARRA)
Health Information Technology (HIT) final rule regarding meaningful
use of electronic health records (EHR) that will provide for
subsequent Medicare and Medicaid incentives. The American
Recovery and Reinvestment Act of 2009 specify three main
components of Meaningful Use (MU):
1.
2.
3.
The use of a certified EHR in a meaningful manner
The use of certified EHR technology for electronic exchange of
health information to improve quality of health care
The use of certified EHR technology to submit clinical quality
and other measures.
Objectives
When analyzing the various core, menu and quality measures of the
meaningful use final rule we understand that care management and
quality are paramount. Preventative measures, appropriate care
delivery, avoidance of adverse events, proper follow up, care
coordination, improved population health and information privacy and
security are key objectives of Meaningful Use.
EHR Application Software
If you do not have an EHR system selected, now is the time to focus
on identification of a system that meets your organizations
requirements. Given Stark relief you may consider contracting with a
larger IDS organization as a service provider to gain access to EHR
technology. Alternatively, you can begin an EHR selection effort. For
information regarding best practice in EHR selection see the
following article: http://www.wipfli.com/resources/images/8658.pdf.
If you have selected an EHR system, then you need to move
forward in earnest with a phased and systematic implementation
given the timeline. For guidance regarding EHR project planning see
the following article:
http://www.wipfli.com/resources/images/11936.pdf.
Keep in mind that if you are using a stand-alone EMR software
application with an existing legacy practice management (PM)
system, the PM system must be a certified EHR application as well.
Some of the required functions of a certified system, such as
recording patient demographics electronically, are likely functions of
your PM software and not the EMR application. If your organization
has home grown (self developed) application software you will need
to have this software certified by one of the Office of the National
Coordinator (ONC) approved certification bodies.
© Wipfli LLP
The ONC approved certification organizations can be found at
http://healthit.hhs.gov/portal/server.pt?open=512&mode=2&objID=31
20. To verify that your EHR vendor and application software version
are certified visit http://onc-chpl.force.com/ehrcert. Be aware that
some vendors are certifying specific modules separately for their
EHR software. Carefully review the certification listings against your
current installation.
How to Move Forward - A Practical Approach to
Meaningful Use
Merely selecting and implementing certified EHR technology will not
result in meeting Meaningful Use. So much of what is required to
meet Meaningful Use lies in your care delivery processes and the
behaviors of the clinicians and staff in your organization. Meaningful
Use predominately involves People and Care Processes and is
supported by certified EHR technology.
To meet Meaningful Use requires education, assessment and
analysis to identify the gaps between your current state and
Meaningful Use. With knowledge of your organizations gaps, a
readiness plan can be developed and executed. Therefore, a
practical five step approach below is defined to help you in meeting
Meaningful Use.
Education and Understanding
First your staff will need to be educated on Meaningful Use. There
are many helpful resources available regarding the core set and
menu set requirements, such as the CMS EHR Incentive site at:
https://www.cms.gov/EHRIncentivePrograms/.
Alternatively other quick reference for information is a the DHSS
Office of the National Coordinator (ONC) site where Steven Posnack,
Director Federal Policy Division and his staff developed helpful grids
to overview the EHR incentive programs for hospitals, CAH facilities,
and eligible providers. The web site is at:
http://www.healthit.gov/buzz-blog/meaningful-use/meaningful-usemashup-quick-reference-grids-to-navigating-the-meaningful-use-andstandards-and-certification-criteria-final-rules/, The grids capture in
one place, the meaningful use objectives, measures, and exclusions,
and the correlated certification criteria and standards. They also
reference the relevant Federal Register sections associated with
each requirement.
Education on MU needs to be delivered at all levels in your
organization: executives, physicians, nursing and ancillary leaders,
clinicians, staff in non-clinical areas as well such as admissions,
scheduling and health information management.
Objectives and Measures
Meaningful Use includes a core set and a menu set of objectives that
are specific to eligible professionals or eligible hospitals and CAHs.
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Insight Article
For eligible professionals, there are 25 meaningful use objectives. To
qualify for an incentive payment, 20 of these 25 objectives must be
met. There are 15 required core objectives and the remaining 5
objectives can be selected from the list of 10 menu set objectives.
For eligible hospitals and CAHs, there are 24 meaningful use
objectives. To qualify for an incentive payment, 19 of these 24
objectives must be met. There are 14 required core objectives and
the remaining 5 objectives can be selected from the list of 10 menu
set objectives.
To demonstrate meaningful use eligible professionals, hospitals and
CAHs are required also to report clinical quality measures specific to
eligible professionals hospitals and CAHs. Eligible professionals
must report on 6 total clinical quality measures: 3 required core
measures (substituting alternate core measures where necessary)
and 3 additional measures (selected from a set of 38 clinical quality
measures). Eligible hospitals and CAHs must report on all 15 of their
clinical quality measures.
Assessment
First and foremost, you want to think as Stephen Covey recommends
- “Begin with end in mind”. Careful detailed assessment and analysis
of your EHR application software configuration against the core,
selected menu and defined quality measures. What specific fields of
data are needed? What will be the numerator and denominator in
running reports? Has your EHR vendor developed all of the required
reports? Is there information that will be captured in certified,
however, disparate systems? How will this information be aggregated
into a single report? Can reports be run as you will attest by provider
number? How reports can be run is important, as some larger
integrated systems have multiple facilities defined under a single
provider number. Are your report queries aligned with how you need
to report?
Ancillary and clinical workflows should be reviewed to understand
where in the workflow data essential to MU reporting is captured.
Analysis of risks to data capture should be identified and strategies to
mitigate those risks developed. For example, a 22 year old male is
admitted unconscious via the emergency department from a motor
vehicle accident and is unable to provide required information before
going to surgery. There is missing medication, problem, allergy,
language, ethnicity, smoking status, and preferred language
information in the medical record.
It is likely the nursing staff in Post Anesthesia Recovery or the
receiving care unit will capture many missing data elements, however
some could be missed. Who on the receiving unit would gather the
missing information? How will the admissions data - preferred
language and ethnicity be identified as missing on the nursing unit,
obtained and recorded? Are the processes efficient and effective in
the capture of information?
Have you considered all areas of workflow such as Registration,
Admissions, Scheduling, Clinical Documentation – Ancillary, Nursing
and Physician. Medication Management, Health Information
Management, Orders Management, Decision Support, Regulatory
Compliance and Reporting? Do they align with capture,
documentation, maintenance of data and your system configuration
over time?
© Wipfli LLP
When you have completed review of the application configuration
and workflow, consider the EHR user interface with the associated
workflow. How is the data captured in the application? Are all the
needed selections available to be captured as discrete elements in
pull downs? Are all the required fields in the application in logical
manner? Are critical data elements configured to impede forward
progress in use of the software? Does the flow of the EHR user
interface align with the workflow?
Conformity to redesigned workflows and essential data capture with
clinicians is required. Champions are needed within the various
clinical areas. All disciplines need to be involved in design of
multidisciplinary documentation. Standardization is key to successful
implementation of an EHR and capture of data to meet MU.
Expectations regarding standard work need to be established and
managed, as standard work fosters both quality and safety in the
delivery of patient care.
Many reports are based on a percentage of the patient population
your organization has cared for. To attain the required percentages,
the EHR MUST capture date elements as discrete data. Clinicians
and staff using the EHR must understand and use defined discrete
data fields to enter information needed for reporting. Free text
documentation should be kept to a minimum as the data defined in
this manner cannot be leveraged for current or future reporting
purposes. There will remain a few limited clinical areas of exception
to the use of unstructured documentation, such as psychiatric care
where free text documentation at times will serve best to capture the
essence of interactions with patients.
The eligible providers in your organization need to be identified and
required data for EHR incentive registration assembled. The
individual provider’s patient population will need to be assessed to
identify what percentage is a Medicare versus Medicaid payment,
and which is larger. Which payment incentive best aligns to the
population each provider cares for?
Identify Gaps and Document Readiness Plan
Based on assessment and analysis of your EHR configuration, work
flows, end user interface, eligible providers and quality management
reporting requirements gaps to Meaningful Use readiness should be
documented and a readiness plan developed that outlines tasks,
assignments, identifies priorities, dependencies deadlines and the
critical path to readiness. Critical to readiness and Meaningful Use
compliance over time will be internal monitoring of compliance to
standard workflow, data capture and measure outcomes. Automated
reporting tools such as dashboards that allow real time day to day
monitoring of data capture against defined objectives and provide a
means to correct missed data capture are essential to compliance,
reinforcement of required workflow behaviors and data
documentation. To gather support for design and implementation of
new workflows, documentation and to sustain compliance with
standard work an effective change management strategy is crucial.
Change Management Approach
Technology is part of the answer to meeting Meaningful Use; process
and people some would articulate are the most important. Change
management facilitates the human transition from current state to
future state. The behaviors of doctors, extenders PA/NP, nurses and
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Insight Article
ancillary staff need to change. Your organization undoubtedly would
like to accelerate the speed at which people move through the
change process so that anticipated incentives and quality outcomes
are achieved quicker.
Ability Versus Motivation
We must first understand, plan and address the ability and motivation
challenge that is presented with both use of EHR technology and
adoption of the required behaviors to enable the redesign of care
delivery workflow and capture of information to achieve meaningful
use.
Information on registration and attestation guidelines can be found at
https://www.cms.gov/EHRIncentivePrograms/32_Attestation.asp#To
pOfPage
Meaningful use validation tool is present in the CMS website. This
could be used as a tool to measure readiness. It will not include your
clinical quality measures however. The readiness tool can be found
at: http://www.cms.gov/apps/ehr/.
We are almost there!
High
Does
di
ne
ss
Won’t
R
ea
Ability
(Skill)
Won’t
Can’t
Low
Low
High
Motivation
(Will)
Adapted from: McCarthy C, Eastman D, Garets D: Change Management
Strategies for an Effective EMR Implementation. Chicago: HIMSS; 2010 and
Influencer: The Power to Change Anything, by Kerry Patterson, Joseph
Grenny, David Maxfield and Ron McMillan (Sep 13, 2007)
Focus on all project phases. Understanding end user perceptions
and motivators, and helping them connect the dots is the key to
moving forward. It’s all about people, process and change
management.
Education
Educating the staff and patients is one of the best ways to address
the gaps. Staffs should be educated to stay up to date on the
regulations and measures. How it can help the clinical and nonclinical staffs in achieving efficiency? Develop materials for patients
to explain the capture of data without invading the privacy e.g., ethnic
group. Educate them on why it’s important and how it can help in the
population study and to improve patient care. Develop and review
your organization’s strategic HIT plan.
When you begin your 90-day period, be sure you are monitoring and
attaining all of the core, selected menu measure and quality
objectives selected within numeric thresholds.
Validation
More likely, you will not get perfect reports on the first try; do not wait
until the last minute. Leave your organization enough time to be able
to have at least 2 or more 3 month windows to run and validate
reports. Use the specification documents for validation https://www.cms.gov/EHRIncentivePrograms/55_EducationalMaterial
s.asp#TopOfPage
© Wipfli LLP
What does future hold?
On March 27, 2011, Health IT News reported that The Centers for
Medicare and Medicaid Services (CMS) has announced
$37,570,328.55 disbursed under the Medicare and Medicaid EHR
Incentive Programs so far this year. The Office of the National
Coordinator for Health Information Technology (ONC) reported that
some 14,000 eligible providers have registered for the program since
it opened January 3, 2011.
The HIT Policy Committee according to Health IT News is expected
to deliver its formal recommendations on Meaningful Use Stage 2 in
mid May 2011.
Stage 2 (expected to be implemented in 2013) and Stage 3
(expected to be implemented in 2015) will continue to expand on this
baseline and be developed through future rule making. Criteria are to
be updated bi-annually. Stage 2 is to be expected at end of 2011 and
Stage 3 is expected by end of 2013
What to expect in Stage 2
•
•
•
•
•
•
Increased e-prescribing & CPOE use
Incorporated structured lab results
E-transmission of patient care summaries
All optional Stage 1 criteria will be required
All thresholds and exclusions to be re‐evaluated
Criteria may be more broadly applied to outpatient hospitals
settings (not just the emergency department)
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Insight Article
Additional Resources
Meaningful Use Check List:
Management of Lender Relationships
http://www.wipfli.com/resources/images/13543.pdf
Selection of EHR Technology
http://www.wipfli.com/resources/images/8658.pdf
Plan an EHR implementation
http://www.wipfli.com/resources/images/11936.pdf
Meaningful Use Attestation Calculator
http://www.cms.gov/apps/ehr/
nation. Wipfli’s national health care practice has 18 partners and
approximately 100 associates dedicated to serving integrated
delivery systems, large community hospitals, critical access and rural
hospitals, physician practices, long-term care organizations, dental
practices, health plans, suppliers, and device manufacturers. Wipfli
can advise in all areas of business, from finance and operations to
human resources, information technology, and reimbursement. For
more information, visit www.wipfli.com/healthcare.
Information Sources:
Meaningful Use Overview https://www.cms.gov/EHRIncentivePrograms/30_Meaningful_Use.as
p#TopOfPage
About the Author
Meaningful Use Attestation Calculator- http://www.cms.gov/apps/ehr/
Janice Ahlstrom, RN, BSN, CPHIMS, FHIMSS, is a partner in Wipfli’s
health care practice. She has over 30 years of experience in the
health care industry. She has helped a variety of organizations
select, implement, and integrate enterprise EHR systems. Janice
helps organizations develop technology strategies, implement
systems, redesign business processes, and enact operational
improvements. Contact Janice at 414.431.9352 or e-mail her at
jahlstrom@wipfli.com.
Reporting Guidelines https://www.cms.gov/EHRIncentivePrograms/32_Attestation.asp#To
pOfPage
List of certified vendors - http://onc-chpl.force.com/ehrcert
CMS EHR Incentive Specification Sheets https://www.cms.gov/EHRIncentivePrograms/55_EducationalMaterial
s.asp#TopOfPage
About Wipfli LLP
McCarthy C, Eastman D, Garets D: Change Management Strategies
for an Effective EMR Implementation. Chicago : HIMSS; 2010
With approximately 1000 associates and 20 offices, Wipfli ranks
among the top accounting and business consulting firms in the
Influencer: The Power to Change Anything, by Kerry Patterson,
Joseph Grenny, David Maxfield and Ron McMillan (Sep 13, 2007)
© Wipfli LLP
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