Meaningful Use:
Relevance in College
Health
American College Health Association
May 30th 2013
UHS Collaborators
• Maria Campanile MD
Primary Care Clinic, Chair of Committee on Clinical Informatics
• Arnie Jennerman CPA, MBA
Director of Administrative Services
• Danielle Oakley PhD
Director of Counseling and Consultation Services
• Theresa Regge MS
Information Technology Services Manager
• Nancy Ranum MS, NP, RN-BC
Informatics Nurse Specialist, NP – Clinical Informatics Manager
• Shelia Zweifel RHIT
HIM and Privacy Manager
AAAHC Coordinator
Learning Objectives
• Use and Importance of Benchmarking
• Meaningful Use Background and Applicability
• What we did at UHS at UW Madison
• Results of the Project
• Usefulness and Recommendations
• Questions and Answers
Benchmarking Standard
• Benchmarking: a systematic comparison of products, services or
work processes of similar organizations, departments or
practitioners to identify best practices known to date for the purpose
of continuous quality improvement. External benchmarking
compares performance between different organizations. Internal
benchmarking compares performance within an organization, such
as by physician or department, or over time.
• Performance measure: a clearly defined statement or question
describing information to be collected for purposes of improving
processes and outcomes of care.
• From the Accreditation Association for Ambulatory Health Care
(AAAHC) Accreditation Handbook for Ambulatory Health Care:
The organization's quality improvement program must include
participation in external performance benchmarking activities that will
allow for comparison of key performance measures with other similar
organizations or with recognized best practices of national or
professional targets or goals [Standard 5.II.C].
Benchmarking at UHS
• Essential Element of Quality Improvement Program
• Process overseen by QMIC Quality Management Improvement
Committee
• Challenge Finding Appropriate Benchmarks
• Challenge Finding External Benchmarks
• Incorporating Benchmarking into Daily Activity Systems
Challenge
Why UHS Considered Meaningful
Use
• Not a Requirement for UHS
• No Reimbursement Incentive
• Went to Paperless EMR June 2008
• EMR a Journey with no Destination
are we there yet?
• Looking for an External Benchmark
• Guide our EMR Strategic Planning
• Possible Vendor Leverage
Review Of Our Process
• What is Meaningful Use?
• UHS approach to understanding MU
• MU alignment in Clinical Services
• Reconciling MU criteria with existing Health
Information Management requirements
• Implications for Information Technology
Services other administrative functions
• Relevance in Counseling, Psychiatry and
Behavioral Health
• The larger conversation: conflicts and
dilemmas
What is Meaningful Use?
What is Meaningful Use?
Drivers for Incentivizing
Health Information Technology
• Unprecedented healthcare spending has not
resulted in improved quality especially in
Medicare and Medicaid populations
U.S. Health Care Quality: Stuck in Neutral, Slowdown has Implications for Reform; NCQA Press
Release, October 22, 2009
• Quality of healthcare in US ranks low in
comparison to other developed countries
K. Davis, C. Schoen, and K.Stremikis, Mirror, Mirror on the Wall: How the Performance of the U.S.
Health Care System Compares Internationally: 2010 Update (New York: The Commonwealth
Fund, June 2010)
• Dovetails with other healthcare reform initiatives
• e.g. Healthcare Affordability Act, Accountable Care
Organizations (ACOs) and Medicare Shared Savings
Program
Health System In Crisis
• Total Healthcare spending 17.9% of GDP in 2011
• Currently at $3 Trillion per year
• Expected to grow to 20% of GDP by 2021
• Spend the most of any nation per capita
• Spending is 2 an 1/2 times the OECD average per person
• According to WHO we rank 50th in life expectance at birth
• Growing faster than the economy, a competitiveness issue
Origin of “Meaningful Use”
ARRA: American Recovery and Reinvestment Act,
2009; the “Stimulus Bill”
HITECH: Health Information Technology for
Economic and Clinical Health Act Title XIII of ARRA
ONC: Office of the National Coordinator for
health information technology
CMS: Centers for Medicare and Medicaid Services
• ONC and CMS worked closely to establish the rules
• Multiple committees, sub committees; members
included clinicians, IT leaders, public policy experts;
public meetings – webcasts, online comments
Goals of HITECH
• Improve quality, safety and efficiency
• Reduce health disparities
• Engage patients and families in their
health care
• Promote public and population health
• Improve care coordination
• Promote the privacy and security of EHRs
HITECH Incentives
Federal program to provide financial incentive
to providers and hospitals for the adoption
AND demonstrated “meaningful use” of
certified health information technology (HIT)
• $27 Billion over 10 years
• Up to $44,000 (Medicare) and $63,750
(Medicaid) per clinician
• Eventually, 2015, penalties (cuts in Medicare
reimbursement for not adopting)
• Numerous deadlines and cutoffs
Components of HITECH
• Meaningful Use “Rule” – guidelines and
requirements for achieving Stage 1 MU
• EHR standards and certification criteria that
support MU (Certification Commission for
Health Information Technology - CCHIT)
• New protections to strengthen and expand
privacy, security and enforcement of HIPAA
• Temporary certification program for HIT
Systems
MU Stage One Measures
Core Measures
• 15 required objectives for eligible professionals (EP), 14 for
eligible hospitals (EH) and critical access hospitals (CAH)
Menu Measures
• EPs and hospitals must also implement 5 of 10 additional
criteria (their choice)
Quality Reporting-Clinical Quality Measures
• For stage 1, EPs must report on 3 core measures:
blood-pressure level, tobacco status, adult weight
screening and follow-up
• EPs also need to report on 3 additional measures from a list
of 38 metrics ready for incorporation into EHRs
• Hospitals must report on 15 required quality metrics
Stage 1: 15 Core Measures for EPs
1. CPOE (ComputerizedProvider Order Entry) for
medication orders
2. Implement drug-drug and drug-allergy
interaction checks
3. Generate and transmit permissible
prescriptions electronically (eRx)
4. Record demographics: preferred language,
gender, race ethnicity, DOB
5. Maintain up to date electronic problem list of
current/active diagnosis
Stage 1: 15 Core Measures cont.
6. Maintain active medication list
7. Maintain active medication allergy list
8. Record and chart changes in vital signs including
BMI and growth charts for age 2-20 yrs.
9. Record smoking status for patients 13 yrs or older
10. Implement one clinical decision support rule
relevant to specialty or of high clinical priority
along with the ability to track compliance
11. Report ambulatory clinical quality measures to
CMS or State
Stage 1: 15 Core Measures cont.
12. Provide patients with electronic copy of their
health information upon request (test results,
problem list, medication and allergy lists)
13. Provide clinical summaries for each office visit
14. Capability to exchange key clinical information
among providers of care and patientauthorized entities electronically
15. Protect electronic health information created
or maintained by the certified EHR technology
through the implementation of appropriate
technical capabilities
Stage 1: Menu Set for EPs
1. Implement drug-formulary checks
2. Incorporate clinical lab-test results into
certified EHR technology as structured data
3. Generate lists of patients by specific conditions
to use for quality improvement, reduction of
disparities, research or outreach
4. Send reminders for preventive/follow-up care
5. Provide patients with timely electronic access
to their health information (lab results,
problem list, medication/allergy lists)
Stage 1: Menu Set Continued
6. Use certified EHR technology to identify and
provide patient-specific educational resources
7. Medication reconciliation as relevant
8. Provide summary of care record for transitions
of care/referral
9. Capability to submit electronic data to
immunization registries/systems
10. Capability to provide electronic syndromic
surveillance data to public health
Attestation
• Incremental approach – 3 stages
• Stage 1 (2011-12) - baseline for electronic data capture
and information sharing; very specific numerator and
denominator parameters
• Stage 2 rules not yet finalized by ONC, delayed to 2014
• Stage 3 – Proposal to support New Care Models now
2016 at the earliest, industry push back
•
•
•
•
Over 291,325 providers received incentives $5.7 B
$8.7 Billion in incentives to 3,880 hospitals
Demanding data-driven process
Will influence industry benchmarks and consumer
expectations
Getting Buy-in for MU at UHS
Leadership Interest In Benchmarking
Point and Click Steering Committee
Committee on Clinical Informatics
Quality Management and Improvement
Committee
Process Used in COCI
Educated committee on background of MU
Blumenthal, D., M.D., M.P.P., and Tavenner, M, R.N., M.H.A. (2010); The “Meaningful
Use” Regulation for Electronic Health Records, New England Journal of Medicine;
August 5, 2010, pg. 501-504
Evaluated various critiques of MU rules
• CHIME-College of Healthcare Information
Management Executives
• AHIMA-American Health Information
Management Association
• HIMSS-Health Information Systems Society –
distributed this to committee
Evaluating MU Criteria
Reviewed & rated Core Criteria for
importance/relevance to college health
• Classified Highly Important, Important, Not
Important
• Focus on EP Eligible Professionals not Hospital
• Focused on finalized Stage 1 rules
• Noted that Measures designed to drive $
• Stage 2 discussion provided a “heads-up” of where
MU is headed, basically more demanding
measures more Participation and integration
How UHS Aligns with MU Core
Requirements
• 1 Medication CPOE
• 2 Drug-drug/allergy interaction checks
• 3 E-Prescribing, and formulary checks, E-fax
migrating to E-Rx
• 4 Demographics – yes no field for preferred language
• 5 Electronic Problem List meets MU criteria but
some issues with functionality e.g. patient entered
data
• 5, 6 and 7 Medication List, Allergy List, Problem List,
but not available to patients via MyUHS portal (not
available in our EMR)
• 8 Vitals, Not using growth charts
How UHS Aligns with MU Core
Requirements (continued)
• 9 Documentation of smoking status: PnC does not
support but UHS has customized risk screening that
includes documentation at all visits and embedded
health maintenance alerts
• 10 Clinical Decision Support
• Primary and Secondary Risk assessment for tobacco use, alcohol
use, depression
• Asthma template includes prompts for influenza and pneumonia
vaccine
• “Disease” Management programs for Employee Health and
Occupational Medicine populations
• 11 Immunization Registry – Separate Interface WIR
• Challenge in college health is that population is mobile and
comes from all over the world
How UHS Aligns with MU Core
Requirements (continued)
• 12 Patient portal for messaging, access to
diagnostic reports, Problem List, Medication and
Allergy Lists etc. Electronic Problem List meets
MU criteria but some issues with functionality
e.g. patient entered data one time
• 13 Visit Summary – EMR has capability but not
using currently, cannot customize
format/content
• 14 Laboratory, Radiology Interfaces, referral not
electronic results via EPIC Carelink
• 15 Data security for PHI fully compliant
How UHS Aligns with MU Menu Set
Requirements
• 1 Drug formulary check
• 2 Lab results as structured data
• 3 Generate patient lists for quality improvement
• 4 Reminders for preventive/follow-up care
• 5 Visit summary
• 6 Education: mechanisms in place using
customized template triggers and mechanisms
for sending links via secure message
• 7 Medication reconciliation few referrals in
where relevant
How UHS aligns with
Menu Set Requirements
• 8 Ability to receive and send patient health
records with providers and ERs in Madison and
beyond Many gaps from Health Information
Exchange (HIE)-IT perspective
• 9 Submission to immunization registries and
systems custom interface
• 10 Ability to submit electronic syndromic
surveillance data to public health agencies not
automatic
Observations of UHS MU Evaluation
• Overall pretty good compliance with Core Measures
and Menu Set, only need 5 of 10
• Followed multidisciplinary process, important dialogue
• Focused on gaps between our processes and MU
criteria
• Evaluated capabilities of our EHR
• Realization this will impact community
standards/expectations and benchmarks
• Provided direction for future IT and Quality initiatives
• Implementing an EHR a journey not a destination
Existing Standards,
Regulations and Laws
How will MU impact accrediting bodies?
• JCAHO: Joint Commission on Accreditation of
Healthcare Organizations
• AAAHC: Accreditation Association for
Ambulatory Health Care
• NCQA: National Committee for Quality
Assurance
State and Federal Law?
• HIPAA, FERPA
Health Information Management
Processes
• Recording
• Storing
• Ordering
• Retrieving
• Releasing
• Modifying Entries
Policy and Procedures
Organizations have existing policies,
procedures and workflows
• Review and align with Meaningful Use
Chart audits and compliance
• Drug allergy reviews
• Problem list audits
• Medication audits
• Appropriate Access/Confidentiality
• Templates have “hard stops”
Privacy and Security of PHI
• Existing standards, rules, law
• Ensure integrity of information not
been altered as it moves around
• Accounting of disclosures and access
• Current state and federal laws
• Patient /consumer anxiety
Request for Records
• Existing state and federal laws
• Possible conflicts with HIPAA, FERPA
• Visit summary making it useful?
• “Human readable format”
• Consumer health literacy
HIE: Health Information
Exchange
• Need for unique patient identifier
• Electronic transmittal of records to
other providers
• EMR versus EHR Interface vs Integrate
• Patients have ability to opt out and
apply restrictions limit usefulness
• Conflicts with state or federal laws
• WISHIN
Implications for Information
Technology Services
Getting disparate systems to communicate
effectively, efficiently and legally
• Evaluate systems capability “as is” and
determine what future requirements will be
• Work with EHR vendor
• CHITT certified – changes embedded in future
releases
• Implications for upgrades
• Implementation and upgrade costs – hardware,
software, IT staff, downtime, training
Relevance in Counseling, Psychiatry,
and Behavioral Health
Implications of the exclusion of Mental
Health providers from the HITECH act.
• No access to the incentive funding
• Excludes some of the most underserved
groups
• Barrier to coordinated care
Relevance in Counseling, Psychiatry
and Behavioral Health
• Status of the Health Information
Technology Extension for Behavioral
Health Services Act of 2010 (HR5040)
• To amend the Public Health Service Act and the
Social Security Act to extend health information
technology assistance eligibility to behavioral
health, mental health, and substance abuse
professionals and facilities, and for other
purposes.
The bill never became law
Relevance in Counseling, Psychiatry,
and Behavioral Health
Mental Health considerations in the MU
conversation at UHS
• Integrated model Behavioral Health mental
health issues as “brain diseases”
• Medical vs. mental health summary privacy
issues
• What goes on Problem List?
Presentation Objectives
• Use and Importance of Benchmarking
• Meaningful Use Background and Applicability
• What we did at UHS at UW Madison
• Results of the Project
• Usefulness and Recommendations
Meaningful Use:
Conflicts and Dilemmas
• Lack of universal patient ID and issues with SSN
• Who “owns” health information; Shared lifetime
EHR/PHR
• Transparency and how to assure that shared
information is “meaningful/understandable” to
the range of users/consumers of the health
information
• “Technological divide” – disparity of electronic
access and literacy
• Vendor co-opting standards proprietary use of
HL7 CommonWell announcement at HIMSS
Meaningful Use:
Conflicts and Dilemmas, cont.
• EMR versus EHR, Interface versus Interoperate
• Role of cloud technology
• Second generation EMR versus third generation “we
have an app for that”
• Clinical Quality measures – aligning clinical guidelines,
evidenced based medicine and local quality initiatives
with MU…. or visa versa?
• Constraints of EMR products, EMR certification, CCHIT….
Instances of “the tail wagging the dog”?
• ROI – What if it does not improve outcomes or it costs
more than it saves?
• Currently heavy industry lobbying against penalties
“regulatory capture”
• Political Uncertainty…..
Thank You!!!
Questions???
Web Links
• Centers for Medicare and Medicaid Services
http://www.cms.gov
• http://www.cms.gov/EHRIncentivePrograms
• HIMSS Meaningful Use information
www.himss.org/ASP/topicsmeaningfuluse.asp
• Federal Register, see pages 44370-443780 for summary
www.gpo.gov/fdsys/pkg/FR-2010-07-28/pdf/2010-17207.pdf