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. 1 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 2 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) 3 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 [email protected]. 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 4