The September HIT Standards Committee Meeting

We began the meeting by noting this was the 40th meeting of the HIT Standards Committee and the bulk of the meeting was spent thoroughly reviewing the Stage 2 ONC and CMS rules so that all members can evangelize about the accomplishments of the past 3 years, ensuring every stakeholder understands the amount of work done to specify content, vocabulary and transport standards for healthcare.   Given the hundreds of pages of detailed regulations outlining very specific standards developed by hundreds of people working thousands of hours, we were confused by yesterday's Wall Street Journal article which noted:

"The industry could not agree on data standards - for instance on how to record blood pressure or list patients' problems"

Those standards were finished and included in the Stage 2 Standards and Certification Final Rule

"Instead of demanding unified standards, the government has largely left it to vendors who declined to cooperate, thereby ensuring years of non communication and non coordination"

For Stage 2, interoperability testing will be done by government authorized bodies using standards mandating by government.

Armed with the details of the Stage 2 rules, the members will ensure such mis-information is not promulgated.

Travis Broome from CMS began the meeting with an overview of the Stage 2 CMS rule.   He noted that the schedule is highly customizable such that a clinician begins and proceeds at a pace that works for his/her practice.  He noted the 2014 reporting period was changed to 90 days instead of a year to enable more flexibility in implementation of Stage 2 technologies.

He outlined the 17 eligible professional core measures

Use CPOE for more than 60% of medication, 30% of laboratory, and 30% of radiology

E-Rx for more than 50% - controlled substances are optional

Record demographics for more than 80%

Record vital signs for more than 80%

Record smoking status for more than 80%

Implement 5 clinical decision support interventions + drug/drug and drug/allergy

Incorporate lab results for more than 55%

Generate patient list by specific condition

Use EHR to identify and provide reminders for preventive/follow-up care for more than 10% of patients with two or more office visits in the last 2 years

Provide online access to health information for more than 50% with more than 5% actually accessing

Provide office visit summaries for more than 50% of office visits

Use EHR to identify and provide education resources more than 10%

More than 5% of patients send secure messages to their EP

Medication reconciliation at more than 50% of transitions of care

Provide summary of care document for more than 50% of transitions of care and referrals with 10% sent electronically and at least one sent to a recipient with a different EHR vendor or successfully testing with CMS test EHR

Successful ongoing transmission of immunization data

Conduct or review security analysis and incorporate in risk management process

The eligible professional menu set measures (pick 3 of 6) are:

More than 10% of imaging results are accessible through Certified EHR Technology

Record family health history for more than 20%

Successful ongoing transmission of syndromic surveillance data

Successful ongoing transmission of cancer case information

Successful ongoing transmission of data to a specialized registry

Enter an electronic progress note for more than 30% of unique patients

The Hospital Core objectives are:

Use CPOE for more than 60% of medication, 30% of laboratory, and 30% of radiology

Record demographics for more than 80%

Record vital signs for more than 80%

Record smoking status for more than 80%

Implement 5 clinical decision support interventions + drug/drug and drug/allergy

Incorporate lab results for more than 55%

Generate patient list by specific condition

eMAR is implemented and used for more than 10% of medication orders

Provide online access to health information for more than 50% with more than 5% actually accessing

Use EHR to identify and provide education resources more than 10%

Medication reconciliation at more than 50% of transitions of care

Provide summary of care document for more than 50% of transitions of care and referrals with 10% sent electronically and at least one sent to a recipient with a different EHR vendor or successfully testing with CMS test EHR

Successful ongoing transmission of immunization data

Successful ongoing submission of reportable laboratory results

Successful ongoing submission of electronic syndromic surveillance data

Conduct or review security analysis and incorporate in risk management process


The hospital menu set measures (pick 3 of 6) are:

Enter an electronic progress note for more than 30% of unique patients

More than 10% electronic prescribing (eRx) of discharge medication orders

More than 10% of imaging results are accessible through Certified EHR Technology

Record family health history for more than 20%

Record advanced directives for more than 50% of patients 65 years or older

Provide structured electronic lab results to EPs for more than 20%

He highlighted the patient engagement and electronic exchange requirements that ensure EHRs must actively share data among payers, providers, and patients before stimulus payments are made to hospitals or professionals.

We discussed the fact that lab results transmission only includes those ordered electronically and this could be challenging because many hospitals receive orders manually and return results electronically.   We also discussed the hardship exceptions for Pathologists, Radiologists,  and Anesthesiologists.

Steve Posnack then reviewed the standards rule, noting that it includes 5 major themes - enhancing standards-based exchange, promoting EHR technolog/safety, enabling greater patient engagement, introducing greater transparency, and reducing regulatory burden.

There are 50 certification criteria - 17 clinical, 7 care coordination, 3 clinical quality measures, 9 privacy/security, 3 patient engagement, 6 public health, and 4 utilization

Standards include a common MU Data set - including standards for Problems and Vital signs, which were two items called "without standard" in the Wall Street Journal article referenced above.

slides 16-18 in his presentation nicely summarize these standards

Certification can be "right sized" to align vendor capabilities with customer needs.  For example, BIDMC could elect not to do advance directives, progress notes, or lab transmissions (since it requires receiving incoming electronic orders to qualify and EHRs in the community may not be able to send them), BIDMC would not have to create or certify technologies for menu set items it does not plan to use in attestation

Farzad noted that based on very valuable feedback on the Governance RFI, there will be more focused work on certificate management, provider directories, and helpful convening instead of writing regulation for the NwHIN.   All concurred that this was a good approach.

Liz Johnson and Cris Ross presented an Implementation Workgroup Update on Testing Methods.
They highlighted the notion of scenario based testing - a workflow that requires the execution of multiple related actions.  Chris Brancato presented a medication management example  illustrating how building blocks of unit testing can be assembled into a single logical progression that aligns with workflow.  Carol Bean noted that the next wave of testing procedures, test data , and test tools will be released this Friday.

Finally, Doug Fridsma, provided an update on ONC Standards Activities, highlighting the new Health eDecisions and Automate Blue Button Initiative.

A great meeting demonstrating very important progress.   It's clear to me that Meaningful Use Stage 2 and its associated testing criteria accelerate interoperability more than any previous initiative.

An Update for the Medical Executive Committee

Of all the governance and oversight bodies I serve at BIDMC, the Medical Executive Committee (MEC) is one of the most important.   Here is a communication I wrote today for the MEC Newsletter which summarizes our major FY13 efforts.

"Every year, Information Systems at BIDMC completes dozens of projects prioritized by steering committees and advisory groups of clinicians, staff, and administrators.    Although those involved in these activities track our progress day to day, it's important to widely share our goals and activities so that everyone knows what to expect over the coming year.

BIDMC has a build and buy strategy.   We buy those clinical products that are mature, are regulated by the FDA, or are required by departments with very specialized functionality.   We build those products that need seamless integration, more functionality than commercial products, or are uniquely innovative.    For example, there is no commercial web-based, iPad compatible provider order entry or inpatient medication reconciliation application available on the market today.   BIDMC created them.

Many of our clinical applications are world class, enabling BIDMC to be the first hospital in the country to achieve Meaningful Use as part of the federal stimulus program for healthcare information technology.  However, there are gaps.      We do not perform bedside medication verification with bar codes at the point of medication administration.   We currently do not chart progress notes or nursing flowsheets from inpatient ward areas electronically.  We do not have an entirely electronic hospital record or billing workflow, instead using a hybrid of paper and electronic approaches.

In the next two years we'll develop and pilot systems to fill many of these gaps.

1.  We have a multidisciplinary committee, led by clinicians, pharmacy, and IS, to optimize the entire medication management process, ensuring that we support the '5 rights' of medication administration:

the right patient
the right drug
the right dose
the right route
the right time

As first steps, we're designing screens for electronic medication administration records, and selecting the right bar coding hardware (a combination of mobile and fixed devices) to support bedside medication verification.

2.  We have another multidisciplinary committee, which includes clinicians, administrators, and expert staff to design inpatient clinical documentation.  We're considering the best approaches including the use of templates (such as disease specific structured data), macros (easy to use standard text), computer assisted coding which can prompt clinicians for the precise details needed to improve documentation, social networking approaches that enable team authorship of notes, and single click incorporation of med lists/labs/other parts of the record.

We've already deployed electronic documentation in the Emergency Department and we hope to pilot inpatient ward documentation/nursing notes in FY13.

3.  ICD10, which expands coding from 14,000 to 170,000 codes, will have a profound impact on the way we document and bill.   This critical project will require the intense participation of stakeholders throughout the medical center.    A side benefit of the project will be automating many of our remaining paper billing processes.

In addition to filling these gaps, the years ahead will include many challenges to support compliance requirements and security mandates.   We have 50 projects that IS and compliance have prioritized together that will reduce our risks over the next two years.   Many of these projects are driven by Federal and State regulations which mandate they be done.  However, some of the projects will introduce restrictions, limitations, and responsibilities that some will find inconvenient.   We'll work closely with all stakeholders to balance confidentiality and ease of use.

Finally, FY13 will be a time of preparation for the next phase of meaningful use.  There will be 16 core objectives for hospitals and 17 core objectives for professionals.   BIDMC was the first hospital in the country to attest to meaningful use and we'll work hard to be an early adopter of the next stage.

These are a few of the many projects we'll work on together in FY13.   As we evolve into a mature accountable care organization coordinating wellness across the community, I'm sure more projects and the need for innovation will keep us all busy."

An Update on Controlled Substance e-Prescribing

I recently had a dialog with Surescripts about the current  state of policy and technology enabling controlled substance e-prescribing.   Here's a summary:

1.       Surescripts is “open for business” nation-wide for e-prescribing of controlled substances (“EPCS”), subject of course to restrictions in state laws that do not permit EPCS.
2.       There are 4 physician vendors who are certified on the Surescripts network to transaction EPCS, and are in fact doing so.
3.       There are 6 pharmacies / pharmacy vendors who are certified on the Surescripts network to transaction EPCS, and are in fact doing so.
4.       There are many other prescriber vendors and pharmacies in our certification pipe-line, including some of the larger vendors.
5.       Admittedly, the actual volume of EPCS is still very modest, but it is beginning to increase.
6.       The primary barriers in my view have been:  the development time and effort the vendors and pharmacies needed to come into compliance with the Interim Final Rule (IFR); the third party-audit (this is a reference to the section required IFR Section 1311 audit, not the Surescripts certification), which is both costly and time-consuming; an incorrect perception that no pharmacies can accept EPCS; vendors’ competing development priorities (Meaningful Use Stage 2, ICD-10, etc.); and having all the docs ID proofed and authenticated in conformance with the Drug Enforcement Agency IFR.
7.       Surescripts has been actively working with vendors to communicate and drive adoption.
8      Surescripts will run a report for me that will illustrate the volume in Massachusetts, which does permit EPCS of all scheduled drugs.  I'll publish that report on my blog.
9   There are about 12 states that either prohibit or limit EPCS.
10.    New York has mandated that all drugs, including controlled substance, be prescribed electronically by 12/31/14.

I hope this is helpful to illustrate the work in progress.    The country is on the right trajectory to e-Prescribe all medications, including controlled/scheduled substances.