Lynn Scheps is Vice President, Government Affairs at EHR vendor SRSsoft. In this role, Lynn has been a Voice of Physicians and SRSsoft users in Washington during the formulation of the meaningful use criteria. Lynn is currently working to assist SRSsoft users interested in showing meaningful use and receiving the EHR incentive money. Check out Lynn’s previous Meaningful Use Monday posts.

A great deal of work, discussion, and debate by the HIT Policy Committee and its Workgroup members went into developing the recommendations for meaningful use Stage 2 (discussed in the last two Meaningful Use Monday posts). Meetings were frequent and lengthy, but I tried to listen in on most of them to gain some insights into the thinking behind the decisions being made and the future direction of meaningful use. 

Committee members struggled with striking the right balance between aggressively pressuring providers so that adoption would be accelerated, on the one hand, and maintaining a realistic and practical view of their capabilities, on the other. Some committee members were adamant about staying on track to reach the Stage 3 end goals within the predetermined 2015 time frame, (i.e. remaining on the escalator, as the progression is often referred to), while others recognized that overburdening providers could lead to program failure, i.e., discouraging adoption by imposing unreasonable expectations that would cause providers to doubt their ability to earn the incentives and abandon the effort altogether. The debate led to an open question: does everything have to be accomplished under the umbrella of meaningful use?

 An issue that I think could have used more discussion is how to make meaningful use relevant for specialists—a subject raised frequently by Committee member Gayle Harrell. There was general agreement about the importance of having all types of physicians participate in the incentive program, and testimony from a variety of specialists was solicited. Other than suggesting a large number of new clinical quality measures, however, the basic recommendations are still predominantly primary-care focused. 

Lastly, there was a prevailing sense of frustration over the fact that the calendar did not allow time for an analysis of the experience of Stage 1 before requiring the definition of Stage 2.

Lynn Scheps is Vice President, Government Affairs at EHR vendor SRSsoft. In this role, Lynn has been a Voice of Physicians and SRSsoft users in Washington during the formulation of the meaningful use criteria. Lynn is currently working to assist SRSsoft users interested in showing meaningful use and receiving the EHR incentive money. Check out Lynn’s previous Meaningful Use Monday posts.

In addition to the Meaningful Use Stage 2 recommendations discussed in last week’s Meaningful Use Monday, the HIT Policy Committee proposed a new framework for the reporting of clinical quality measures that was designed by its specifically-tasked Quality Measure Workgroup. The recommended concept is depicted in the graphic below—the intention is to broaden the scope of reporting to address a wider spectrum of factors affecting care and to accommodate all types of physicians.

Providers would report on some number of the core measures, (between 5 and all 8 or 9 is the recommendation), and at least one measure from each of the 6 menu “domains”. The core quality measure set would include all of the core and alternate core measures from Stage 1 and an additional 2 measures related to care coordination. Interestingly, there was no mention of establishing required thresholds to be met on any of the quality measures.

The intention is that all physicians (including specialists) will find measures relevant to their specialty in the core set as well as in each of the domains. This seems like a tall order from a practical perspective, given the primary-care focus of the Stage 1 quality measures, (particularly true of the core, but also the additional measures.) To accomplish this, the workgroup submitted quite a lengthy “library” of measures to CMS for its consideration—some measures are carried forward from Stage 1, others are recently retooled, and many are still “to be developed”.

We’ll be watching intently to see what CMS does with clinical quality measures, since this is such a fundamental part of meaningful use.

Lynn Scheps is Vice President, Government Affairs at EHR vendor SRSsoft. In this role, Lynn has been a Voice of Physicians and SRSsoft users in Washington during the formulation of the meaningful use criteria. Lynn is currently working to assist SRSsoft users interested in showing meaningful use and receiving the EHR incentive money. Check out Lynn’s previous Meaningful Use Monday posts.

A few weeks ago, the HIT Policy Committee forwarded its Stage 2 meaningful use recommendations to CMS. CMS is expected to issue a Proposed Rule in early 2012 and the Final Rule in mid-2012. 

The first recommendation—intensely debated, but overwhelmingly supported in the end—is to delay the start of Stage 2 until 2014, recognizing the unrealistic time pressure that vendors and providers would face if required to upgrade, implement, and train for the new set of requirements by 2013. 

Most of the proposed changes to the measures themselves are not dramatic in scope. Some measures did not change at all, (e.g., problem list, medication list, etc.) Others, (e.g., ePrescribing, smoking status), would have higher thresholds to meet—not a major obstacle if the higher-than-required performance trend reported among early attesters continues—and some would have a slightly broader scope, (e.g., CPOE would include radiology). 

All menu measures would become core measures, which means that they would be required of all providers. If CMS adopts this recommendation, it will be important to identify exclusion criteria to accommodate physicians for whom particular measures may not be relevant, as they did for specific core measures in Stage 1. 

The changes that are more controversial are those that hold physicians responsible for factors beyond their control, such as requiring that a given percent of patients actually view their electronic health information (Stage 1 only requires that the information be made available), or requiring that a given number of patients send a secure message to the physician/practice. Also interesting is that some of the new measures recommended for Stage 2 are measures that were specifically removed by CMS during the Stage 1 rule-making process, such as advance directives and progress notes.

If you are interested in the specifics associated with the recommendations summarized above, Computer Sciences Corporation’s Update on Stage 2 (PDF) presents a nice review.

CPOE (Computerized Provider Order Entry), is the direct entering of orders into a computer (or mobile device), so that the order is documented in a digital, structured, and computable format.

Meaningful Use Core Measure: CPOE
More than 30% of unique patients with at least one medication in their medication list seen by the EP have at least one medication order entered using CPOE.
Exclusion: providers who write fewer than 100 prescriptions during the reporting period.

CPOE is one of the measures that elicited quite an animated response from the provider community. When initially proposed, this measure required 80% of all orders to be directly entered by the provider. To overcome objections to the scope of the requirement and the burden it would impose, CMS ultimately limited the measure to medication orders and reduced the threshold to 30%. (The proposal for Stage 2 reinstitutes lab and radiology orders, but the requirements have not yet been finalized.)

There was also a great deal of conversation about who has to enter the order into the EHR—does it have to be the authorizing physician him/herself? This is the only measure in the Final Rule in which CMS addresses who can perform the function, identifying “…any licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines.” While some providers are unsure about where these specific guidelines can be found, CMS does provide further guidance, stating that CPOE should be done by someone who can exercise clinical judgment and take action based on the alerts and/or clinical decision support information that the order might generate.

Because for now CPOE is limited to medication orders, it is accomplished either in the course of ePrescribing or by using the same workflow but not transmitting the prescription electronically, (e.g., when prescribing controlled substances or prescribing for patients who request a printed prescription.) All of these prescriptions count in the numerator of this meaningful use measure because they are entered into the EHR.

Lynn Scheps is Vice President, Government Affairs at EHR vendor SRSsoft. In this role, Lynn has been a Voice of Physicians and SRSsoft users in Washington during the formulation of the meaningful use criteria. Lynn is currently working to assist SRSsoft users interested in showing meaningful use and receiving the EHR incentive money. Check out Lynn’s previous Meaningful Use Monday posts.

In my previous post about the benefits of inter operable EMR software, Russ Reese left the following comment about the benefits of CPOE and whether CPOE will make it into the ARRA EMR stimulus requirements or not. Plus, he ends with an interesting thought about the EMR stimulus program. I thought it was interesting and more people should read it and comment.

Here is a link to a study that showed some positive results for EMR use – http://jamia.bmj.com/content/17/1/78.full

“Conclusions: A basic CPOE system in a community setting was associated with a significant reduction in medication errors of most types and severity levels.”

Note, this study is about CPOE which is not featured in all EMRs and I think that HIMMS has even been trying to get HHS to back off on making CPOE required for the stimulus $.

But here is real data that shows real benefits. This study is about error rates and not dollars – but if errors are reduced then lawsuits are reduced and hopefully malpractice insurance premiums follow.

IMO, we never needed the tax payer funded stimulus to begin with. Malpractice insurance companies should offer radically reduced rates to physicians that use CPOE and that would be all the “stimulus” that is needed to move doctors toward EHR.

If you’ve had enough of my posts from a talk Marc Probst gave, then you’ll be glad to know this is the last one. There’s no hiding my respect for Marc and hearing him in person did nothing but elevate that respect for him. Some of the comments below will feel a bit random, but I thought they were interesting enough to share with you all.

Meaningful Use and Certified EHR Overlap
I asked Marc about the challenge of reconciling the overlap between the certified EHR criteria modeled after the meaningful use matrix and meaningful use itself. It seemed that they were measuring basically the same thing. Marc’s response was, “That’s a battle I lost.” Then, Marc muttered under his breathe something about certifying the software versus the users. Basically, he was in agreement and under the same confusion I’ve had in regards to the value of certifying the software related to MU versus you actually meaningful using your EMR.

Challenge for Hospital Systems
At one point Marc talked about the challenge of a hospital to adopt an EHR if they haven’t started this already. He started listing off things like a data center and encryption. The data center for a hospital is a significant challenge that takes time. I’ve been a part of the design, creation and building of a couple of data centers and infrastructure like this takes time to implement. I still believe it’s premature to purchase an EHR, but I don’t think it’s premature to plan for things like network infrastructure, data centers, etc.

Certification and Procurring the Right EMR
I had to smile when Marc, co-chair of the EHR certification workgroup, said point blank, “EHR certification is not about procuring the right EHR system.” If you’ve read this blog for any length of time you know how I feel about this subject. Glad to hear Marc say it too.

Funding and EHR Adoption
Marc was really honest when he described that IHC had 0 doctors doing CPOE. I was surprised by this since my childhood doctor was from IHC and had an EHR back then. That said, Marc made an interesting point after saying that IHC had 0 doctors doing CPOE. He proceeded to say he didn’t think the reason they hadn’t adopted CPOE yet was because of a lack of funding. It was all the other things that took time to figure out which has delayed adoption.

I recently came across an interesting term that I’d never heard of: Information Therapy. Here’s the wikipedia description of Information Therapy:

Information therapy works by engaging the consumer in the process of care. Unlike health information which a patient or family member may find on an open website like webmd or yahoo, information therapy is providing plain language evidence based medical information to a patient at the exact time that a patient needs it to help them in their heatlh care process. An example would be when a person who leaves a doctor’s office is provided an after-visit summary of instructions on how they can take care of their ailment at home. Information therapy may be prescribed by a clinician, (i.e. nurse, doctor or other health professional), by a electronic system in a medical institution (i.e.an electronic medical record), or consumer-prescribed.

Interesting term. Learn something new every day. I must admit that I’m pretty horrible with terms. Abbreviations are even worse. Sometimes people contact me with a bunch of abbreviations and I’m just totally lost. So, I either Google them or look past them. Either way, I’m so practical that I don’t care about abbreviations much.

The one that’s always killed me is CPOE. I never remember what that even means. I prefer to call it doctors entering orders. Maybe the abbreviation DEO was already in use somewhere else.

Well, I’ll embrace the term Information Therapy at least for this post. Information therapy is interesting and a PHR really takes it to the next level. However, I think it gets even more interesting when a PHR goes beyond information therapy and actually helps a patient make decisions on their own without seeing the doctor. Yes, I know there are so many legal issues around this, but we’re all far too familiar of the times where you go to the doctor and they basically do nothing but send you home with a script.

I won’t get into all the issues related to this, but I think that the term Information Therapy should be expanded to include a PHR or other website that helps patient save a visit to the doctor or even possibly provides an online doctor’s visit.

Otherwise, I’ll just have to change the definition of Information Therapy to what you experience when reading this blog. Wait, maybe that’s called EMR therapy.