assessing your meaningful use stage compliance as you ... · assessing your meaningful use stage...

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West Coast Regional

Annual Conference

June 17, 2011

Assessing your Meaningful Use Stage Compliance as you Prepare

for Stage 2

Session Objectives

� Success strategies for achieving Stage 1

• Define the key players

• Reporting matrix

• Gap analysis

• Mitigation strategies

• Managing the project to meet the timeline

� Identify the role of Compliance in the Meaningful Use initiative.

� How organizations can leverage their implementation efforts to satisfy broader compliance and quality improvementefforts.

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Audience Question #1

What is your role with EMR transition

at your organization?

*1 Subject Matter Expert; or Other

*2 Assigned to formal project team

*3 Strategic Leadership related

Stage 1 – Infancy – Don’t be fooled

MeaningfulUse

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Meaningful Use Stage 1

1. Use of certified EHR technology in a meaningful manner (e.g. e-Prescribing)

2. Electronic exchange of health information to improve quality of care

3. Report clinical quality measures using certified EHR technology

� CORE Set – 15 mandatory objectives� Menu Set – Pick 5 of 10 objectives

“It’s not so much reporting that’s the challenge, it’s getting the data to report”

~Erica Drazen

Managing Director/Emerging Practices

Computer Sciences Corporation

Stage 1 Final Rule

Proposed Stage 2 Proposed Stage 3 Comments

Drug-drug/drug-

allergy interaction

checks

Employ drug-drug

interaction checking

and drug allergy

checking on

appropriate evidence-

based interactions

Employ drug-drug

interaction checking, drug

allergy checking, drug age

checking (medications in

the elderly), drug dose

checking (e.g., pediatric

dosing, chemotherapy

dosing), drug lab checking,

and drug condition

checking (including

pregnancy and lactation)

on appropriate evidence-

based interactions

Reporting of drug interaction checks to be defined by quality measures workgroup

CPOE for

medication orders

(30%)

CPOE (by licensed

professional) for at

least 1 medication, and

1 lab or radiology order

for 60% of unique

patients who have at

least 1 such order

(order does not have to

be transmitted

electronically)

CPOE (by licensed

professional) for at least 1

medication, and 1 lab or

radiology order on 80% of

patients who have at least

1 such order (order does

not have to be transmitted

electronically)

Measures Requiring Compliance Involvement

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Maintain problem list (80%)

Continue Stage 1 80% problem lists are up-to-date

Expect to drive list to be up-to-date by making it part of patient visit summary and care plans

Maintain active med list (80%)

Continue Stage 1 80% medication lists are up-to-date

Expect to drive list to be up-to-date via medication reconciliation

Maintain active medication allergy list (80%)

Continue Stage 1 80% medication allergy lists are up-to-date

Expect to drive the list to be up-to-date by making it part of visit summary

Record vital signs (50%)

80% of unique patients have vital signs recorded

80% of unique patients have vital signs recorded

Record smoking status (50%)

80% of unique patients have smoking status recorded

90% of unique patients have smoking status recorded


Implement 1 CDS rule Use CDS to improve performance on high-priority health conditions. Establish CDS attributes for purposes of certification: 1. Authenticated (source cited); 2. Credible, evidence-based; 3. Patient-context sensitive; 4. Invokes relevant knowledge; 5. Timely; 6. Efficient workflow; 7.

Use CDS to improve performance on high-priority health conditions. Establish CDS attributes for purposes of certification: 1. Authenticated (source cited); 2. Credible, evidence-based; 3. Patient-context sensitive; 4. Invokes relevant knowledge; 5. Timely; 6. Efficient workflow; 7.

Implement drug formulary checks*

Move current measure to core

80% of medication orders are checked against relevant formularies

What is the availability of formularies for eligible professionals?

Record existence of advance directives (EH) (50%)*

Make core requirement. For EP and EH: 50% of patients >=65 years old have recorded in EHR the result of an advance directive discussion and the directive itself if it exists

For EP and EH: 90% of patients >=65 years old have recorded in EHR the result of an advance directive discussion and the directive itself if it exists

Potential issues include: state statutes; challenges in outpatient settings; age; privacy; specialists; needs to be accessible and certifiable; need to define a standard

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Stage 1 Final Rule Proposed Stage 2 Proposed Stage 3 Comments

Provide electronic copy of health information, upon request (50%)

Continue Stage 1 90% of patients have timely access to copy of health information from electronic health record, upon request

Only applies to information already stored in the EHR

Provide electronic copy of discharge instructions (EH) at discharge (50%)

Electronic discharge instructions for hospitals (which are given as the patient is leaving the hospital) are offered to at least 80% of patients (patients may elect to receive only a printed copy of the instructions)

Electronic discharge instructions for hospitals (which are given as the patient is leaving the hospital) are offered to at least 90% of patients in the common primary languages (patients may elect to receive only a printed copy of the instructions)

Electronic discharge instructions should include a statement of the patient’s condition, discharge medications, activities and diet, follow-up appointments, pending tests that require follow up, referrals, scheduled tests [we invite comments on the elements listed above]

EHR-enabled patient-specific educational resources (10%)

Continue Stage 1 20% offered patient-specific educational resources online in the common primary languages


Incorporate lab results as structured data (40%)*

Move current measure to core, but only where results are available

90% of lab results electronically ordered by EHR are stored as structured data in the EHR and are reconciled with structured lab orders, where results and structured orders available

Generate patient lists for specific conditions*

Make core requirement. Generate patient lists for multiple patient-specific parameters

Patient lists are used to manage patients for high-priority health conditions

Send patient reminders (20%)*

Make core requirement.

20% of active patients who prefer to receive reminders electronically receive preventive or follow-up reminders

How should ―active patientǁ be defined?

(NEW) 30% of visits have at least one electronic EP note

90% of visits have at least one electronic EP note

Can be scanned, narrative, structured, etc.


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(NEW for EH) 80% of patients offered the ability to view and download via a web-based portal, within 36 hours of discharge, relevant information contained in the record about EH inpatient encounters. Data are available in human-readable and structured forms (HITSC to define).

80% of patients offered the ability to view and download via a web-based portal, within 36 hours of discharge, relevant information contained in the record about EH inpatient encounters. Data are available in human readable and structured forms (HITSC to define).

Inpatient summaries include: hospitalization admit and discharge date and location; reason for hospitalization; providers; problem list; medication lists; medication allergies; procedures; immunizations; vital signs at discharge; diagnostic test results (when available); discharge instructions; care transitions summary and plan; discharge summary (when available); gender, race, ethnicity, date of birth; preferred language; advance directives; smoking status. [we invite comments on the elements listed above]

Provide clinical summaries for each office visit (EP) (50%)

Patients have the ability to view and download relevant information about a clinical encounter within 24 hours of the encounter. Follow-up tests that are linked to encounter orders but not ready during the encounter should be included in future summaries of that encounter, within 4 days of becoming available. Data are available in human-readable and structured forms (HITSC to define)

Patients have the ability to view and download relevant information about a clinical encounter within 24 hours of the encounter. Follow-up tests that are linked to encounter orders but not ready during the encounter should be included in future summaries of that encounter, within 4 days of becoming available. Data are available in human readable and structured forms (HITSC to define)

The following encounter data are included (where relevant): encounter date and location; reasons for encounter; provider; problem list; medication list; medication allergies; procedures; immunizations; vital signs; diagnostic test results; clinical instructions; orders: future appointment requests, referrals, scheduled tests; gender, race, ethnicity, date of birth; preferred language; advance directives; smoking status. [we invite comments on the elements listed above]



Provide timely electronic access (EP) (10%)

Patients have the ability to view and download (on demand) relevant information contained in the longitudinal record, which has been updated within 4 days of the information being available to the practice. Patient should be able to filter or organize information by date, encounter, etc. Data are available in human-readable and structured forms (HITSC to define).

Patients have the ability to view and download (on demand) relevant information contained in the longitudinal record, which has been updated within 4 days of the information being available to the practice. Patient should be able to filter or organize information by date, encounter, etc. Data are available in human readable and structured forms (HITSC to define).

The following data elements are included: encounter dates and locations; reasons for encounters; providers; problem list; medication list; medication allergies; procedures; immunizations; vital signs; diagnostic test results; clinical instructions; orders; longitudinal care plan; gender, race, ethnicity, date of birth; preferred language; advance directives; smoking status. [we invite comments on the elements listed above]

This objective sets the measures for ―Provide timely electronic access (EP)ǁ and for ―Provide clinical summaries for each office visit (EP)ǁ

EPs: 20% of patients use a web-based portal to access their information (for an encounter or for the longitudinal record) at least once. Exclusions: patients without ability to access the Internet

EPs: 30% of patients use a web-based portal to access their information (for an encounter or for the longitudinal record) at least once. Exclusions: patients without ability to access the Internet

(NEW) EPs: online secure patient messaging is in use

EPs: online secure patient messaging is in use


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(NEW) Patient preferences for communication medium recorded for 20% of patients

Patient preferences for communication medium recorded for 80% of patients

How should ―communication mediumǁ be delineated?

Offer electronic self-management tools to patients with high priority health conditions

We are seeking comment on what steps will be needed in stage 2 to achieve this proposed stage 3 objective

EHRs have capability to exchange data with PHRs using standards-based health data exchange


Patients offered capability to report experience of care measures online


Offer capability to upload and incorporate patient-generated data (e.g., electronically collected patient survey data, biometric home monitoring data, patient suggestions of corrections to errors in the record) into EHRs and clinician workflow


New Measure: Communication PreferencesStage 1 Final Rule Proposed Stage 2 Proposed Stage 3 Comments


Perform test of HIE Connect to at least three external providers in ―primary referral networkǁ (but outside delivery system that uses the same EHR) or establish an ongoing bidirectional connection to at least one health information exchange

Connect to at least 30% of external providers in ―primary referral networkǁ or establish an ongoing bidirectional connection to at least one health information exchange

Successful HIE will require development and use of infrastructure like entity-level provider directories (ELPD)

Perform medication reconciliation (50%)*

Medication reconciliation conducted at 80% of care transitions by receiving provider (transitions from another setting of care, or from another provider of care, or the provider believes it is relevant)

Medication reconciliation conducted at 90% of care transitions by receiving provider

Provide summary of care record (50%)*

Move to Core Summary care record provided electronically for 80% of transitions and referrals


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Submit immunization data*

EH and EP: Mandatory test. Some immunizations are submitted on an ongoing basis to Immunization Information System (IIS), if accepted and as required by law

EH and EP: Mandatory test. Immunizations are submitted to IIS, if accepted and as required by law. During well child/adult visits, providers review IIS records via their EHR.

Stage 2 implies at least some data is submitted to IIS. EH and EP may choose not, for example, to send data through IIS to different states in Stage 2. The goal is to eventually review IIS-generated recommendations

Submit reportable lab data*

EH: move Stage 1 to core EP: lab reporting menu. For EPs, ensure that reportable lab results and conditions are submitted to public health agencies either directly or through their performing labs (if accepted and as required by law).

Mandatory test. EH: submit reportable lab results and reportable conditions if accepted and as required by law. Include complete contact information (e.g., patient address, phone and municipality) in 30% (EH) of reports. EP: ensure that reportable lab results and reportable conditions are submitted to public health agencies either directly or through performing labs (if accepted and as required by law)

Submit syndromic surveillance data*

Move to core. Mandatory test; submit if accepted




Conduct security review analysis & correct deficiencies

Additional privacy and security objectives under consideration via the HIT Policy Committee’s Privacy & Security Tiger Team

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� Structured electronic template development to support:• ICD-9 & 10 specificity

• Meaningful Use• Medical Necessity

• Co-morbids and complications• Present on Admission

• Severity of Illness• Risk of Mortality

Meaningful Use: New/Emerging Roles Vanderbilt University Medical Center -Nashville, TN

Physician Educator

“By focusing on ‘meaningful use,’ we recognize that better healthcare does not come solely from the adoption of technology itself, but

through the exchange and use of health information to best inform clinical decisions at the point of care.”

~David Blumenthal, National Coordinator

Key Considerations

� Problem List Management• Accurate and standardization of the problem list can yield the most

precise information for decision support, clinical care, coding and billing

• Strive for uniformity/standardization by practice

� Challenges with adoption• Defining/refining responsibility of maintenance

• Complexity of integrated health networks with a shared EMR impacts scope

• EMR Governance

• Tools to assist with problem capture – SNOMED CT – ICD-9 (picklist), complexity increases with ICD-10

� Solutions

� Consider PCP accountability for maintenance of accurate problem lists; with ability for Specialists to provide recommended additions

� Create and implement new policy

� Identify technology solutions to accomplish accurate capture

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Key Considerations (cont.)

� Reporting

• Assure ample resources

• Assess use of databases external to the EMR

• Use of separate, uncertified systems may be used to generate reports so long as the data is captured using certified EHR technology

� Meaningful Use Ownership/Governance

• Define how to drive MU

• Clarify roles/responsibilities within the organization

� As you navigate a hybrid system environment & review Technology Infrastructure:

• Consider how standalone systems, such as ROI, will be used in conjunction with a certified EMR

• Review hardware, training and security needed to provide electronic PHI (e.g., discharge instructions)

• Explore opportunities to release to patient portal or PHR

Stage 1 Reporting

for EPs

Timelines

Jan 2010

Proposed Rule Final RuleStage 1 Reporting for

Hospitals

July 2010 Oct 2010

Stage 2 Reporting for Eligible Professionals

Jan 2012

Stage 2 Reporting for Hospitals

July 2012 Oct 2012

Development

July 2011

Implementation

Proposed Rule Final Rule

Development

Implementation

Stage 1

Stage 2

Some hospitals/EPs will take longer for implementation.

Some hospitals/EPs will take longer for implementation.

3

Meaningful Use Timelines

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Meaningful Use: Stage 2 –Are we having fun yet?

� Unreasonable timelines impact:

• EMR system development, testing and release

• Customer implementation timeline

• Risk to patient safety

� Quantity of proposed quality measures could distract from stage 1 core EMR adoption

� Lack of specificity with proposed standards enables variance in system development and fosters concerns with clinical quality measure reporting

Meaningful Use: Stage 3All Grown Up

� Introduction of IOM demographic categories

• Relies on clarification of demographics to be captured in stage 2

� Standards also include vague language, which can enable non-standard or non-compliant implementation

� Proposed establishment of clinical decision support (CDS) attributes expands beyond current EMR capabilities and may be too rigid

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Meaningful Use: Stage 3All Grown Up (Cont.)

� New proposed measures• Patient-Reported experience of

care measures – standard lacks specificity

• Incorporation of patient-generated data– requires sufficient lead time for development

• Public Health Button – requires further clarification for development and reporting

• Patient Generated Data submitted to Public Health Agencies – debate on validity of inclusion within EHR

So where to begin?

� Leverage opportunities to learn and understand Meaningful Use Criteria

� Seek participation in a dedicated, multi-disciplinary Task Force

• Not involved yet? Ask to join current efforts!

� Support completion of a gap analysis and help drive timely rollout of resulting actions

� Complete Privacy & Security risk assessment

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About Rady Children’s Hospital –San Diego

� Vision

• We will be a leader, recognized nationally and internationally, for excellence in patient care, education, research and advocacy.

� Mission

• To restore, sustain and enhance the health and developmental potential of children through excellence in care, education, research and advocacy.

Where we Provide Services

� Through Rady Children's network of physicians, kids can receive specialized clinical and primary care services at more than 30 satellite locations throughout the county.

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� Rady Children's is the largest children’s hospital in California • 442-bed pediatric care facility providing the largest source of

comprehensive pediatric medical services in San Diego, Southern Riverside and Imperial counties;

� Team Of• nearly 700 physicians; � more than 1,000 nurses on staff;

� nearly 3,500 employees;

� 450 active volunteers; and

� more than 1,200 Auxiliary members.

Unique among California’s eight children’s hospitals

� Serves as the only dedicated safety net provider for the region

• Providing 90% of all government funded pediatric services.

� Is a Level 1 pediatric trauma center.

� Provides all of the non-neonatal CCS specialty care services in the region.

� Has the lowest average length of stay of any California children’s hospital.

� Is the only pediatric teaching hospital in the region for doctors, nurses, pharmacists, and all other pediatric specific clinical disciplines.

Unique among California’s eight children’s hospitals

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In 2010, the RCHSD ranked specialties are:

� Orthopedics (#4)

� Urology (#12)

� Neonatology (#27)

� Pulmonology (#30)

� Diabetes and Endocrinology (#30)

US News & World ReportOur Journey to World Class

� Scripps Memorial NICU: partnership established in 1999 managing

14 beds;

� Scripps Encinitas NICU: partnership established in 2003 managing 6

beds;

� Sharp Grossmont Pediatric Acute Care: three-year partnership

established in 2008 managing 11 beds;

� Palomar Hospital NICU and Pediatric Acute Care Beds: implemented

in August 2010 managing 20 beds; and

� Sanford Children’s Clinic: in Oceanside opening in April 2011.

Clinical Care Partnerships

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� In 2009, Rady Children’s Specialists of San Diego, a medical practice foundation, was formed to improve the delivery of care to our patients while enhancing clinical research, teaching and innovation.

As the major provider of pediatric care, RCHSD has become the pediatric clinical laboratory for its extended service area. Current partnerships include:

� UCSD

� The Scripps Research Institute

� Salk Institute

� Sanford-Burnham Medical Research

Institute

� San Diego State University

� St. Jude Children’s Research Hospital

� Child Adolescent Service Research Center (CASRC): a consortium of over 100 investigators and staff from multiple research organizations in San Diego County strategically focused on improvement of pediatric mental health.

Research Partnerships

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� In Fiscal Year 2010, Rady Children’s:• Cared for 147,228 children

• 220,000 outpatient visits and more than 15,600 inpatient admissions

• 1,159 trauma cases; Ambulance and helicopter transport was used in 60 percent of all trauma cases

• 67,933 emergency care visits

• More than 20,000 surgeries

• Nearly 11,000 visits at the cardiology clinic and performed 400 open-and closed-heart surgeries

• Peckham Center for Cancer and Blood Disorders, cared for 200 new patients, attended to more than 15,400 visits at the Carley Copley Outpatient Clinic, and performed 29 bone marrow transplants.

Fingertip Facts

New Acute Care Pavilion

� Opened on October 10, 2010

� LEED-Certified (green) building

� Home to the incredible new Peckham Center for Cancer and

Blood Disorders, the state-of-the-art Warren Family Surgical

Center, and a Neonatal Intensive Care Unit that cares for our community’s most fragile newborns.

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What is the status of EMR

implementation at your organization?

*1 Partially implemented

*2 Implementation in progress

*3 Vendor selection underway

EHR Implementation at RCHSD and CHN

What we did at Children’s Health Network

in San Diego, to select and deploy an EHR

Across the integrated delivery system:

Background:

� Integrated Delivery System • Rady Children’s Hospital-San Diego

• Rady Children’s Specialists San Diego

• Medical Practice Foundation

• Children’s Primary Care Medical Group

• Practice Management Group

• Rady Children’s Physician Management

Services

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EHR Journey Started in 2002

� Single Repository, Simultaneous Access, Payor and Community MD Portal, MD completion, Legal Electronic Record – 2002

� Selection of Epic across the IDS – CHN

� Revenue Cycle, HIM, ED, Urgent Care Satellites, Ambulatory – 2009

� Care Everywhere (HIE), My Chart, EpicCare Link, Inpatient, Pharmacy, Surgery, Oncology - Kick-off – 2010

Start with a clear vision

http://www.code-muse.com/blog/wp-content/uploads/2007/11/df20021001.jpg

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Improve Care through Investment in IT

� Achievement of “Paper-lite” and automation through standardization, integration, common infrastructure and applications, and consolidation as appropriate

� Alignment with performance measurement initiatives

� Support increasing demand for e-health functionality for CHN/IDS patients and clients

� Seamless patient recognition and access across all entities in the IDS

� Elimination of redundant data collection points

� Full visit & encounter history within the IDS

� Sharing clinical data and patient information across entities

� Developing advanced clinical functionality, clinical decision support

Plan your journey

� Guiding Principles

• Full Participation

• Full Focus

• Business/Clinical Ownership &

• Accountability

• Relentless Communication

• Early, Often

• Empower Decision Makers

• Excellence, not perfection

• Leverage Success of Others– Model System

• Standardization– Drive efficiency in quality by minimizing

variation

– Value and respect the business needs of each entity

• On Time/On Budget

• It’s for the Kids!

� Develop a comprehensive project charter

� Clearly define and communicate vision & goals

� Create & adhere to guiding principles

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Keep an eye on what’s ahead

Timeline: Years 5-8

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It takes a Village…

� Core implementation team comprised of:

• Executive Sponsors, Clinical Champions, Project Management and Team

� Assure diversity in discipline representation across the organization

� Must be Clinical & Quality Leadership driven

And a super,Fabulous Team!

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Plus more…

� Leadership

� Subject Matter Experts

� Super Users

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EMR/RC Steering CommitteeEMR/RC Steering Committee

“CHN" Executive Committee“CHN" Executive Committee

EMR/RC Workgroups (Ad Hoc)EMR/RC Workgroups (Ad Hoc)

Leadership and Advice

Direction/ Initiatives

Strategy/Plan

Information

EMR/RC Governance Structure

RCHHC Board of Directors

CPCMG Board of Directors

RCSSD Board of Directors

Governance is a must!

Technology Advisory Council

Clinical InformationAdvisory Council

RCPIP Stakeholder & Sponsor Group

EMR/RC Executive CommitteeEMR/RC Executive Committee

Strategic leadership, policy setting, funding guidelines and budget

approval for “CHN”projects/initiatives, (including IT),

report to Board(s).

EMR/Rev Cycle strategy, prioritize all Epic related IT initiatives, make recommendations to Executive

Committee and allocate resources.

Provide perspective to identify, evaluate, justify, prioritize,

recommend, and monitor EMR/Rev Cycle project (need to make sure

there is adequate representation from each Entity- these are working

groups).

Perform detailed tasks such as data gathering, analysis, and

implementation (process & system design, build, validate, test, train,

support).

PMG Board of Directors

RCPMS Board of Directors

Ad-hoc. Conflict resolution, enforcement of decisions.

CIOCIOAd-hoc. Conflict resolution, enforcement of decisions.

Organization

9/05/2008

� Ongoing updates, multiple methods• Meetings

• Intranet

• Bulletin Boards, table tents

• Brochures

• Monthly Provider and Organizational Newsletters

� Events!• Epic Day

• Product Demos

• Integrated Workflow Walkthrough

• Dress Rehearsal

Organization Change Management -Visibility is everything

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Manage Communication Closely

Sample announcements, posters & take-aways

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Go-Live & Training Posters

Manage your milestones carefully and be comfortable with being a ‘scope creep’ in order to avoid

scope creep

Stay focused…

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Back to the Future -Workflow Redesign

� Assess current state workflow, design future state thereafter

� Plan for optimal environment; understand revisions may occur as the timeline and project advances

� Perform gap analysis of change

� Think out of the box!

Sample Future State Workflow: ED to Inpatient

� A picture is worth a thousand words…

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Training & Education

� Critical success factor for implementation success and long term adoption

� Mandate training; develop competency checklist

• Stand firm on requirement for all roles/disciplines

• Flex on duration and timing, depending on user and their level of system use or knowledge.

� Identify & Engage Super Users in end user training process

Understand (and accept) that go-live is just the beginning…

there is no true “end”

Are we there yet?

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EHR: Core, Ancillary, and Specialty Applications Before (2008)

Key: Core System Component Interfaced Application Standalone Application No Application

ICU Clinical Patient Record

Ambulatory Computerized Patient Record

Surgical Apps - departmental

Surgical Apps - clinical

Medication Management

Clinical Trials

Oncology Computerized Patient Record

Neonatal Computerized Patient Record

EDComputerized Patient Record

Online Patient Education &

Entertainment

Home Health Services

Core Clinical Information System

Nursing Clinical Documentation

Physician Documentation

Computerized Physician Order Entry

Advanced Care Planning Clinical

Protocols and Pathways

RT / PT & Speech Therapy

Ordering and Documentation

Medication Administration

Record

Point of Care MAR with Bar

Coding

Clinical Data Repository

Integrated Inpatient & Outpatient

Knowledge Engine and links to

Knowledge Bases

Document Imaging

Results Review

Intelligent Results Reporting

Physician Portal

Laboratory Pathology

Order Communication and Order

Management

Discharge Planning / Summary

Surveillance Reporting

Blood BankDietary and

Nutrition

Neurology / EEG / EMG

Cardiology / Pulmonary

Radiology

Ancillary Systems

Data Warehouse

Advanced Query and Research Tools

Neonatal Point of Care

Registration(ADT)

Professional BillingHospital Billing

Scheduling EMPI

Outpatient Pharmacy -

billing

HIM – Abstracting, Release of Information

Inpatient Pharmacy

PACS

Outpatient Pharmacy –

E-prescribing

EHR: Core, Ancillary, and Specialty Applications Fall 2011







Clinical Trials



Nutrition



Radiology


Billing

Inpatient Pharmacy

Ancillary Systems

PACS


E-prescribing










Record


Coding




Knowledge Bases

Document Imaging

Results Review


Physician Portal


Management



Data Warehouse


Registration(ADT)


Scheduling EMPI






Entertainment



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Clinical Trials



Nutrition



Radiology


Billing

Inpatient Pharmacy

Ancillary Systems

PACS


E-prescribing










Record


Coding




Knowledge Bases

Document Imaging

Results Review


Physician Portal


Management



Data Warehouse


Registration(ADT)


Scheduling EMPI






Entertainment



EHR: Core, Ancillary, and Specialty Applications Winter 2012


According to the e-HIM Practice Transformation Practice Brief there are three states of transformation. Which state are you at?

*1 Traditional – paper health record

*2 Transitional – Hybrid- paper and electronic

*3 Electronic Hybrid – electronic legacy legal health record transitioning to a new EHR

*4 Fully Electronic - arrived at the future state (why aren’t you giving this talk)

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Reporting Considerations

Design your data collection system with the

“end in mind “- It is difficult if not impossible

to turn back the clock if discrete data

elements are not populating your data

warehouse, decision support system, or

data repository

Health Information Exchange

� Meaningful Use requires participation in HIE – choice of state, regional, Beacon exchange project

HIM roles in HIE and P&S (job functions/positions being created or expanded due to HITECH)

� Scope of work has expanded for Privacy/Security in all settings of healthcare, including previously non-covered entities, and HIE organizations

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Collaborative Grant

Part of a $220 million American Recovery and Reinvestment Act initiative to use HIT to advance meaningful, measurable improvements in healthcare. San Diego was the only region in CA to be selected due to:

� Joint efforts of San Diego’s healthcare providers

� The strength of our healthcare stakeholder community

� The innovative application of HIT already taking place throughout San Diego

Beacon Goals are to:

� Positively impact the care of San Diego patients and the health of our community, while advancing HIT throughout the region.

� Foster secure access, clinical integration, interoperability, and data exchange, while working to cover gaps in the region’s HIT infrastructure.

� Serve as a prototype community as we develop solutions that can be widely applied.

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http://sandiegobeacon.org/Pages/default.aspx

SDBC’s Four Overarching Goals:

� Information Technology: Improve the region’s HIT Infrastructure by creating an electronic health data exchange to facilitate interactions among patients, providers and hospitals;

� Health Quality: Improve care of cardiovascular and cerebrovascular disease across the continuum, from prevention to acute care to chronic disease management;

� Population Health: Improve immunization and syndromic reporting and public health surveillance;

� Cost-Efficiency: Reduce unnecessary and preventable care utilization by reducing unnecessary testing, ED visits and hospital re-admissions

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San Diego Beacon project

Connections

1. National Health Information

Network

2. Local health services

3. Hospitals and practices

NHINNHIN

CDC

Community A

State/Local

Government Community B

Clinics

EMS

County Public

Health

San Diego

VA/DOD

1

2

2

Immunization

Registry

2

3

Non-governmental

hospitals

3

SDBC HIE

NHIN

VAKaiser

NavySan Diego

Beacon

CCC

UCSD

Rady

SharpScripps

PublicHealth

EMS

Others

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Health Information Exchange and Privacy and Security Roles

� HIE Coordinators

� Privacy Officers, Coordinators

� Privacy Auditors

� Identity Managers

� MPI Integrity Coordinators

� Consent Directive Coordinators

� Patient Advocate

� Patient Portal Manager

� Physician Practice Outreach Manager

� Data Quality Interoperability Manager

Journey – LMR to Epic LMR

� Acknowledge changes on the horizon, 3+ years

� Worked with Senior Management/Directors in IM to assure the appropriate structure/involvement

� Made key staffing decisions

• Skill Inventory

• Harmonization with key roles

• Governance Involvement

• Integration Inventory

• Update and create new Job Descriptions

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Compliance Officer’s Role in the EHR

� Communicate with Key Constituencies:• EHR status

• Future Compliance Changes and Challenges

• Potential Opportunities

• Build, Validation, Testing, Training and Implementation roles

� Compliance’s Role in Stages/Phases of EHR• Mantra – Find our New Niche – Trusted Source & Player

� Don’t wait to be asked – be proactive, invite yourself

� Question current state – don’t assume just because it is done now it is needed in future state

� Get Trained – Key roles Certified, but SMEs also trained

COMPLIANCE VISION

� To Provide Excellent Customer Service and Expert Leadership in:

• EHR Education: LMR, EMPI, Confidentiality, Patient, MD and Payor Portal

• Maintaining a structured format/content

• Actively participate and lead as appropriate activities related to the input and output of the EHR

• Maintaining documentation standards, principles and regulatory requirements

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The EHR vs. the LHRElectronic Health Record• Pt. Care Tool –supports treatment

functions – supports clinical decision support at the point of care

• Built to store and display data – data can be combined, graphed, displayed & analyzed by rule engines to create the optimal clinical decision

• Built for the patient care provider

• Focus is on the present and near future

• Dept. or role centered around clinical workflows

• Contains all data, including non-discoverable portions

• Constantly evolving information on a patient, with no sense of completion or omission

• Episodic – focus on the current episode of care

• Short term focus – primary use is during the course of the patients stay

Legal Health Record• Business Record – supports payment &

operational functions

• Built to store and produce documents –focus is on actions & results – orders, progress, procedures, results

• Built for outside requestors – supports coding, payment, risk management, release of information. Organized around document type

• Focus is on the historical record

• Patient or encounter centered – built primarily for business workflows & needs

• Based on designated record set –contains the releasable medical record

• Complete – conforms to hospital policies, federal and state regulations. All accesses are tracked

• Longitudinal – contains a complete patient history of all encounters

• Long term focus – primary use is in first month following discharge then retained per policy

Slide courtesy of eWebHealth, a division of ChartOne

One Patient...One Record………Dual Cycles

� Common patient access / front-end

� Patient identification is key

� Linkages between revenue and patent care cycles

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Current State to Future State

PAPER:

Medical Record Comm.

� Paper - Hybrid

Forms Comm.

• Focus:• Regulatory/Legal

• Efficiency

• Communication

• Document

ELECTRONIC:

EHR Governance

� Managed regardless of Media

LMR/Chart Review/Confidentiality Workgroup:

• Focus:• Regulatory/Legal

• View Appropriate to role

• Consistency

• Confidentiality

New Skills Required

� The Compliance professional, as well as their staff will need to develop new skills that include:

• Collecting, Managing, Auditing, and Maintaining the electronic health record – integration with legacy LHR

• The Compliance professional can prepare themselves for the new roles that will become available with the electronic health record by taking an inventory of their current skills

• A skills assessment can assist the Compliance professional in determining which areas of skills may need further education or knowledge.

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Process Skill - Self Assessment - Name

Please review the following sections to determine your level of skill or awareness associated with each line item. Place an "X" in the column that best describes your assessment of your capability to satisfy each line item

1=Beginner 2=Intermediate 3=Advanced 4=Expert -- Leave blank if not applicable to your skills set.

Skill Description 1 2 3 4

Analytical Skills

Analytic and research skills to recognize trends, performance, and availability issues

Effective problem analysis and research skills

Extensive problem analysis, research and prevention techniques (statistical analysis)

Gap analysis and assessment techniques

Problem solving techniques, including root cause analysis and system outage analysis

Trending skills

Ability to troubleshoot and pass off to the appropriate person for resolution

Ability to use customer satisfaction survey tools

Some new or additional skills the Compliance professional may need are:

� Core Knowledge Set

• Analytical skills

• Business awareness

• Critical thinking skills

• Electronic records management

• Project management skills

• Workflow analysis

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Some new or additional skills the HIM professional may need are:

� Advanced Knowledge Set• Electronic record retention issues

• Identity Management

• Privacy guidelines

• Security guidelines

• Data storage and Retrieval

• Software Development

• Report Writing

• System Integration – HL7

• SNOMED-CT mapping to ICD-9

HID Ownership vs. Collaboration

� KEY CONSIDERATIONS:• Don’t split accountability and responsibility

• Compliance Involvement in:

– Identity Management

– Epic Care Link

– Scanning Integration

– Transcription Integration

– Legal Health Record

– Clinical Terminology (SNOMED CT – ICD-9)

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Compliance Collaboration

� KEY CONSIDERATIONS (cont.):

� Inbasket

� Template Development

� Problem List

� Order Development to drive a deficiency, i.e. bed side procedure

� Note Types

� MyChart

� CareEverywhere (Epic HIE)

� Patient Health Record (PHR)

Items to Hold Your Ground

� Master Patient Index Migration:

• Complete MPI (Vendor recommended only last 2 years)

• Complete Visit History – links to legacy legal health record (Roadmap at RCHSD)

� Data Integrity/Pt. Safety

� External Reporting

� Revenue Cycle

� Patient Access

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Challenges/Focus with Meaningful Use

� Concurrent Analysis:

• Clinical Documentation Improvement Specialists

• Record Analysts – check discrete entry

� Release of Information Specialists

• Meet quicker TAT with Meaningful Use

• Augment traditional release into Patient Portal, PHR, CD

• Attach release restrictions

• 2nd level external record access issues

Standardization Decisions

� Chart Order in Epic

� Chart Review

� Patient Headers

� Access

� Research

� Confidentiality

� Quick Disclosure/Printing

� Transcription

� Documentation Templates

� Chart Corrections/Moves/Amendments/Addendum/Pended Notes

� Patient Identity/EMPI Oversight

� Copy/Paste

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The Needs of a Growing Campus

� Resources –Functional areas (ROI, Scanning, Coding)

� Build – Scan Links in Epic, New Locations in Chartmaxx

� Residual paper –centralized/POC Scanning?

� Legal Record Considerations with Medical Foundation Services:

• Centralized/Decent-tralized

• Legacy Record Management

• Transcription/Voice capture options?

Results Since Epic Go-Live –Transcription Reduction

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Results Since Epic Go-Live – MPI Duplicates Created (Reflects Clean-up)

Results Since Epic Go-Live – MPI Duplicate Rate

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Results Since Epic Go-Live –Overlay Creation

Results Since Epic Go-Live –Overlay Creation

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Other Challenges Since Epic Go-Live

� Chart Corrections (Guide – handouts)

� Managing Access

� Confidentiality Build

� Inbasket

� Claims Edit Work Queue Management

� Re-visiting Workflow – at each stage of the go-live and future go-lives

Don’t Forget About What is Coming?

� ICD-10

� Clinical Documentation Improvement

� 5010

� Health Care Reform (ACO) Considerations for HIM

� Stage 2 and Stage 3 Meaningful Use

� Health Information Exchange

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Transition to ICD-10

Preparation Plans:ICD 10 Readiness Assessment –3M/Accenture – leaders in Coding and Documentation Revenue Cycle/Data Analytics – 2/1 – 3/30/11

• Project Plan – Mitigate Issues Identified

• Budget

• Roadmap with specific migration path to address: resources, technology and processes that need to be designed or re-tooled

• Detailed Training Plan

• Targeting coding and documentation improvement opportunities

10 Benefits if ICD -10 CM/PCSThe transition to ICD-10-CM/PCS will allow for precise diagnosis and procedure codes, resulting in the improved capture of health care information and more accurate reimbursement. Benefits of ICD-10-CM/PCS include:

1. Improved ability to measure health care services, including quality and safety data

2. Reduction in coding errors

3. Increased sensitivity when refining grouping and reimbursement methodologies

4. Enhanced ability to conduct public health surveillance

5. Decreased need to include supporting documentation with claims

6. Increased ability to distinguish advances in medicine and medical technology

7. Provide more detail on socio-economic status, family relationships and ambulatory care

8. Facilitate use of administrative data to evaluate medical processes and outcomes, to conduct biosurveillance and to support value-based purchasing incentives

9. Flexibility to expand in the future

10. Facilitate greater compliance with HIPAA electronic transactions, code set requirements

Clinical Documentation Improvement (CDI)

Preparation Plans:The project planning phase was kicked off on January 13, 2011 with a project implementation date of March 14, 2011.

• Project Planning – January 13th-Jan 31st

– Scheduling of Key Meetings with Functional Areas

– Obtain updated APR-DRG opportunities with comparative analysis

– Review specifications for CDI software implementation

• Implement CDI System

• MD Communication

• Hire CDI Staff/Select MD CDI Director

• Select MD Champions in each area

• CDI onsite Kick-off – March 15 - Weekly visits through the end of June.

Clinical Documentation Training will Clinical Documentation Training will provide physician-to-physicianinteraction, observation and enhanced process flows.

Outcomes will include:

• Improved hospital and medical staff profiles

• Improved coder efficiency

• Improved ICD-9 and APR-DRG accuracy

• Medical records accurately reflecting resources

• Reduced risk of noncompliance

• Reduced physician interactions

• Improved physician understanding of accurate medical documentation

• Increase in Case Mix Index

• Increased Professional fees

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Lessons Learned

� Take time to visualize the workflow of key clinical and revenue cycle related functions supporting a paperless health record.

� During the planning stage, identify what clinical data will be needed for any population-based reports.

� Ensure all other department implementation electronic modules also visualize their potential workflow changes.

� If moving information from an active data base to an archival data base, ensure that the record is retrievable.

� Compliance should be actively involved in testing the backup systems.

� Don’t forget to include in the project plan the ability to reproduce documents in the appropriate format.

� If the organization is implementing several different systems, ensure that hardware needs for each system is reviewed independently as well as a whole.

Lessons Learned (cont.)

� Evaluate whether your electronic system updates occur on the server and or require manual Intervention on each computer or desktop.

� Don’t under estimate the resistance to change and fear of job loss.

� Define the legal health record.

� Ensure interoperability of multiple systems.

� Ensure a process is in place for the monitoring of audit logs and reports.

� Ensure that Compliance department is working with IT services to incorporate technology updates to maintain best practices for system updates and maintenance

� COLLABORATION IS THE KEY – INTEGRATED APPROACH

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Audience Questions

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