Wednesday, July 28, 2010

The July HIT Standards Committee

The July HIT Standards Committee meeting focused on a review of the final Meaningful Use/Standards regulations and the processes for the next stage of our work.

Today, the Federal Register published the Meaningful Use Final Rule (down to 276 pages from 874) and the Standards and Certification Final Rule (down to 65 pages from 228).

Karen Trudel and Doug Fridsma began the meeting with an in-depth overview of Stage 1 Meaningful Use and Standards/Certification criteria.

Key discussion points included:

*EHRs do not have to be certified before the 90 day Stage 1 Meaningful Use demonstration period, just by the end. You can start the demonstration data collection before certification is completed. The entire CMS program begins January 2011, so it's possible to demonstrate Meaningful Use January 1 to March 31 using an EHR that is certified February 15.

*Although the Meaningful Use Menu set contains 10 choices from which Eligible Professionals(EPs) must choose 5, one of those five must be a public health/population health measure. Since there are only two choices for EPs, Immunization reporting and Syndromic Surveillance reporting, every professional must demonstrate one of these two public health transactions to qualify for meaningful use.

*Emergency Departments are now included in Hospital measure computation. This may create challenges for some organizations that have 100% CPOE use in the hospital but 0% CPOE use in the ED. Many hospitals have niche systems in the ED that may not integrate into hospital CPOE workflows. There is no question that the ED should have CPOE, but in 2011, not all EDs will. If a hospital has 60,000 ED visits without CPOE and 20,000 inpatient admissions with 100% CPOE use, the computation of 20,000 patients with medication orders entered via CPOE/(60,000 ED patients + 20,000 inpatient admissions) = .25 and thus will not qualify for meaningful use.

*EHRs must be capable of producing electronic Office visit summaries, as discussed in my previous blog, but meaningful use supports (and requires upon patient request) use of paper.

*It's unclear if Meaningful Use/Stimulus payments are taxable income to eligible professionals. No one has clarified this yet.

*The current standards required for patient summaries are CCR or CCD/C32. The current problem list vocabularies are ICD9 or SNOMED-CT. Although the CCR can use ICD9, the CCD/C32 implementation guide requires SNOMED-CT. It may be that the implementation guide will be relaxed to allow either ICD9 or SNOMED-CT for the problem list vocabulary in the CCD/C32.

*The Syndromic Surveillance Standards required are HL7 2.3.1 or HL 2.5.1. Although 2.5.1 has a detailed implementation guide (Public Health Information Network HL7 Version 2.5 Message Structure Specification for National Condition Reporting Final Version 1.0 and Errata and Clarifications National Notification Message Structural Specification), there is no current HL7 2.3.1 guide. It's been retired and is no longer used. Hence it may make sense for ONC to remove HL7 2.3.1 as a possible standard for this transaction. Otherwise it will be challenging to certify the transaction and guarantee interoperability.

*Although no transport standards are currently specified, enabling innovation in this area, it is important than in the future, after we learn more from HIE pilots, NHIN Direct, and Beacon Communities, that some specificity is provided to accelerate interoperability.

*A Smoking status vocabulary has been suggested, but is not a certification criterion.

*Eligible professionals have a choice of quality measures to report (3 core or 3 alternate core plus 3 from a list of 38 measures), thus EHRs have to produce at least 9 quality measures to be certified. The Meaningful Use Final Rule on page 238 states: “In order to permit greater participation by EHR vendors, including specialty EHRs, the certification program will permit EHRs to be certified if they are able to calculate at a minimum three clinical quality measures in addition to the six core and alternative core measures.”

*Medication Reconciliation needs only to be done between institutions not within an institution to satisfy the Meaningful Use measure.

Doug also informed the committee that of the 10 Standards and Interoperability Framework RFPs, two have been awarded - the NHIN RFP to Stanley (a large consulting company) and the Standards Harmonization RFP to Deloitte. It will be interesting to see how the Standards Harmonization activity serves as a successor to HITSP.

Next, Jamie Ferguson discussed the need for a framework to support clinical summaries of all kinds. The committee discussed that a modular, CDA-template-based approach would work well. Efforts such as hData and Green CDA are complementary to this idea. Basically, anyone needing to send a summary document for a particular purpose could assemble CDA templates as needed to create a human readable and computable content package. We also agreed to followup on any modular approaches the CCR authors may be working on.

Jamie updated us on the Vocabulary Task Force and its upcoming hearings. Our hope is to document the requirements for a vocabulary/codeset resource containing all intellectual property needed for Meaningful Use in a web-based repository.

Janet Corrigan and Floyd Eisenberg described the process of work group meetings and information gathering to specify the stage 2 and 3 quality metrics.

I had to leave the meeting to moderate the afternoon session of the ONC/Institute of Medicine Building a Learning Healthcare System conference. I'll blog about that on Monday.

Per Jon Perlin, the afternoon of the HIT Standards Committee meeting including a rich discussion of the Privacy and Security Tiger Team Update by Deven McGraw/Paul Egerman, an Enrollment Workgroup Update, and public comment. During the public comment period, the committee was deeply moved by a speech from the mother of a child with a serious illness. She thanked the committee for all their work to date to empower patients and improve the quality, safety and efficiency of care.
Regulations are final, stakeholders are thankful, and we're making progress! Thanks to everyone who has contributed the process thus far.


Bristow said...

Clarification on this: "Although eligible professionals have a choice of quality measures to report (3 core or 3 alternate core plus 3 from a list of 38 measures), EHRs have to be able to produce all of them. This is an interesting point because although the menu set gives EPs and hospitals optionality, EHRs have to support all data exchanges in the Menu set in order to be certified."

Do you mean that EHRS have to support 3 core, 3 alternate, and another 3 measures to be certified? Or all 38 measures plus 3 core and 3 alternate? That would make zero sense for specialty EHRs.

John Halamka said...

Interesting point. I'll ask CMS.

Based on the discussion today, it would seem that at least 9 quality measures (core, alternative, 3 from the menu set) would be required for a specialty EHR.

Anonymous said...

The ED/CPOE issue in your post doesn't quite as bad as indicated due to many ED patients also being inpatients (either from the ED directly or as a separate visit).

Wouldn't that make meeting 30% of unique patients easier?

Bristow said...

Okay, another question about a specialty EHR.... To be certified as a complete EHR, how many modules have to be tested and certified?

Core Set plus 5 of the menu set including at least one public health measure


Core Set and ALL of menu set

From one point in the final rule when it said 14 modules counted as a complete EHR, it sounds like only the Core set is required.

We're also wondering whether doctors are required to have certified modules for the core set and ALL menu set OR just for the 5 menu objectives they choose to submit.

I've sent these questions into the ONC last week, but I haven't heard anything in response. I cannot tell you how much we appreciate your education efforts - between your talk at HIMSS re: HIT Standards, willingness to answer questions afterwards, and your blog, I think my colleagues and I at our small eyecare specialty EHR company are ready to nominate you for Health IT's MVP.

John Halamka said...

Regarding the ED issue, I recommended that the measure be changed to count only admitted ED patients, which would solve the problem since EDs with CPOE and EDs without CPOE would both be able to meet the threshold.

For an eligible professional to qualify for meaningful use stimulus payments, they must use software that is certified to perform all Core set functions and the menu set functions they use. Hence, if an EHR provider wants to be a "complete" EHR, they must be certified for ALL functions a provider might use. My guess is that many organizations will use site certification or modular certification - several software systems each of which are certified for specific functions but together cover all the functions providers utilize to achieve meaningful use.