Monday, August 30, 2010

A Meaningful Use and Standards Rule FAQ Part II

As a followup to the HIMSS Webinar I gave last week, here's an FAQ in the spirit of last month's Meaningful Use and Standards Rule FAQ.

1.. The Emergency Department is mentioned in 9 Core Measures and 3 Menu Measures, yet industry discussions seem to focus on the ED for CPOE and Discharge instructions. What functions do ED Information Systems need to support? Are these functions for just admitted patients or all ED Patients?

In my conversations with CMS, I believe that CMS will be issuing a corrections notice to clarify the role of the ED in the rule.

2. There are 44 Quality measures for Eligible Professionals. Do EHRs need to support all 44 measures to be certified?

To achieve certification, EHRs must support the 3 Core Measures, the 3 Alternate Quality Measures and at least 3 others from the remaining 38 measures.

3. Can eligible professionals from ancillary service providers such as stand alone radiology imaging centers qualify for meaningful use?

Although it seems a bit of stretch, if these professionals can meet all the meaningful use measures, then can qualify. This implies that radiologists will have to chart weight/height, ask about smoking status, record race/ethnicity etc.

4. The original implementation guide for the CCD specified one preferred vocabulary for each data content type. The Final rule includes SNOMED-CT and ICD9 as problem list vocabularies. Is there an inconsistency?

No, the C32 2.5 implementation guide supports all the vocabularies specified in the final rule. See Keith Boone's blog for details.

The XML for CCD in the C32 v. 2.5 implementation can accept any vocabulary for structured data elements.

5. The Quality Measures in Meaningful use mention vocabularies like RxNorm and SNOMED-CT to compute numerators and denominators. The Standards Final Rule offers vocabulary options. Is this an inconsistency?

No. The Final Rule for certification indicates “Any source vocabulary that is included in RxNorm, a standardized nomenclature for clinical drugs produced by the United States National Library of Medicine.” The Final Rule further difines the following source vocabularies as being included in RxNorm: GS – Gold Standard Alchemy, MDDB – Medi-Span Master Drug Data Base, MMSL – Multum MediSource Lexicon, MMX – Micromedex DRUGDEX, MSH – Medical Subject Headings (MeSH), MTHFDA – FDA National Drug Code Directory, MTHSPL – FDA Structured Product Labels, NDDF – First DataBank NDDF Plus Source Vocabulary, NDFRT – Veterans Health Administration National Drug File – Reference Terminology, SNOMED-CT – SNOMED Clinical Terms (drug information), and VANDF – Veterans Health Administration National Drug File. “Consequently, an one of these “source vocabularies” identified by NLM may be used, or any other source vocabulary successfully included within RxNorm.” (pages 132-133 of DHHS Final Rule 45 CFR Part 170, RIN 0991-AB58)

In creating value sets for the measures, providing 11 options (those listed in the Final Rule) was overly cumbersome, as was selecting NDC codes. By listing medications with RxNorm codes, the measures allow any user of an acceptable source vocabulary to map to the medications required by the measure. The measure criteria, therefore, can be used by any compliant EHR that uses a source vocabulary.

In general the measure specifications provide currently used terminologies as expected in the Final Rule. However, since there is a requirement for billing to use ICD-10 by 2013, the measures also provide, for those considering future implications, ICD-10 and SNOMED for appropriate concepts. While ICD-10 and SNOMED are not required, many have appreciated the ability to consider how to map their local term usage to these potential future options. Note, all measures provide “Groupings” (or nested) value sets which include a number of options. For example, all conditions (diagnoses) include ICD-9, OR ICD-10, OR SNOMED. There is one exception: persistent asthma is not an available concept in ICD-9. Therefore the measure provides an option of “persistent asthma” in ICD-10 OR SNOMED; it also provides the option of “asthma” using ICD-9 with a constraint that severity = persistent. The measures do not seek to require any terminology that is not specified in the Final Rule. The decision to include ICD-10 and SNOMED options was a conscious decision made in concert with CMS.

6. The Syndromic Surveillance implementation guide in the Final Rule seems to be the wrong document - it's the CDC's "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" which is for disease reporting, not symptom reporting.

It's true that the wrong implementation guide is included in the final rule. ONC is hard at work correcting this. We'll discuss it today at the HIT Standards Committee August meeting.


Anonymous said...

Almost all Medicare-participating physicians will be "eligible professionals" for the Medicare version of the program for EPs. "Hospital-based" in the CMS rule means that 90%+ of the physician's services must be in a POS Code 21 or 23 (inpatient or ER) setting to be hospital-based and therefore ineligible -- only 14% of all Medicare participating physicians will meet this narrow definition, most of which will be ER doctors. If you are eligible, you are also subject to the payment reductions beginning in 2015 and beyond.

Therefore, the fact that there are any meaningful use requirements that do not fall within the scope of practice for all physicians (including radiologists, pathologists, anesthesiologists, chiropractors, opthamologists, dentists, etc), is the ultimate failing of CMS, ONC, and federal advisors on the HIT Policy Committee. Any such MU requirements should, frankly, not exist -- they imply automatic reimbursement cuts for all physicians who fall outside of the relatively small percentage doctors who are PCPs.

On behalf of medical specialists everywhere, I implore you to explore meaningful use without your primary care goggles. Tap the expertise of specialty societies, and consider the comments, testimony, and recommendations they provide to you.

Unknown said...

And the Observation Status hospitalizations that Hospitalists know well will likely mean that Hospitalists will be able to qualify based on these outpatient overnight stays on our hospital floors. Will EHR vendors build hospital work flows that collect the EP required data for this non-office based outpatient work?

Henry Perretta said...

Question on your FAQ 2- where you say: To achieve certification, EHRs must support the 3 Core Measures, the 3 Alternate Quality Measures and at least 3 others from the remaining 38 measures.

Isn't it true that the concept of "certification" applies to the testing & certification of "Complete EHR" and "EHR Module" - and not how that Complete EHR (or combination of EHR Modules) is "Meaningfully Used" or not?

Here's where I'm going: Suppose I, Dr. Eligible Professional, have 15 EHR Modules - each certified. Either my vendor got this specific assembly of EHR Modules certified by (example) Drummond - or - I had (example) CCHIT come in and do a site test/certification. Whatever.

Now - say that only ONE of those EHR Modules satisfies the Quality Reporting measures(the '38') - (being dramatic to illustrate the point). I'm fine, right? As long as the "COMPLETE EHR" made up of my EHR Modules - as long as that combination meets all applicable certification requirements - and I document my Meaningful Use (including quality reporting) - I qualify for incentive- would you agree?

In any case - thanks for your presentation last week!

Alex I said...

You mentioned that CMS might issue a correction to clarify the role of the ED in the final rule. Both CCHIT and Drummond Group have provided boilerplate feedback to me and I'm looking for more specific feedback. I've emailed to CMSs email address but no response yet.

Anonymous said...

Sorry I'm just commenting but, on the Quality Measures I have had some questions on SNOMED-CT before and specifically asked NQF to help me on this. My basic question was...

"There is a conflict between the information given by ONC regarding quality measurements and the information being given regarding NQF measures. PQRI reporting is performed using CPT Cat 2 codes, while NQF reporting is performed using SNOMED. All quality reporting should utilize the current systems until the requirement to utilize ICD-10 and SNOMED becomes effective in October, 2013. The retooling information is great for helping provide tools for design and education but reporting using this methodology in 2011 is almost impossible and creates undue hardship for providers and vendors."

NQF responded with
"Thank you for your comment. You are correct that the Final Rule indicates that ICD-9 and SNOMED are both acceptable for certification. The challenge faced in the retooling is that some concepts the measure stewards tried to express did not appropriate codes in multiple terminologies (‘crossover codes’) that were acceptable for the meaning intended by the measure. This issue arises in a number of measures originally specified to use CPT II attestation codes. SNOMED was sometimes the only taxonomy that provided an acceptable code. I can defer to CMS about the certification question although I believe it is acceptable for you to map locally used terms to the same concepts in the SNOMED code list provided to successfully report the measure for 2011. The measure suggests that the information (not specifically the SNOMED codes) came from the EHR.

Not sure if there is a question here but I have asked CMS and ONC to clear this up and would like to hear your thoughts Dr. Halamka. I would assume that it is ok to map to the ICD-9 but not sure if there is a correct map for Tobacco Assessment. I really appreciated your HIMMS talk. It was by far the most informative talk that I have heard.

Anonymous said...

Regarding #6 - the implementation guide for Syndromic Surveillance; has there been any follow up? I listened to the mp3 file of the 8/30/10 HIT Standards Committee meeting but didn't hear any mention of what the plan was to correct this issue.

Lkatz said...

Is there a published list of Snomed Elective Carotid Interventions codes that can be used for hospital clinical quality measure exclusions?