Meaningful Use Stage 2 Simplified for Us Pharmacy Folk: Part 5

In Part 1 we covered basic timelines and goals, in Part 2 we reviewed Core Objectives,  Part 3 we reviewed Menu Objectives, and our Part 4 touched on clinical quality measures.  

It is important to separate Meaningful Use from the ONC HIT certification criteria for EHR technology.  Although there are many similar criteria in both, Meaningful Use focuses on how healthcare workers should use EHRs.  ONC HIT criteria focus on the capabilities of the EHR, and what vendors have to build into the system they sell to health systems and clinics.

The 2014 ONC HIT Criteria attempt to parallel reporting criteria with Meaningful Use in addition to setting the quantity of certified EHR technology to meet each stage of Meaningful Use.  Requirements for EHR technology coupled with new Core, Menu, and clinical quality measures ensures 2014 will be busy for most health systems.  

In 2014 some criteria will remain the same, while others are modified,  removed, or brand new.  The following lists each criteria categorized respectively.  Green are directly related to medication use and will likely be influenced by Informatics Pharmacists. 

Unchanged criteria:

1.  CPOE

2.  Medication List

3.  Med Allergy List

4.  Authentication, access controls and authorization

5.  Integrity

6.  Incorporation of lab test results

7.  Advanced Directives

8.  Immunization information

9.  Auto log off

10.  Emergency Access

11.  Accounting of disclosures

Modified criteria:

1.  Vital signs, BMI, growth charts

2.  Patient lists

3.  Smoking status

4.  Drug formulary checks

5.  Patient reminders

Removed criteria:

1.  Public health surveillance

2.  Reportable laboratory rests and values/results

New criteria:

1.  Calculation and Reporting 

2.  Safety-enhanced design (drug warnings, CDS, eMAR, ePrescribing included)

3.  Quality design measures integration

Although many of us have or will have these technologies in place by 2014, accurate reporting will likely be our largest challenge.  Many health systems are still learning to use EHRs, creating a plethora of incongruous and unnecessary orders, visits, notes, and results.  I will be sifting through the mined data like the rest of you, trying to produce an accurate attestation for the folks at CMS.  

You can review updated information at the healthit.gov website.  

This concludes our direct summary of Stage 2 Meaningful Use and ONC HIT certification criteria.  Thanks for reading and please feel free to post questions or comments.  

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Meaningful Use Stage 2 Simplified for Us Pharmacy Folk: Part 4

In Part 1 we covered basic timelines and goals, in Part 2 we reviewed Core Objectives.  Part 3 reviewed Menu Objectives and our 4th installment will briefly review clinical quality measures.  

The big year for Clinical Quality Measures (CQM) will be 2014.  Due to the parallel requirements for ONC certified EHR technology during the year, it will be busy.  Thank goodness we only have to attest for 3 months during 2014!  CQMs are focused on conditions that contribute to morbidity or mortality.  These coincide with many national public health priorities or common health disparities.  Currently Eligible Hospitals must meet 100 %, or 15 of 15 measures.  Stage 2 adds 14 new measures to the foray, but only requires 16 of the total 29 to be met.  Many of you have implemented a slew of these already, albeit on paper or EHR.  

Keep in mind many of these require workflow and process redesign as well as implementation within an EHR.   Pharmacists are commonly involved in core measures surrounding medication use; now we get to use the Informatics knowledge to implement them in the EHR. 

Here is the list (some broken out for clarity).  Green are new for medication use in Stage 2.   

1.  Aspirin at Arrival:  Acute MI patients who received aspirin within 24 hours before or after hospital arrival.

2.  Discharge Instructions:  Heart failure patients 

3.  ACEI or ARB for LVSD

4.  ASA Prescribed at Discharge

5.  Relievers for inpatient asthma

6.  Corticosteroids for inpatient asthma

7.  Initial ABX selection for CAP in immunocompetent patients

8.  Blood Cultures performed in ER prior to first ABX dose

9.  Beta blocker prescribed at discharge

10.  Fibrinolytic Therapy within 30 min of hospital arrival

11.  VTE Prophylaxis within 24h prior or 24 hours after surgery

12.  Perioperative Beta blocker admin in surgery patients

13.  Home Management Plan for Pediatric asthma caregiver

14.  VTE Prophylaxis during Hospital Admission

15.  ICU VTE Prophylaxis during Admission

16.  VTE Patients with overlap of IV and warfarin therapy

17.  VTE Patients receiving Heparin with Monitoring Protocols

18.  VTE Discharge Instructions

19.  Incidence of preventable VTE

20.  VTE Prophylaxis in stroke patients

21.  Antithrombotic therapy at discharge in Ischemic stroke patients

22.  Anticoagulation therapy at discharge in Ischemic stroke patients with Afib/flutter

23.  Thrombolytic Therapy within 3 hours of admission in acute ischemic stroke patients

24.  Antithrombotic therapy by end of hospital day 2 in ischemic stroke patients

25.  Statin medications written for discharged ischemic stroke patients with LDL > 100

26.  Stroke Education

27.  Infants 22 to 29 weeks gestation treated with surfactant within 2 hours of birth

28.  Prophylactic ABX within 1 hour prior to surgical incision

29.  Prophylactic ABX selection for surgical patients

30.  Prophylactic ABX discontinued within 24 hours post surgery end (48h cardiac)

31.  Statin prescribed at discharge for AMI patients

32.  Pneumococcal Immunization prior to discharge

33.  Influenza Immunization prior to discharge

34.  ED Throughput 

For updated information please visit the CMS section on CQMs.  Next we will review Certified EHR Technology.  

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Meaningful Use Stage 2 Simplified for Us Pharmacy Folk: Part 3

In Part 1 we covered basic timelines and goals, in Part 2 we reviewed Core Objectives.  Welcome to the third installment, where we will outline the Menu Objectives.  

Stage 2 Meaningful Use provides a large update to the Menu Objectives when compared to Stage 1.  In Stage 1, we only saw Advanced Directives as an objective.  In Stage 2 we have a number of new additions, including a few relevant to Pharmacy Informatics.  As mentioned in Part 2, Eligible Hospitals must meet 3 out of 6 for Meaningful Use.  Those relevant to pharmacy include:

Progress Notes for more than 30 % of unique patients.  While this might primarily be an objective for providers, pharmacists are also writing notes related to medication therapy.  Common examples include anticoagulation or pharmacokinetic consults, as well as a number of items we will cover in Part 4 on Clinical Quality Measures.  Informatics Pharmacists may be asked to help provide contextual tools to aid the clinical pharmacist in writing notes.  The more targeted and meaningful notes we can write, the more likely we are to be accepted as members of the healthcare team.  Informatics is an important platform for pharmacists to show others the benefits of an EHR. 

ePrescribing in more than 10 % of discharge prescriptions.   Informatics Pharmacists play a role in configuring and maintaining the medication database used by providers to create electronic prescriptions.  Depending on the facility, they may own it entirely, or support it indirectly with another team.  A more comprehensive and accurate medication ordering database will translate to safer prescriptions and better physician acceptance.  Don't underestimate the importance of maintaining your medication libraries for prescribing use.  It is the linchpin in the connection to the continuity of care and will come full circle if a patient comes back to your hospital.  

Other objectives more unrelated to pharmacy include:

• Imaging results:  more than 20 % are accessible using certified EHR technology
• Family histories are recorded in more than 20 % of patients
• Advanced directives are recorded for more than 50 % of patients 65 years or older
• Lab results are provided to providers for more than 20 % of patients

If you like charts, CMS provides a nifty comparison table for both core and menu objectives. 

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ONC Dashboard on Health IT Adoption

The Office of the National Coordinator for Health IT has released a dashboard showing various adoption statistics.  Lots of fun to play with, I recommend you give it a try.  

Of note:

• Provider adoption is anywhere from 12 to 40 %.   Rural providers have adopted quicker than small practices in general.  
• Hospital adoption of Basic EHR (I will explain this in a future post) went from around 20% in 2010 to 35% in 2011.  
• About 93% of community pharmacies are in the Surescripts network for ePrescribing.  

Data based on Feb 2012 ONC Brief.  

With ONC clarifying layers of certified EHR technology and requiring implementation by the end of 2014, how much of a jump will we have in Basic EHR adoption in 2012?   

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Meaningful Use Stage 2 Simplified for Us Pharmacy Folk: Part 2

In Part 1 we discussed the intent of Meaningful Use Stage 2 Final Rule, as well as the timelines for implementation and attestation.  

Welcome to Part 2, where we bite off a chunk of core objectives, and how they relate to the Informatics Pharmacist.  

Starting out with what has changed, we see the have added a few core objectives for both Eligible Professionals (private doctor's offices) and Eligible Hospitals (and health systems).  We will primarily focus on the Eligible Hospital (EH) objectives, as these involve most Informatics practices.  

CMS added 2 additional core objectives, and is requiring all 16 be met.  The measures directly relevant to pharmacy include:

CPOE used for more than 60 % of medication orders.  This is a slight bump from Stage 1, but the impact on Pharmacy remains important.  Pharmacists play an integral role in order verification and perfection.  Informatics Pharmacists may build and design medication ordering systems EHRs, creating a unique opportunity to help providers make the 60 % threshold.  Spend as much time as possible with IT and provider groups to help bridge the gap between IT implementation and physician acceptance.  

Interventions:  implement 5 clinical decision support tools plus drug/drug and drug allergy support systems.   As a red hot topic in the world of Pharmacy Informatics, Stage 2 puts us to task and requires these tools to be in place.  Naturally the issue of alert fatigue and truly "meaningful" medication warnings surfaces as the gorilla in the room.   We could talk about this topic for hours, but let's cut to the real issue:  health systems are relying on Informatics teams to reduce noise and only show actionable warnings.  We will continue to beat on drug data vendors to streamline their content for clinical use, but until the legal ramifications as worked out we have to rely on each other.  Now that we have the backing of CMS the real question: as a profession what can we do to revolutionize this critical content?

eMAR implemented and used for more than 10 % of medication orders.  If you have eMAR in place, chances are you meet this objective easily.  If you have yet to implement, start buying your nurse colleagues donuts and coffee now.  It will be an interesting journey!  My main recommendation here is to really get to know your nurses.  Meet with them as often as you do pharmacy and you will discover some amazing new workflows.  Some you will want to change, others you might implement.  Success at eMAR is dependent on cooperation, and it is up to us to extend the hand. 

Immunization data transmitted successfully to external systems.  Many EHRs place immunizations within the purvue of databases designed mainly for medications, so Informatics Pharmacists may inherit some responsibilities for this objective.  It would most likely be pertaining to adequate documentation and codification of orders to allow transmission to third parties.  If you are not familiar with immunization workflows within your EHR it might be a good time to find a nurse colleague and transfer some knowledge.  

The remaining core objectives are not considered to have direct impact on Pharmacy Informatics, but as a member of the EHR team they are important to review.  

• Demographics:  Record for more than 80 % of patients
• Vitals:  Record for more than 80 % of patients
• Smoking Status:  Record for more than 80 % of patients
• Labs:  Incorporate lab results for more than 55 %
• Patient List:  generate patient list by specific conditions
• Patient Access:  Provide online access to health information for more than 50% with more than 5 % actually accessing. (if broadband available in community)
• Education Resources:  Use EHR to identify and provide education resources more than 10 %
• RX Reconciliation:  Medication Reconciliation at more than 50 % of transitions of care
• Summary of Care:  Provide summary of care document for more than 50 % of transitions of care and referrals with 10 % sent electronically and at least 1 sent to a recipient with a different EHR vendor or successfully testing with CMS test EHR
• Labs:  successful ongoing transmission of reportable laboratory data
• Syndromic Surveillance:  Successful ongoing transmission of electronic syndromic surveillance data
• Security Analysis:  Conduct or review security analysis and incorporate in risk management process

You can review the information directly at the CMS website as well.  

In Part 3 we will discuss Menu Objectives, and Part 4 will cover Clinical Quality Measures.  The 5th installment will break down ONC criteria certified EHR technology.  

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Meaningful Use Stage 2 Simplified for Us Pharmacy Folk: Part 1

The Meaningful Use Stage 2 Final Rule was recently published, so I wanted to put together a series of posts to help everyone sift through the "government speak" in the Federal Register.  Part 1 will include an overview of the intent and try to set a foundation for the proceeding posts. 

Before we start talking about anything it is important we all understand this point:

Meaningful Use rules specify how hospitals and providers use EHR technology.  ONC rules specify the capabilities an EHR needs to be certified.  

This is critical, because many discussion mix the terms.  However, both MU and ONC rules are intended to work in unison to provide a successful framework.  In other words, requiring a hospital to meet a guideline that the EHR doesn't have the tools for could be difficult at best.  Now on to MU.  

For those readers that want to watch the full monty, almost 2 hour presentation you can view it here.  If you want the quick and dirty, read on.  

The great news is Stage 2 is largely predictable.  Most of it builds on Stage 1, and due to its publicity it is a bit easier to understand the intent of the publication.  So what's in the box?  Here is a bulleted list of major themes in the rule.  

• Patient Engagement (interaction between patient and caregivers)
• Advancement of Stage 1 Thresholds
• Interoperability 
• Providers and Hospitals MUST implement certified EHR technology that meets ONC standards
• Streamlined reporting through alignment of measures and methods (think ONC and MU synergy)
• No Eligibility changes (these were set in the HITECH Act)
• New clinical quality measures and more flexibility

Timelines

Here are the 3 most important points concerning dates:  

• Stage 2 starts in 2014 (as previously announced)
• Because upgrading sucks, you only have to report 3 of 12 months data to be eligible in 2014
• Everyone must upgrade to 2014 technology and criteria by 2014

Yes, 2014 is going to be a busy year.  It is critical to understand that even if you are going for MU stage 1 in 2014 you must still use certified EHR technology (ONC).  This is one of those points where it becomes hard to understand where MU and ONC fit, but hopefully this helps clear the mud.  Basically ONC certified EHRs are required t to participate in MU and get paid!  

That takes care of the timelines and sets the stage for a more in-depth look at the changes to the second installment of Meaningful Use.  In Part 2 of this post we will cover specifics of Stage 2 and how they impact or involve Pharmacists.  Stay tuned! 

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Meaningful Use Stage 3 Full Steam Ahead @Meaningful Use

Thanks to my colleague John Poikonen for the Meaningful Use Stage 3 update for everyone.  The Working Group met on August 1, 2012 and among other things set the timeline for upcoming events.  Get ready for things to heat up.  

•Aug, 2012 – present draft preliminary stage 3 recs

•Oct, 2012 – present pre-RFC preliminary stage 3 recs

•Nov, 2012 – RFC distributed

•Dec 21, 2012 – RFC deadline

•Jan, 2013 – ONC synthesizes RFC comments for WGs review

•Feb, 2013 – WGs reconcile RFC comments

•Mar, 2013 – present revised draft stage 3 recs

•Apr, 2013 – approve final stage 3 recs

•May, 2013 – transmit final stage 3 recommendations to HHS

I am also attaching the Presentation from the event.  Please feel free to download and review.  Time permitting I will review and summarize the preliminary recommendations soon.

MU Stage3 prelim 080112.pptx Download this file

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EHR use in Pediatric Populations by Anne Bobb et al

Another fantastic contribution to the informatics community on behalf of NIST and the always professional Anne Bobb.  Anne has been a long time colleague and one of the very best at quality measures in the field.

 

To put it in perspective, the word "medication" is used 82 times in the article.  Anne is the only Pharmacist on the team of 30.  Although I did not have time to read the entire 44 page article before writing this post, my comfort level with the outcomes and discussion are very positive.

 

 

 

My overall summary:

 

1.  EHR Adoption by pediatric providers has lagged behind their general adult counterparts.

 

2.  Overall usability is a seldom addressed but  critical piece to successful implementation in high risk populations such as pediatrics.  Current EHRs have a long way to go.

 

3.  Time pressure shouldered by healthcare providers makes usability all the more important in pediatric populations.

 

4.  Pediatric patients are unique, and small delays in care due to usability issues can have extreme consequences on patient care.

 

Thanks to Anne and the NIST team for putting together a wonderful and informative article on the impact of EHRs to pediatric medical practice.

 

Article Link and Download

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The quest for an organized peripheral brain

John's wonderful post on the Peripheral Brain sent on a quest to find tools to organize my life.  I spent a few hours this weekend looking over Springpad, and decided it is not ideal for those that manage documents.  At least for me, I am still getting the majority of my information in a document format.  Springpad is fantastic if you spend lots of time on the Internet, and if most of your cataloging comes from web pages.  In the Informatics world many of our articles and references are not mainstream (or behind a password protected site) so this makes it hard to conveniently add all articles in Springpad.  This coupled with the inability to add multiple documents to one "Spring", and one can see where it quickly falls behind. 

It seems as though Springpad might be good for someone that works in a smaller more amoebic type office, or one that deals with mostly internet based business relationships. 

After this revelation, I was obviously disappointed!  My attempt to make some sense of the email monstrosity, tweets, blog posts, RSS feeds, publications, and articles remained a mystery.  At this point I turned my attention back to Evernote.  It allows easy cataloging and even easier searches to find those old, obscure articles from years past.  Before Evernote I organized items into folders.  Before Spotlight on OS X, it was really difficult.  Folders had to provide all organization, so I ended up with hundreds of them.  Needless to say it was still difficult to find anything.  John and I have both been long time users of Evernote, using it on a daily basis.  I have a few thousand notes, and I am sure he has many more. Evernote is fantastic for its simplicity.  Evernote has no substitute for document cataloging, and it is comparable to other products for all other forms of digital media. 

You may be wondering why I was looking for an alternative if Evernote is so fantastic at managing my digital media.  Well, my focus this weekend was organizing my tasks and projects.  There are many methodologies available to the novice consumer such as myself.  One might fall upon GTD or Personal Kanban.  However, my goal was to find one product that could do both.    To accomplish this in Evernote, we typically rely on tags and notebooks.  My research brought me to an interesting system called The Secret Weapon.  This methodology uses tags to organize email based on who, what, where and when it needs to get done.   For instance, my “what” might be Projects, Informatics Consulting, and Expert Witness.  My “where” might be Home, Office, and Town.  My “when” could be represented by Now, Next, Later, Someday, and Waiting.  To organize the messages you tag each with as many of these categories as you can.  So an email about an expert witness report I need to finish might be tagged with Chad, Now, Office.  Then next time I am in my Office, I would look through Evernote and find tasks with these tags to work on.  This can also be used for home life, say remodeling a room.  You could use tags to set the who, what, where, when and organize them into a meaningful, prioritized plan. 

So my appetite for organization is sated right?  Not so fast.  The Secret Weapon is fantastic for organizing emails if you are using Outlook.  Where this fails is with simple tasks or lists for small things.  No one wants to create a new note in Evernote to say “get laundry”.  It just takes too much time.  Springpad was great at this type of simple easy to review list management, but weak on document cataloging.  Maybe I have yet to stumble upon a simple elusive feature in Evernote to accomplish this.  I ran across Nozbe, a GTD application that has promise.  It interfaces with the Evernote API and shows notes with related tags right in a task.  Nozbe has great reviews on the Apple App Store, as well as the web.  They offer versions for iOS products, OS X, as well as a very well designed web application.  However, all of this functionality does not come without a price.  Each version is a separate purchase, and there is a monthly subscription.  However, if Nozbe is the destination on my journey for GTD awesomeness, it is well worth the cost.  I am going to give it a try for a few weeks to see if it meets my needs.   I will report back on my quest for the best solution!

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