Abstract
Intermountain Healthcare hospitals and providers are eligible for approximately $95 million in incentives from the Health Information Technology for Economic and Clinical Health Act (HITECH), which requires that hospitals and providers use a certified electronic health record (EHR) in a meaningful way. This paper describes the our progress in readying legacy systems for certification, including measuring, and filling gaps in (EHR) functionality. Also addressed are some of the challenges and successes in meeting meaningful use. Methods for measuring and tracking levels of clinician meaningful use behaviors, and our most recent results impacting meaningful use behaviors in a large integrated delivery network are described. We identified 20 EHR requirements we can certify now, 16 requirements with minor issues to resolve, and 38 requirements which are still in some state of development. We also identified 6 meaningful use workflows that will require significant work to bring all of our hospitals and providers above the measure requirement.
Introduction
The majority of U.S. hospitals1 and ambulatory practices2 are planning to meet meaningful use requirements stemming from the Health Information Technology for Economic and Clinical Health Act (HITECH), part of American Recovery and Reinvestment Act (ARRA). Over 19 Billion dollars was targeted for healthcare information technology (HIT) projects to accelerate the adoption of EHRs and other technology, and to have the technology used in a meaningful way. Much of this money will be used for incentives for ambulatory physicians and hospitals that use a certified EHR and demonstrate meaningful use of HIT.3 The final rules for EHR certification and meaningful use were published on July 13, 2010, in two related documents; referred here as the EHR Standards Rule4 and Incentive Rule.5
Intermountain Healthcare facilities and providers are eligible for approximately $95 million in incentives from Medicare and Medicaid between 2011 and 2015. $70M is estimated for our hospitals and $25M for our ambulatory providers. These incentives are time limited and tied to the demonstration of meaningful use of ARRA certified EHRs by physicians and other clinicians in hospitals and clinics. The 2011 to 2015 time frame is broken up into 3 stages; Stage 1 (2011–2012), Stage2, 2013–14, and Stage 3, 2015. EHR functionality and meaningful use requirements increase at each Stage, while incentive amounts decrease at each stage. Then, significant payment penalties will be imposed on practitioners and facilities that do not meaningfully implement EHRs following 2015.
A previous publication described the state of Intermountain readiness to meet HITECH requirements using the early interim rulings for EHR certification and meaningful use.6 Input on the interim rules was sought and submitted to the Office of the National Coordinator (ONC) and Centers for Medicare and Medicaid Services (CMS), under the direction of the Department of Health and Human Services (HHS). After review of this input, ONC and CMS released the final rules. This paper describes the challenges and successes over the last year on the journey to reach meaningful use. Intermountain’s EHR functional readiness and meaningful use readiness to meet the final Stage 1 rules are described.
Changes to Requirements for Certification of EHRs and Demonstration of Meaningful Use
HHS reviewed over 2000 public letters of comment in response to the interim rules released January 13, 2010. Most of the comments described the proposed criteria as too rigid and burdensome. The release of the final rules were generally felt by many to be more flexible, and more likely to allow eligible hospitals (EHs) and eligible providers (EPs) to meet the requirements.
Some of the key changes included:
Fewer Stage 1 meaningful use objectives. The mandatory EP and EH requirements dropped from 25 and 23 respectively, to 15 and 14. A more flexible menu of 10 additional objectives were included of which EPs and EHs must select and meet 5. Electronic billing and eligibility verification were removed from Stage 1. Quality measure reporting was reduced to 6 for both EPs and 15 for EHs.
Lower Thresholds. CPOE requirements in the interim rule required medication, imaging, and laboratory orders to be counted. The final rule changed CPOE orders to medications only for Stage 1. EP E-prescribing requirements dropped from 75% of all prescriptions to 40%. Decision support requirements dropped from five to one.
Additional Requirements. Two new menu items were added, advance directives, and provision of educational material to patients.
Expanded Eligibility. Critical Access Hospitals (CAHs) became eligible to receive both Medicare and Medicaid incentives.
Methods
This analysis was performed at Intermountain Healthcare, a not-for-profit integrated health care delivery network which operates 23 hospitals (130,000 admissions per year), employs over 850 physicians working in 170 ambulatory clinics and insures approximately 500,000 individuals. Intermountain’s clinical information systems are relatively extensive and have been described previously.7,8 We currently use two home-grown, legacy clinical information systems, HELP in the hospitals and HELP2 primarily in the ambulatory setting. Over 13,500 unique users access HELP to retrieve results and/or document care for over 123,000 patient records per month. Over 13,000 clinicians use the HELP2 EHR each month to access records or document care on over 258,000 unique patients. Providers access different modules for different functionality, including documentation of progress notes, problem lists, medication orders, nursing documentation, etc.
EHR Functionality and Certification
Because our EHR at Intermountain is self-developed, we must certify our EHR prior to meeting meaningful use. In order to understand the EHR functional requirements necessary to certify ambulatory and hospital systems, we reviewed the EHR Standards rule and related National Institute of Standards and Testing (NIST) Approved Test Procedures for certification.9 The NIST documents, with some exceptions, gave clear guidance for how to certify specific EHR functionality. Table 1 shows the NIST Criteria. The table is separated into general EHR criteria, ambulatory-specific EHR criteria, and inpatient-specific EHR criteria, These are grouped in Table 1 by “Setting” and delineated by shading in the table. In some cases, the criteria are duplicated in order to account for the testing required to certify our ambulatory system and inpatient system.
Table 1.
NIST Approved Test Procedures for EHR Certification
| NIST_Reference | Criteria | Setting |
|---|---|---|
| 170.302(a)(amb) | Drug-drug, drug-allergy interaction checks | Ambulatory |
| 170.302(a)(inpt) | Drug-drug, drug-allergy interaction checks | Inpatient |
| 170.302(b)(amb) | Drug-formulary checks | Ambulatory |
| 170.302(b)(inpt) | Drug-formulary checks | Inpatient |
| 170.302(c)(amb) | Maintain up-do-date problem list | Ambulatory |
| 170.302(c)(inpt) | Maintain up-do-date problem list | Inpatient |
| 170.302(d)(amb) | Maintain active medication list | Ambulatory |
| 170.302(d)(inpt) | Maintain active medication list | Inpatient |
| 170.302(e)(amb) | Maintain active medication allergy list | Ambulatory |
| 170.302(e)(inpt) | Maintain active medication allergy list | Inpatient |
| 170.302(f)(1)(amb) | Vital Signs | Ambulatory |
| 170.302(f)(1)(inpt) | Vital Signs | Inpatient |
| 170.302(f)(2)(amb) | Calculate BMI | Ambulatory |
| 170.302(f)(2)(inpt) | Calculate BMI | Inpatient |
| 170.302(f)(3) | Plot and Display Growth Charts | Ambulatory and Inpatient |
| 170.302(g)(amb) | Smoking Status | Ambulatory |
| 170.302(g)(inpt) | Smoking Status | Inpatient |
| 170.302(h) | Incorporate Laboratory Test Results | Ambulatory and Inpatient |
| 170.302(i) | Generate Patient Lists | Ambulatory and Inpatient |
| 170.302(j) | Medication Reconciliation | \Ambulatory and Inpatient |
| 170.302(k) | Submission to Immunization Registries | Ambulatory and Inpatient |
| 170.302(l) | Public Health Surveillance | Ambulatory and Inpatient |
| 170.302(m) | Patient-specific education resources | Ambulatory and Inpatient |
| 170.302(n)(amb) | Automate measure calculation | Ambulatory |
| 170.302(n)(inpt) | Automate measure calculation | Inpatient |
| 170.302(o) | Access control | Ambulatory and Inpatient |
| 170.302(p) | Emergency access | Ambulatory and Inpatient |
| 170.302(q) | Automatic log-off | Ambulatory and Inpatient |
| 170.302(r) | Audit log | Ambulatory and Inpatient |
| 170.302(s) | Integrity | Ambulatory and Inpatient |
| 170.302(t) | Authentication | Ambulatory and Inpatient |
| 170.302(u) | General Encryption | Ambulatory and Inpatient |
| 170.302(v) | Encryption when exchanging EHI | Ambulatory and Inpatient |
| 170.302(w) | Accounting of disclosures | Ambulatory and Inpatient |
| 170.304(a) | Computerized provider order entry | Ambulatory |
| 170.304(b) | Electronic prescribing | Ambulatory |
| 170.304(c) | Record demographics | Ambulatory |
| 170.304(d) | Patient reminders | Ambulatory |
| 170.304(e) | Clinical decision support | Ambulatory |
| 170.304(f) | Electronic copy of health information | Ambulatory |
| 170.304(g) | Timely Access | Ambulatory |
| 170.304(h) | Clinical summaries | Ambulatory |
| 170.304(i) | Exchange clinical information and patient summary report | Ambulatory |
| 170.304(j) | Submit clinical quality measures | Ambulatory |
| 170.306(a) | Computerized provider order entry | Inpatient |
| 170.306(b) | Record demographics | Inpatient |
| 170.306(c) | Clinical decision support | Inpatient |
| 170.306(d)(1) | Electronic copy of health information | Inpatient |
| 170.306(e) | Electronic copy of discharge instructions | Inpatient |
| 170.306(f) | Exchange clinical information and patient summary report | Inpatient |
| 170.306(g) | Reportable Lab Results | Inpatient |
| 170.306(h) | Advanced Directives | Inpatient |
| 170.306(i) | Submit clinical quality measures | Inpatient |
We assembled twelve teams and divided all of the Stage 1 EHR NIST requirements among the teams. Each team consisted of a team lead analyst, programmer, terminology analyst, quality assurance analyst, and often an interface analyst. These teams reported to a single project manager, and certification lead. The teams were responsible for determining if the EHR function can be certified according to the NIST test procedure. If there was a deficiency, the team was responsible for developing a sub-project plan to certify, including tasks, resources, and time estimates. Each sub-project was entered into a master certification project plan. This provided us with a detailed EHR certification gap analysis and plan to obtain EHR certification.
Meaningful Use
We also reviewed the Incentive Rule to understand the Stage 1 requirements necessary to meet meaningful use in the ambulatory and hospital settings. We built a spreadsheet containing the meaningful use requirements for both the outpatient and inpatient workflow requirements.
In order to quantify our actual EHR adoption for comparison to the meaningful use requirements, we pulled EHR adoption data from our EHR Utilization Data Mart. Our EHR utilization data mart contains detailed EHR usage for both Inpatient and outpatient systems. The Utilization Data Mart has been described in detail previously.10,11 We calculated the required numerator, denominator, and percentage described in the EHR Certification Rule and Incentive Rule. For example, the number of unique ambulatory patients with a problem list entry admitted to a hospital or seen in a provider’s clinic in the last ninety days. Using data from the Utilization Data Mart, we built a report which allowed comparison between current EHR adoption and the the meaningful use adoption requirements. This provided us a meaningful use workflow gap analysis.
Results
EHR Functionality and Certification
Our EHR Certification Dashboard gives a graphic representation of our EHR gap analysis. We identified 20 requirements we can certify now, 16 requirements with analysis complete and minor issues to resolve, and 38 requirements which are still in some state of final analysis by any of the project team members. Of the 38 requirements still in some state of analysis, some requirements are estimated to be trivial, while some are estimated to require more work. See an example of the EHR Certification Dashboard in Figure 1. Columns include Data Exchange Functionality, Vocabulary Functionality, and Application Software. White cells labeled “OK’ identify status indicating currently certifiable, cells with gray shading identify minor issues present, and solid black cells identified areas still under analysis at the time of this writing. This figure shows only 20 of a total of 74 rows of the entire table.
Figure 1.
EHR Certification Dashboard
Meaningful Use
The Meaningful Use Dashboard gives a summary view of the gaps between the current EHR utilization and the utilization required to meet meaningful use. Table 2 shows the summary status of the ambulatory provider status (EPs) and Hospitals at Intermountain. Our workflow analysis identified 6 meaningful use workflows that will require significant work to bring some all of our hospitals and EPs above the Measure Requirement. These six workflows are identified in yellow, and include inpatient Problem List, Medication Allergy List, EP Smoking Status, Calculation of Quality Measures, Advance Directives, and Medication Reconciliation. Advance Directives and Mediation Reconciliation are menu items for Stage 1 Meaningful Use.
Table 2.
Meaningful Use Dashboard - Hospitals
| Final Meaningful Use Stage 1 Objectives | Measure Requirement | EP status, % that meet, Yes or No if Binary Attestation | Hospitals Detail Yes or No if Binary Attestation |
|---|---|---|---|
| Use Computerized Provider Order Entry (CPOE) | 30% | >55% | 18 of 23 hospitals comply |
| Implement Drug-drug, drug-allergy interaction checks | Enabled | Yes | Yes |
| E-Prescribing [EP only] | 40% | < 5% EPs meet | |
| Record demographics | 50% | > 90% meet | 20 of 23 hospitals meet |
| Problem List | 80% | 20% meet | No hospital meets (1.9–40% of pts w/ Problem) |
| Medication List | 80% | 81% meet | 18 of 23 hospitals over 80%, 4.3–94% |
| Medication Allergy List | 80% | 45% meet | 5 of 23 hospitals over 80% |
| Vital Signs | 50% | 68% meet | 20 of 23 hospitals over 0% 27–94% (8.2010) |
| Smoking Status | 50% | < 20 meet | 19 of 23 hospitals meet |
| Implement clinical decision support | One Rule | Yes | yes |
| Calculate and Transmit CMS Quality Measures | Hospitals −15, EP − 6 | <25% of EPs | no hospitals fully comply |
| Electronic Copy of Health Information | 50% | ∼50% meet | Probable Yes |
| Electronic copy of their discharge instructions [Hospital Only] | 50% | ? | |
| Clinical summaries for each office visit [EP Only] | 50% | Probable Yes | |
| Exchange Key Clinical Information | One test | Yes | Yes |
| Privacy/Security | Conduct or review Security risk analysis - 7 steps | Probable Yes | |
| Implement drug-formulary checks | Enabled | yes | yes |
| Advance Directives [Hospital Only] | 50% | 3 of 23 hospitals meet | |
| Lab Results into EHR | 40% | yes | yes |
| Patient List | One List | yes | yes |
| Patient Reminders [EP Only] | 20% | ||
| Timely Electronic Access to Health Information [EP Only] | 10% | Yes | |
| Patient Specific Education | 10% | yes | yes |
| Medication Reconciliation | 50% | no | 2 of 23 Hospitals Meet |
| Summary of Care | 50% | Yes | Yes |
| Immunization Registries | One test | Yes | Yes |
| Lab Results to Public Health Agencies [Hospitals Only] | One test | Yes | Yes |
| Syndromic Surveillance | One test | Yes | Yes |
This dashboard shows a summary for all hospitals and ambulatory EPs. We have built reports that allow each of our 23 hospitals drill down to identify their progress toward meaningful use. For example, Hospital A can view the rate of problem list usage for the entire hospital, or may drill down to individual units or floors to identify deficient areas. We also have a similar report for our ambulatory medical group. A single provider can pull up their individual meaningful use progress report to see how they are progressing toward meaningful use, or reports can be pulled by clinic region or for all ambulatory providers. Clinic Mangers can also drill down to identify how well their clinic is doing relative to the rest of the enterprise.
Discussion
A previous publication described the state of Intermountain readiness to meet HITECH requirements using the interim rulings for EHR certification and meaningful use.6 We now have final rulings that are guiding us towards meaningful use. We are now able to track progress in EHR Certification, using the EHR Certification Dashboard, and our overall certification project plan, which allows us to allocate resources to the HITECH and other high level projects at Intermountain.
Our analyses demonstrate that we still have significant work to do to close the EHR functional gaps and the meaningful use gaps. We have divided the work into three major projects; EHR certification, led by our Information Systems (IS) division, hospital meaningful use implementation, and ambulatory meaningful use implementation. Intermountain has made reaching meaningful use a board goal for our system, giving the project top 10 status in our list of enterprise projects. This decision by leadership has gone a long way. It has allowed all three project teams to obtain the staffing and clout to mobilize to meet the challenge. Projects prioritized lower have been postponed to allow for the meaningful use project to move forward. Project estimates show that 10 new IS FTEs will be needed to complete certification, and at the same time, other IS projects will be postponed.
EHR Certification
Our successes include obtaining consensus from Intermountain’s leadership that the HITECH project should be prioritized highly. We have made progress forming the EHR certification teams, and the progress toward EHR certification is now measureable. We are on track to certify our hospital and ambulatory EHR by August, 2012.
We have enhanced our EHR to improve workflow for clinicians in order to meet meaningful use. For example, new concepts were created to enable physicians to document ‘no current active problems’ and ‘no current active medications’ where appropriate. Smoking status was moved from social history to the vital signs panel to make it more accessible. Clinical Summaries will not only be available to print, but will sent to our patient portal.
We still have significant challenges to overcome. Some of the notable EHR certification challenges include building the EHR functionality to capture clinical quality measures (CQMs) in the hospital, transforming our clinical summaries into the required standard formats for clinical exchange, developing new CPOE functionality in our ambulatory product, and functionality to produce discharge and transition summary reports. CQMs and discharge reporting require enhancing our discharge application, and nursing documentation. Clinical Summaries require enhancements to comply with Continuity of Care Documentation (CCD) requirements and our ambulatory order module is being enhanced to include lab and imaging orders. The certification process is expected to be challenging. We are partnering with CCHIT to self-certify our EHR. We are planning to run mock certification on all modules as they are handed off by our development teams.
Hospital Meaningful Use
Hospital leadership is engaged and all 23 hospitals have set goals to meet Stage 1 meaningful use by 2012. We have hired a dedicated clinical meaningful use specialist who works with each hospital’s appointed, accountable team to build and implement plans to meet meaningful use. These plans include education of the hospital leadership and staff about meaningful use, assembling teams representing nursing, physicians, information systems, finance, regulatory compliance, and health information management –medical records (HIM). Nursing, HIM, and information system analysts are meeting to review the hospital requirements and reinforce or establish workflows to meet the meaningful use targets. Hospitals that have deficiencies in particular areas, such as Problem List and Advance Directives are meeting with those hospitals that have met or are close to meeting the meaningful use threshold in order to learn about successful workflows that are in place. Hospital units are using a variation of our Meaningful Use Dashboard that allows them to drill down to specific units to identify progress on specific meaningful use workflows, such as Allergy List or Smoking Status documentation. Expectations are being set by nurse leadership to stress the importance of compliance with the meaningful use measures. Hospitals and hospital units check their meaningful use status periodically and feed back to their clinicians the status of each meaningful use measure.
Ambulatory Meaningful Use
The Intermountain Medical Group of ambulatory physicians has prioritized meaningful use highly, and has set a board goal to have 75% of their physicians meet meaningful use for Stage 1 by 2012. They have worked with regional operations directors to build and implement meaningful use plans to meet the deadline. Implementation staff has been focusing on the meaningful use measures where there are deficiencies, using the Meaningful Use Dashboard to guide them. Where there are deficiencies, training teams work with clinic staff to modify and improve needed workflows. Yearly provider incentives (20% of base pay) are now based partially on whether a provider reaches meaningful use. Clinics are now able to receive reports on meaningful use status each month, and they are very motivated to work to reach these goals.
Conclusion
This paper describes the current state of our EHR functions and EHR adoption compared to those required by the ONC and CMS final rules. We describe the method use to determine the gaps between our EHR functions, EHR adoption, and required to certify our EHR and meet meaningful use. Also addressed are some of the challenges and successes in certifying our EHR and moving to meet meaningful use in our hospitals and clinics.
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