1 EHR Meaningful Use Stages 1 and 2 What They Mean To You Pat Wolfram
2 What We ll Cover Update on Meaningful Use Stages 1 and 2 EMR Trends and Learnings During MU Stage 1 But It s Really More Than Just Meaningful Use The Practice s Expectations What The EMRs Can Do What You Can Do
3 Our Mission Enhance the physician s ability to make timely and accurate diagnostic decisions Enhance our lab and imaging partners services through integration within the practices EMR workflow Our Company Focus on physician-centric interoperability Developing EMRs and EMR Integration since 1997 Rapid and accurate software development and customer implementation Our Customers 18,000 users, 6000 physicians on EMRs using EMR-Link today Over 300 practices use EMR-Link for lab and radiology integration Over 100 labs and radiology systems supported across US 2,000,000 clinical transactions per quarter
4 EMR-Link is Deployed Nationwide through cloud-based SaaS No EMR: Web-based OrdersAnywhere EMR with HL7 only EMR with workflow integration Orders Results Lab Radiology Practices Labs Providers
5 EMR-Link Hub Lab-to-Practice Connectivity No EMR: Web-based OrdersAnywhere EMR with HL7 only Orders Lab EMR with workflow integration Results Radiology HL7 HIE, public health reporting, etc. EMR EMR EMR
6 OK About Meaningful Use
7 It s Complicated
8 Meaningful Use Goals Through incentive payments the HITECH Act promotes the adoption of EHR technologies with the goal to: Improve quality, safety, efficiency of health care Engage patients and families Improve care coordination Improve population and public health Ensure adequate privacy and security protections for personal health information. $18,000,000,000 in total $44,000 per care provider
9 MU Certification Stage 1 For Labs 1. Lab Test Results An optional menu item (one of 10 menu items) Incorporate 40% of clinical lab test results as structured data 2. Computerized Physician Order Entry (CPOE) Not required for phase one But a likely requirement for phase two, starting 2014 Not great for labs. Orders can be on paper In the absence of orders, results are less robust (patient chart mismatches, provider ID mismatches, order reconciliation,..)
10 MU Stage 2 For Labs (Proposed Rule) 1. Lab Test Results Becomes a CORE item (now required) 55% structured data requirement 2. Computerized Physician Order Entry (CPOE) - Core item >60% of orders (labs, meds, imaging, ) must be placed/documented in the EMR - Must be entered by the care provider making the decision to order the test. - Order does not have to be sent electronically 3. HL7 v LOINC Support It s part of the standard set HUGE workflow impact to the practice Orders, Orders, Orders
11 About The MU Stage 2 Process Notice Of Proposed Rule Making Comments due May 7, 2012 Rules will likely be relaxed again. MU about 20% of rules were relaxed, as was the timing. HL7v2.51 and LOINC compliance are going to be difficult. First attestation in 2014
12 EMR Trends and Learnings from the MU Stage 1 period.
13 EMR Adoption Includes structured lab results Source: CDC/NCHS, National Ambulatory Medical Care Survey. Electronic Medical Record/Electronic Health Record Systems of Office-based Physicians: United States, 2009, and Preliminary 2010 State Estimates
14 EMR Trends and Learnings During MU Stage 1 EMR Innovation was frozen for two years Vendors had to comply with MU measures So, EMR Orders did not get better (this will hurt the labs in 2014) EMR Vendors multiply 35 EMR vendors in Certified EMRs and/or modules in Certified EMRs and/or modules as of March 2012 Greater EMR Adoption Volume Ignis integration projects starts with current labs rose 70% More labs came to us for outreach Thinned out EMR integration talent implementations are slower Long waiting periods for all new EMRs to kick off projects
15 Consolidation Starts Some Positive Notes Some IT vendors have dropped lower volume EMRs that haven t gotten traction Many smaller EMRs silently stop showing up The Market Nudges Back To Normal Late Majority initially acts uncharacteristically Late Majority makes an adjustment
16 A Normal Product Adoption Curve At 25% adoption, we d typically still be in the Early Majority EM is willing to deal with newer technology Resilient. Don t need referrals, or cookie cutter approaches.
17 But Because Of Stimulus Dollars....adoption moves into the late majority
18 The Late Majority Wiggles A Bit Initially LM adopted earlier than they re accustomed --- MU $$ Chose new low-cost EMRs Difficult projects for lab integration Backed-up queues for lab result interfaces Today Trending back to normal LM conservatively choosing vetted products Seeing mostly top tier EMR vendors now Beginnings of EMR consolidation
19 EMR Trends and Learnings During MU Stage 1 Physicians qualifying for MU checks were low 91% of physician qualified for MU program, based on Medicare billings Yet, only 11% had qualifying EMRs and applied..so, MORE VOLUME IN For mature EMRs users, MU was a small bump in the road EMR User Group % of papers were about MU 2012 EMR User Group Less than 10% of papers were about MU Now, they re gearing up for MU 2.and more... GET READY FOR ORDERS!!!. GET READY FOR PATIENT CONNECTIVITY!!! 2012 EMR User Group WE WANT RULES BASED ORDERS 2012 EMR User Group WE WANT PATIENT CONNECTIVITY
20 So, You re Adopting EMR
21 Investment (time, tools, etc ) Pre MU A Practice Adopts EMR Usually begin with low impact, high value modules; then move up Lab results at Step 1 Required in 90% of EMR go-lives Office Communication Orders come later. More difficult to set up. Workflow impact is greater. Medication Management Script legibility Interaction checks Formulary compliance Full Encounter Documentation Orders Face sheet documentation E&M Compliance Billing efficiencies Disease management CPOE requirement Complete EMR workflow View and Sign Phone notes Virtual to do list Office efficiencies Minimal workflow impact Populates chart with clinical data; lab results and transcription Chart review from home EMR Function Adoption Timeline
22 Investment (time, tools, etc ) MU Stage 1 Compresses Adoption Timeframe Still a later step Orders Full Encounter Documentation Full Encounter Documentation Medication Management Medication Management Office Office Communication Communication View and Sign Lab Results: Still step 1 Forced EMR vendors to change their deployments Results are still job 1 EMR Function Adoption Timeline
23 Investment (time, tools, etc ) MU Stage 2. To The Practice It s All About Orders Still a later step Orders Full Encounter Documentation Full Encounter Documentation Medication Management Medication Management Office Office Communication Communication View and Sign No big deal moving from 40% to 55% structured Results no big deal Orders are now in play. This will be tough for practices new to EMR EMR Function Adoption Timeline
24 Buyers Of Seasoned EMRs Expect This Clinic AOE questions Minimize data entry Lab Order Completion Lab Easy to order ABN validated Provider Ordering Provider Lab Review Desktop notification Updates the order status Order ID Provider ID Patient ID Verify insurance Verify ABN Minimize data entry Accessioning & Testing Lab reports to the patient EMR Chart Matching Results match to charts. Results into the flowsheet
25 And Support For Multiple Labs Clinic AOE questions Minimize data entry Lab Order Completion Lab Easy to order ABN validated Provider Ordering Provider Lab Review Order ID Patient ID Accessioning & Lab Testing Desktop notification Updates the order status Provider ID Lab Lab reports to the patient EMR Chart Matching Results match to charts. Results into the flowsheet
26 Stage 1 MU Clinic AOE X questions Minimize data entry Lab Order Completion X Lab X Easy to order ABN validated Provider Ordering Provider Lab Review Order X ID Patient ID Verify insurance Verify ABN Minimize data entry Accessioning & Testing X Desktop notification Updates the order status Provider ID X Patient friendly lab reports EMR Chart Matching Results match to charts. Results into the flowsheet
27 Stage 2 MU X X Easy to order ABN validated Provider Ordering Provider Lab Review Clinic AOE X questions Minimize data entry Lab Order Completion Order X ID X Patient ID Lab Verify insurance Verify ABN Minimize data entry Accessioning & Testing X X Desktop notification Updates the order status Patient friendly lab reports EMR Chart Matching Provider ID Results match to charts. Results into the flowsheet
28 The Types Of EMRs We re Dealing With
29 Four Basic EMR Types..when discussing lab integration 1. Strong EMR that creates clean orders and receives results 2. Moderate EMR with good integration hooks 3. Moderate EMR with no integration hooks 4. Weak EMR
30 Strong EMR Physician orders in the EMR Medical necessity checked AOEs are complete ABN validation Rules checks Redundancy checks Specimen collection in the EMR Clean orders sent to the lab Results returned and managed well Order Entry Questions Requisition printing ABN printing Label printing ORM Clinic s EMR Order tests Draw and order completion Provider lab review ORU Lab Result review Patient view
31 Moderate EMR Orders Good Integration Hooks Physician orders in the EMR ABN checks in the background ABN validation Rules checks Redundancy checks Specimen collection in the Portal Clean orders sent to the lab Results returned Patient friendly reporting via Portal Draw and order completion Order Entry Questions Requisition printing ABN printing Label printing Clinic s EMR Order tests Provider lab review ORU Lab Result review Patient view Provider-friendly report. Patient-friendly report
32 Typical EMR weak orders, simple HL7 interface Physician orders in the EMR, but no rules checked Specimen collection managed outside the EMR Results returned Draw and order completion Receives clean and complete orders No data entry HL7 ORM Orders in EMR Lab EMR Result review Patient view Nice HTML view Or CCD, or
33 A Weak EMR Order placed outside the EMR Specimen collection managed outside the EMR Results returned Orders entered in Lab portal Draw and order completion ADT EMR Result review Provider lab review Nice HTML view Lab
34 But Practices Want All Of This. Clinic AOE questions Minimize data entry Lab Order Completion Lab Easy to order ABN validated Provider Ordering Provider Lab Review Desktop notification Updates the order status Order ID Provider ID Patient ID Verify insurance Verify ABN Minimize data entry Accessioning & Testing Lab reports to the patient EMR Chart Matching Results match to charts. Results into the flowsheet
35 An Approach To Satisfying The Practice...Fill The EMR Workflow Gaps
36 The Challenge The Difficulty Will Be With Orders Workflow Most EMR Vendors Will Struggle Orders workflow is much tougher than meds, or lab result review Interface Engines Can t Help With Orders Workflow
37 Surround the EMR With Order/Result Functions. Fill It s Gaps.. Tests ordered Specimen collection Orders Lab Practice s EMR Result review Results Flowsheet Provider-friendly report. Patient-friendly report
38 The Strong EMR Receives clean and complete orders No data entry ABN validation Orders Clinic s EMR Order tests Draw and order completion Results Lab Result review Single Lab Connection Simple HL7 interfaces No Gap Filling Needed.
39 The Moderate EMR Orders, with integration hooks ABN validation Rules checks Redundancy checks Order Entry Questions Requisition printing ABN printing Label printing Receives clean and complete orders No data entry Orders Clinic s EMR Order tests Draw and order completion Provider lab review Results Lab Result review Patient view HIE Patient Portal Public Health Same single Lab Connection ABN checking in the background One click to Draw application Link to patient friendly reporting Provider Network for Clinical Interoperability
40 The Moderate EMR Orders, No integration hooks Single Lab Connection Draw app in the Portal ABN checking at draw by nurse/phlebotomist Patient friendly reports in the portal Draw and order completion Receives clean and complete orders No data entry Orders HL7 ORM Orders in The EMR EMR Provider lab review Patient view Results Lab Result review HIE Patient Portal Public Health Provider Network for Clinical Interoperability
41 Weak EMR Orders --- Enter Order in the Portal Single Lab Connection Order in the Portal Draw in the Portal Patient friendly reports in the portal Draw and order completion Receives clean and complete orders No data entry Orders ADT feed EMR Decision to order. Provider lab review Patient view Results Lab Result review HIE Patient Portal Provider Network for Clinical Interoperability Public Health
42 Summary of EMR Meaningful Use It s More Than Just HL7 Interfaces Now Get Ready For Orders MU 2 will require a major overhaul of the EMR vendor capabilities Get Ready For Patient Connectivity Mature EMR Vendors Are Going Well Beyond MU They re demanding workflow integration They re demanding full bi-directional integration We ve Just Started Only 11% have attested so far. 80% more to go.
43 Lab Setup and Maintenance
44 Beyond MU --- EMR Setup and Maintenance Ideally the EMR team and processes will Build a flow-sheet from your utilization report Map from your result codes to the EMR s codes (LOINC?) Load your DOS (directory of services) in an automated fashion. Load your ordering rules (requisition splitting, AOE questions, specimen requirements,..).. from a compendium. Use your utilization report to create custom order lists Or is setup customized? Customized order lists. Great for a practice s unique workflow and a valuable EMR feature. But, some EMRs build this from the ground up with templates. Part of repeatable process
45 Your Lab Information System Setup and Maintenance Evaluate your LIS Can it provide a compendium with a full directory of services (DOS)? Will that compendium include ordering rules, specimen data, ABN cost data Can your LIS provide a utilization report? History of tests for this practice Evaluation your resources. Can they Set up the orders categories in the EMR? Set up the custom order list in the EMR? Set up the flow sheet views in the EMR? Set up the cross-reference files for the result codes Part of repeatable process
46 EMR Integration Maintenance Results maintenance When you update a results code, what happens in the EMR? Orders maintenance When you update an order code, what happens in the EMR? Who troubleshoots a missing lab result?
48 The Situation More and Different EMRs Adoption rate increases Installing at practices that are less prepared Less savvy EMR consultants Here are some approaches. For your lab As an industry group
49 Your Plan: Review Your Resources Look at your LIS capabilities Can your LIS provide a utilization report? Can your LIS provide a compendium with your lab ordering rules? Can it accept an electronic order from an outpatient EMR? Must it receive a registration event from the HIS first? Is this really a show-stopper? (it s not for the reference labs) Your interface engine (or middleware) capabilities Is your team ready for 2X the volume? Can you map to the result codes of the EMR Can you map to LOINC? Look at your processes for providing lab-to-emr integration *you re welcome to use the Ignis project plan as a starting point.
50 Your Plan: Get Involved in the EMR Selection Conduct your own EMR assessment Ask your interface team to rank the EMR that were easiest to deploy and support. Ask your middleware vendor to rank EMRs for integration (have them to plan bandwidth for your upcoming projects) Partner with your practices. Create an RFP they can use for EMR selection (use the Results and Orders checklist in this presentation)
51 Help Your Practices Choose An EMR Results Checklist Does the EMR have its own result code database? Does the vendor provide result code mapping services? How are mismatched results dealt with? How are result codes maintained? Can the EMR support results from multiple labs? Will the result codes from the various labs import to the same flow-sheet?
52 EMR Orders Checklist Orders Checklist Can an HL7 electronic order (HL7) be sent to the lab (or to outreach product) Is ordering easy to use for the physician? If it s installed,is it being used? Is medical necessity being checked when physician places the order? Lab specific AOE support Can lab specific requisitions be printed? Can the EMR support orders to multiple labs? Must the physician choose the correct lab, or can they choose from a single list and the EMR route to the right lab? Is the staff ordering workflow easy to use? Is the setup automated? Is it derived from lab s utilization report and directory of services? Are order and result codes easy to set up and maintain?
53 Your Plan: Reach Out To The Practices Host an EMR open house Tell them you ll help with meaningful use Offer to assist them in the evaluation Give them your EMR integration report card
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