Meaningful Use and Beyond. John D. Halamka MD CIO, Beth Israel Deaconess Medical Center and Harvard Medical School

Meaningful Use and Beyond John D. Halamka MD CIO, Beth Israel Deaconess Medical Center and Harvard Medical School

Meaningful Use Improving quality, safety, efficiency, and reducing health disparities Engage patients and families in their health care Improve care coordination Improve population and public health Ensure adequate privacy and security protections for personal health information

Draft Stage 2 MU Objectives Improving Quality, Safety, Efficiency & Reducing Disparities Stage 1 Final Rule HITPC Proposed Stage 2 Key: Red indicates proposed change based on HITPC 5/11 comments Improving Quality, Safety, Efficiency & Reducing Health Disparities >30% of unique patients with at least one med order have at least one med order entered using CPOE Implement drug-drug and drug-allergy interaction checks (enabled functionality) EP: Generate and transmit permissible prescriptions electronically for >40% of prescriptions >50% of all unique patients have demographics recorded as structured data. (preferred language, gender race ethnicity, DOB, date and preliminary COD- EH ONLY). Raise threshold to >60% for medication orders and include at least one lab order using CPOE for >60% of unique patients who have at least one lab test result; at least one radiology test is ordered using CPOE (unless no radiology orders) Employ drug interaction (drug-drug, drug-allergy) checking; Providers have the ability to refine DDI rules. [In stage 3, goal is to have nationally endorsed lists of DDI with higher positive predictive value and ability to record reason for overriding alert] 50% of outpatient medication orders and 10% of hospital discharge medication orders transmitted as erx 80% of patients have demographics recorded and can use them to produce stratified quality reports; for stage 3, use more granular demographic categories per IOM report (HITSC needs to work on standards for granular demographics) Report CQM as per CMS attestation Report CQM electronically as per CMS Maintain an up-to-date problem list for >80% of all unique patients Maintain problem list (80%)

Draft Stage 2 MU Objectives Improving Quality, Safety, Efficiency & Reducing Disparities, II Stage 1 Final Rule HITPC Proposed Stage 2 Key: Red indicates proposed change based on HITPC 5/11 comments Maintain active med list for >80% of all unique patients Maintain active med allergy list for >80% of all unique patients Record and chart vital signs for >50% of all unique patients age 2 and over Maintain active med list (80%) Maintain active med-allergy list (80%) 80% of patients have vital signs recorded during the reporting year; change age for peds BP from 2 yrs to 3 yrs Record smoking status for >50% of all unique patients 13 years or older Implement 1 clinical decision support rule relevant to specialty or high clinical priority along with ability to track compliance Menu: Implement drug-formulary checks with access to at least one drug formulary Menu: Record AD for 50% of all unique patients 65 years and older 80% of patients have smoking status recorded [stage 3 add new field in certification for secondhand smoke] Use CDS; HITSC: Suggest changing certification criteria definition as indicated on comment summary Move to Core: Implement drug formulary checks according to local needs (e.g., may use internal or external formularies, which may include generic substitution as a formulary check ) Move to Core: For hospitals (inpatient), 50% of patients 65 years and older have recorded whether an advance directive exists (with date and timestamp of recording) and access to a copy of the directive itself if it exists; for EPs, >25 unique patients have recorded whether an advance directive exists (with date and timestamp of recording) and access to a copy of the directive itself if it; (signal ability to store and retrieve AD for Stage 3)

Draft Stage 2 MU Objectives Improving Quality, Safety, Efficiency & Reducing Disparities Stage 1 Final Rule HITPC Proposed Stage 2 Key: Red indicates proposed change based on HITPC 5/11 comments Menu: Incorporate clinical lab-tests results as structured data for more than 40% of all lab tests results ordered New Menu: Generate at least one report listing patients by specific conditions Menu: Send an appropriate reminder for preventive/follow up care to more than 20% of all unique patients 65 years or older or 5 years or younger New New New Move to Core: Incorporate lab results as structured data (40%); HITSC: Use LOINC where available EHs: Hospital labs send (directly or indirectly) structured electronic clinical lab results to outpatient providers for 40% of electronic orders received; HITSC: Use LOINC where available; (note challenge to small hospitals; may require exclusions) Move to Core: Generate patient lists for multiple patient-specific parameters Move to Core: EPs:10% of all active patients are sent a clinical reminder (reminder for existing appointment does not count) 30% of EP visits have at least one electronic EP note and 30% of EH patient days have at least one electronic note by a physician, NP, or PA; non-searchable, scanned notes do not qualify [use broad definition of qualifying note types] EH medication orders automatically tracked via electronic medication administration record; (in-use in at least one hospital ward/unit) ( automatically implies 5 rights recorded without manual transcription) Consider adding recording of family health history in stage 3 (due to absence of standards for FH)

Draft Stage 2 MU Objectives Engaging Patients and Families Stage 1 Final Rule HITPC Proposed Stage 2 Key: Red indicates proposed change based on HITPC 5/11 comments Provide >50% patients with an electronic copy of health information EH: Provide >50% of all discharged patients patients with an electronic copy of their discharge instructions New Menu: Provide >10% of all unique patients with timely electronic access to health information (EP) Provide Clinical Summaries to patients for >50% of all office visits within 3 business days Menu: Use certified EHR technology to identify patient-specific educational resources and provide to patient if appropriate for >10% of all unique pts. New New New (combined with other objectives) Hospitals: 25 patients receive electronic discharge instructions at time of discharge Hospitals: 10% of patients/families view and have ability to download [took out relevant ] information about a hospital admission; information available for all patients within 36 hours of the encounter Move to Core: EPs: >10% of patients/families view & have ability to download their longitudinal health information; information available to all patients within 24 hours of an encounter (or within 4 days after available to EPs) [P&S TT to consider whether a P&S warning should be put in S&C criteria] EPs: patients are provided a clinical summary after 50% of all visits, within 24 hours (pending information, such as lab results, should be available to patients within 4 days of becoming available to EPs; (electronically accessible for viewing counts) Move to Core: Both EPs and hospitals: 10% of patients are provided with EHRenabled patient-specific educational resources; make core; take out if appropriate instead of raising threshold EPs: patients are offered secure messaging online and at least 25 patients have sent secure messages online EPs: Patient preferences for communication medium recorded for 20% of patients Stage 3: Provide mechanism for patient-entered data (supply list); consider information reconciliation for stage 3 to correct errors

Draft Stage 2 MU Objectives Improve Care Coordination Stage 1 Final Rule HITPC Proposed Stage 2 Key: Red indicates proposed change based on HITPC 5/11 comments Improve Care Coordination Capability to exchange key clinical information Perform at least one test ELIMINATED IN FAVOR OF USE CASE OBJECTIVES BELOW Menu: Perform medication reconciliation for >50% of transitions for receiving provider Move to Core: Medication reconciliation conducted at >50% of transitions by receiving provider Menu: Provide summary of care record for >50% transitions of care for the referring EP or EH New New Move to Core: Summary of care record. EH: 10% of all discharges have summary and care plan sent electronically to EP or post-acute care facility. EP: at least 25 transactions sent electronically (if exclusion for lack of electronic recipients, then must send on paper) [Need HIE preamble.] List of care team members (including PCP, if available) available for 10% of patients via electronic exchange; (unstructured data for stage 2; for stage 3, code by NPI) (Care plan objective merged with summary of care)

Draft Stage 2 MU Objectives Improving Population and Public Health Stage 1 Final Rule HITPC Proposed Stage 2 Key: Red indicates proposed change based on HITPC 5/11 comments Improve Population and Public Health* Capability to submit electronic data to immunization registries or immunization IS Perform a test EH: Capability to submit electronic lab data on reportable lab results to public health agencies Perform a test Capability to submit electronic syndromic surveillance data to public health agencies - Perform a test CMS to Consider CMS to Consider New for Stage 3 EH and EP: Submit immunization data (attest to at least one) in accordance with applicable law and practice; move to core for both EH and EP [In Stage 3, view cumulative immunization record and recommendations] EH: Submit reportable lab results (attest to submitting to at least one organization) in accordance with applicable law and practice; move to core EH: Submit syndromic surveillance data (attest to at least one) in accordance with applicable law and practice; move to core EP: Submit syndromic surveillance data (attest to at least one) in accordance with applicable law and practice EP: Submit reportable cancer conditions (attest to at least one) in accordance with applicable law and practice (to HITSC: possible use of IHE cancer reporting implementation guide) For Stage 3: Patient-generated data submitted to public health agencies *Signal to HITSC to include a single standard to be used for submitting PH data for each PH objective.

Draft Stage 2 MU Objectives Ensure Privacy and Security Protections Stage 1 Final Rule HITPC Proposed Stage 2 Key: Red indicates proposed change based on HITPC 5/11 comments Ensure adequate privacy and security protections for personal health information Conduct or review a security risk analysis and implement security updates as necessary and correct identified security deficiencies as part of the its risk management process Perform, or update, security risk assessment and address deficiencies. Address encryption for data at rest and attest to policy (not required for all but need policy).

Standards Work this Summer Standards Summer Camp Deliverables Metadata Analysis Power Team Patient Matching Power Team eprescribing of Discharge Meds Power Team Surveillance Implementation Guide Power Team NwHIN Power Team Clinical Quality Workgroup & Vocabulary Task Force Recommendations and Transition Plans Standards and Interoperability Framework update Certificates Provider Directories Reportable Lab Transitions of Care

BIDMC s Accountable Care Organization Strategy New health information exchanges New analytics Genomics

Pull Healthcare Information Exchange Atrius Epic Needham Meditech eclinicalworks BIDMC webomr Atrius Epic X Needham Magic Button went live March 2011 ecw Magic Button being developed in 2011 webomr Magic Button went live January 2010 Needham Meditech Reverse Magic Button go live enables us to plan Meditech integration X ecw Magic Button being developed in 2011 Careweb enables viewing of all BIDMC and Meditech data eclinicalworks Reverse Magic Button go live enables us to plan ecw integration Needham Magic Button went live January 2010 X webomr Magic Button went live January 2010 BIDMC webomr Reverse Magic Button went live March 2011 Needham Magic Button went live January 2007 ecw Magic Button being developed in 2011 X

Push Health Information Exchange EMRs and Other Enterprise Systems Local Gateway Participant Interface Engine or Portal Local Provider Directory Published Patient Data Published Patient Data Local Gateway Participant Local Provider Directory Interface Engine or Portal EMRs and Other Enterprise Systems HIE Application Server / Gateway CCD Standard Messages, e-mail or fax encapsulation HIE Application Server / Gateway Secondary Local System Local gateway users control integration, E-Mail Server etc. Web Server Can leverage infrastructure for internal integration Interfaces can be direct or use interface engine or similar tools Fax Server Fax Server Web Server E-Mail Server Secondary Local System Summary / Results Viewer Summary / Results Viewer E-mail, fax or HTTP encapsulation Internet / Network CCD Standard Messages, HTTP encapsulation Summary / Results Viewer Network Subscriber Hosted Portal Published Patient Data Web Server Fax E-Mail Server External Networks Community Provider Directory Printer No infrastructure support requirement just Internet connection, fax or e-mail HIE Application Server / Gateway Hosted by service provider (MA-SHARE) Provides document / data storage, HTTP viewing for subscribers, and common provider index for dissemination to local gateway participants 13

BIDPO QDC Project BIDPO/BIDMC engaged MAeHC to provide a quality data warehouse service to: Enable automated extraction and aggregation of selected clinical data from member physicians ecw and WebOMR EHR systems Develop selected clinical quality measures for BIDPO internal benchmarking, case management, and reporting to commercial and government health plans BID QDC Enhancements: Automated extraction of clinical data from live ecw and WebOMR practices Calculation and reporting of measures required by health plans, including BCBSMA (AQC) and CMS (Meaningful Use and PQRS) Implemented HHS approved HITSP standard C32 Continuity of Care Document (CCD) as the vehicle for data exchanged(i.e. the payload). Using national vocabulary standards CCDs are transmitted via the NEHEN Clinical Data Exchange Using Patient Identifiable data Richer data set (includes payer information) Slide title Massachusetts ehealth Collaborative MAeHC. All rights reserved. - -

BIDPO QDC Electronic reporting MU, PQRS, AQC, etc ~ 2500 users WebO MR BIDPO QDC Data management Report viewing Case tracking ~300 users ecw Data extraction Queries Pre-defined data marts Management Info System User information Utilization analysis Other Documentation & Extraction Transport Validation & Analysis User Access

Patient-Level Information Assets BIDPO QDC Massachusetts ehealth Collaborative MAeHC. All rights reserved. - -

BIDPO QDC Measures Measure sets: 35 Contract Incentive Measures 44 NQF Meaningful Use Measures 24 PQRS Measures Substantial overlap in terms of intent between measures developed for BIDPO QDC, those required for the PQRI program, and those required for Meaningful Use. QDC was a qualified registry for the CMS 2010 PQRS program We submitted PQRI reports on behalf of 319 BIDMC Providers QDC is currently completing qualification for the 2011 CMS PQRS program QDC is currently completing submission for ATCB (CCHIT)-certification for all 44 MU Stage 1 measures Massachusetts ehealth Collaborative MAeHC. All rights reserved. - -

Extract of Provider Measure Scorecard Massachusetts ehealth Collaborative MAeHC. All rights reserved. - -

Extract of Provider Measure Scorecard Organized by Payer Massachusetts ehealth Collaborative MAeHC. All rights reserved. - -

Extract of Provider Panel Profile by Payer & Plan Massachusetts ehealth Collaborative MAeHC. All rights reserved. - -

Current status of BIDPO QDC Project # Documents Rcvd (Care Events) # Patients # Providers 1,725,116 191,343 2506 QDC went "live" with the Production NEHEN CDX gateway on September 6 th We ve securely received 14,500 production test documents sent by BIDMC via the gateway (to test throughputs and error rates), which translate to approximately 1 GB of patient data. Completing ehx lite deployment in Q4 at which time we will receive identically specified CCDs from all ecw users through NEHEN CDX gateway Massachusetts ehealth Collaborative MAeHC. All rights reserved. - -

Empowering Users with New Analytics Identifying cohorts for clinical trials Access to human specimens Population health surveillance Observational studies of genetic variants

Find Patients Drag-and-drop query design interface

Demographics Plugin Analysis of a saved patient set using a plugin

Two Patient List Plugin Compare multiple patient sets

Timeline Plugin An example of visualization of patient data

No central database Privacy Protections Patients signed HIPAA notice allowing personal health information to be used for research Aggregate counts only; obfuscate by adding small random number; display <10 for small counts Log all queries Local PI responsible for data

Prototype Architecture Central aggregator broadcasts query to local hospital adaptors, which return aggregate counts only

SHRINE Prototype

Genomics

My Genome Charcot Marie Tooth IV Severe Combined Immunodeficiency Susceptibility to Tuberculosis 2x risk of Prostate Cancer Negative Kell Antigen Glaucoma

Questions? jhalamka@caregroup.harvard.edu http://geekdoctor.blogspot.com