Using Electronic Health Records (EHRs) for Improving Chronic

Disease Care

Margaret O. Casey RN MPHNACDD CVH Council Consultant

Outline Background and pertinent legislation “Meaningful Use” Alphabet soup Recommended EHR components Role of public health

“Our recovery plan will invest in electronic health records and new technology that will reduce errors, bring down costs, ensure privacy, and save lives.”

-  President Obama, Address to Joint Session of Congress, February 2009

Background 2000 – IOM report released – To Err is Human:

Building a Safer Health System 98,000 Americans die each year from medical errors Health care delivery system was fragmented and

decentralized Outlined principles for computerized health

records Became basis for future certifications

Insert

Pertinent Legislation 2004 Executive Order 13335

Widespread adoption of EHRs by 2014 Creation of a position for the National Coordinator for

Health Information Technology 2009 American Reinvestment and Recovery Act

(ARRA) Health Information Technology for Clinical and

Economic Health (HITECH) Act Office of the National Coordinator for Health Information

Technology (ONC) given statutory permanence Funding for “meaningful use” (MU) of certified EHR

technology

Office of the National Coordinator(ONC)

Developed a Federal Health IT Strategic Plan; initial framework: Inform clinical practice Interconnect clinicians Personalize care Improve population health

Administers MU incentive program with the Centers for Medicare and Medicaid Services (CMS)

What is Meaningful Use?Using certified EHR technology to: Improve quality, safety, efficiency, and reduce

health disparities Engage patients and families in their health care Improve care coordination Improve population and public health

While maintaining privacy and security

MU Incentive Programs Medicare EHR Incentive Program Medicaid EHR Incentive Program

Comprised of three regulations1. Certification standards and criteria that EHR

technology must embody2. Certification process 3. Measures of use and quality to achieve CMS-

specified objectives

MU Incentives Through HITECH – Incentive payments totaling

up to $27 billion over 10 years Medicare – Up to $44,000 per clinician over 5 years Medicaid – Up to $63,750 per clinician over 6 years Medicare/Medicaid – $2M+ per hospital

After 2015 – Medicare reimbursement payment adjustments

No payment adjustments for Medicaid

MU Stage 1Eligible Professionals must : Complete15 core objectives Complete 5 objectives out of 10 from menu set Report 6 total Clinical Quality Measures

3 core or alternate core, and 3/38 from menu set 2011 – submit via attestation 2012 – submit electronically

Current rules define requirements for stage 1 of 3 stages

MU Core ObjectivesComputerized provider order entry (CPOE)E-Prescribing (eRx)

Report ambulatory clinical quality measures to CMS/StatesImplement one clinical decision support rule

Provide patients with an electronic copy of their health information, upon request

Provide clinical summaries for patients for each office visit

Drug-drug and drug-allergy interaction checks Record demographics

MU Core Objectives (cont’d) Maintain an up-to-date problem list of current and active

diagnoses Maintain active medication list Maintain active medication allergy list Record and chart changes in vital signs Record smoking status for patients 13 years or older Capability to exchange key clinical information among

providers of care and patient-authorized entities electronically

Protect electronic health information

MU Menu Set Incorporate clinical lab test results as structured data Generate lists of patients by specific conditions Drug-formulary checks Medication reconciliation Send reminders to patients per patient preference for preventive/follow

up care Provide patients with timely electronic access to their health information Use certified EHR technology to identify patient-specific education

resources and provide to patient, if appropriate Summary of care record for each transition of care/referrals Capability to submit electronic data to immunization registries/systems* Capability to provide electronic syndromic surveillance data to public

health agencies*

* At least 1 public health objective must be selected.

MU Clinical Quality Measures – Core Set

Hypertension: Blood Pressure Measurement (NQF 0013)

Preventive Care and Screening Measure Pair: a) Tobacco Use Assessment b) Tobacco Cessation Intervention

(NQF 0028) Adult Weight Screening and Follow-up

(NQF 0421, PQRI 128)

MU Clinical Quality Measures – (Selected) Menu Set

Controlling High Blood Pressure Ischemic Vascular Disease (IVD): Blood Pressure Management IVD Complete Lipid Panel and LDL Control Coronary Artery Disease (CAD): Drug Therapy for Lowering LDL-

Cholesterol IVD: Use of Aspirin or Another Antithrombotic CAD: Oral Antiplatelet Therapy Prescribed for Patients with CAD Smoking and Tobacco Use Cessation, Medical Assistance Diabetes: Low Density Lipoprotein (LDL) Management and

Control Diabetes: Blood Pressure Management Diabetes: Hemoglobin A1c Poor Control Diabetes: Hemoglobin A1c Control (<8.0%)

MU Stage 2 Recommendations in development – end of

2011? Builds on Stage 1 To include ABCS measures (planned)

Regional Extension Centers (RECs) $677M allocated to support a US system of

RECs; currently 62 are funded To support and serve priority primary care

providers : Solo and small group practices Community and rural health centers Rural and critical-access hospitals (n=46) Other settings that predominately serve uninsured,

underinsured, or medically underserved patients

http://www.healthit.gov/buzz-blog/local-implementation-support/regional-extension-centers-enabling-meaningful-use-all/

REC Responsibilities Provide training and support services to assist

doctors and other providers in adopting EHRs Offer information and guidance to help with EHR

implementation Give technical assistance as needed Potential CD partners??

Health Information Exchanges March 2010 – $548M – State Health Information

Exchange (State HIE) Cooperative Agreement Program awardees

Funds states’ efforts to rapidly build capacity for exchanging health information across the health care system both within and across states

Jan 2011 – $16M – HIE Challenge Grant Supplement Amount for innovative and scalable solutions

http://healthit.hhs.gov/portal/server.pt?open=512&objID=1488&mode=2

Beacon Communities Beacon Community Cooperative Agreement Program:

Funding to 17 selected communities – $250M Build and strengthen HIT infrastructure and exchange

capabilities

Beacon Communities will focus on goals in three areas of health systems improvement: Quality Cost-efficiency Population health

Best Practices

http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__onc_beacon_community_program__improving_health_through_health_it/1805

Certifications, Standards, Vocabularies, and Formats

HL7

LOINC

SNOMED CTANS

ISCRIPT

DI

COM

ASTM

ELINCS

RxNorm

NIST

CCHIT

ONC

NCVHS

XML

ICD-9 &10

Alphabet Soup HIT – Health Information Technology

General concept that supports storage, retrieval, sharing, and use of health info, data, and knowledge for communication and decision making

EMR – Electronic Medical Records Within one organization

EHR – Electronic Health Records Across multiple organizations

More Alphabet Soup HIO – Health Information Organization –

oversees and governs HIE through a formal governance structure and participant agreements

RHIO – Regional Health Information Organization – regionally organized HIO

NHIN – National Health Information Network – a network of networks with standards, services, and policies that enable secure HIE via the Internet

Even More Alphabet Soup HL7 – standards for the exchange, integration, sharing,

and retrieval of electronic health information PHR – Personal Health Records – a health record

controlled by the individual CCR – Clinical Care Record

Standardized elements to be sent to physician referrals or transfers

CCD – Clinical Care Document Standardized elements (the “what) of a CCR transmitted

using a standardized exchange architecture (the “how”)

EHRs are COMPLICATED

http://www.openehr.org/29-OE/version/1/part/ImageData/data/landscape_diag-1.png?branch=main&language=default

Simplified EHRPractice Management System

Point-of-Care Data

Clinical Data Repository

- CPOE- CDS

e-Rx Labs

ImagesHospital

Clinical Data

Warehouse

PHR

CCD

Public Health

Reporting

HIE/HIO

Scanned or Faxed

Documents

Computerized Physician Order Entry (CPOE)

A process of electronic entry of medical practitioner instructions for the treatment of his/her patients e-prescribing Labs Drug-drug and drug-allergy interaction checks Drug-lab checking Imaging Consults Microbiology, pathology

e-Prescription (eRx) Computer-generated prescriptions created by a

healthcare provider and sent directly to a pharmacy NOT computer-generated faxed or printed

prescriptions Sent electronically through a private, secure,

and closed network using nationally recognized transmission standardized

Fast, convenient, LEGIBLE, economical

e-Rx (cont’d) HITECH requirements

Generate a complete active medication list Select meds, print prescriptions, electronically transmit

prescriptions, and conduct alerts for inappropriate dose/route, drug-drug interactions, allergies, etc.

Provide info on lower-cost alternatives (generics) Provide info on formulary, patient eligibility, and

authorization requirements from patient’s insurance Convey above info using the messaging and

interoperability standards of Medicare Part D eRx program

Clinical Decision Support (CDS) Interactive programs that directly assist clinicians

with decision-making tasks Varied functionality – Treatment algorithms, 10-

year CVD risk calculator, drug dosing support, alerts/flags/prompts

Alerts Colors, sounds, icons as indicators “In-basket” functionality Pop-up boxes

Over-alerting effect

Challenges with EHR Implementation Cost Current vendor efforts are targeted at MU

criteria only Restructuring workflow and processes to allow

for POC charting Telling the patient story within constraints of

structured data Medical vs. lay terms

Challenges (cont’d) Physicians like dictation and hate data entry Gag orders from vendors

May prevent buyers from showing software to others or even discussing potential faults

Heightened privacy and security concerns Legal issues

Potential CD Program Roles Through existing provider/practice relationships,

encourage certain MU objective menu options: Generate lists of patients by specific conditions (aka

registry) Incorporating clinical lab test results as structured data Medication reconciliation Patient reminders Drug formulary checks

Potential CD Program Roles Partner with state medical associations,

primary care associations, or health center organizations to develop recommendations for clinical decision supports to be included in EHR systems

Recommended guidelines (e.g. JNC-7, ATP III) Recommended functionality (e.g. treatment

algorithms, 10-year CVD risk calculator, drug dosing support, basic alerts/prompts)

Potential CD Program Roles Partner with Regional Extension Centers

Provide training and technical assistance • Chronic diseases

Make connections between practices and RECs Guidelines, guidelines, guidelines ICD-10 code transition

Potential CD Program Roles Get involved with Health Information Exchange

efforts DOH IT staff are thinking about reportable conditions

and immunizations because of MU requirements

Chronic diseases need to be represented

EHR Examples US Department of Veteran’s Affairs – VistA

Free system due to FOIA http://www.ehealth.va.gov/EHEALTH/CPRS_Demo.asp

Google “EHR demo”

ResourcesTopic URL

CMS Incentive Programs

www.cms.gov/EHRIncentivePrograms/

CDC MU www.cdc.gov/ehrmeaningfuluse

MU-certified EHRs

http://onc-chpl.force.com/ehrcert

REC Info http://healthit.hhs.gov/portal/server.pt?open=512&objID=1495&mode=2

HIE Info http://healthit.hhs.gov/portal/server.pt?open=512&objID=1488&mode=2

CDC Public Health Information Network

http://www.cdc.gov/phin/index.html

Questions?

Special thanks to:Hilary K. Wall MPH

Health Scientist at CDC DHDSPSlides are adapted from her slides

and notes