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Meaningful Use And Quality
1. w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD
Meaningful Use and Quality
Measures and Healthstory
Nick van Terheyden, MD
Chief Medical Information Officer, Nuance
Executive Committee, Healthstory Project
Board of Directors, MTIA
October 16, 2010
2. w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD
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3. w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD
Session Objectives
At the end of this session you will:
Understand the underlying principles of Meaningful Use (MU)
and the broad intentions of the program
Identify key Quality Measures and their source in the clinical
encounter
Be familiar with the goals and document standards of the
Health Story Project
Recognize how these initiatives are working together to
accelerate EMR adoption and can help guide successful
healthcare reform
Get to know your Simultaneous Translators
4. w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD
What is Meaningful Use?
“Meaningful use, in the long-term, is
when EHRs are used by health
care providers to improve patient
care, safety and quality.”
“HIT is the means, but not the end.
Getting an EHR up and running in
health care is not the main
objective behind the incentives
provided by the federal
government under ARRA.
Improving Health is. Promoting
health care reform is.
David Blumenthal, MD
National Coordinator for HIT
Slide Courtesy of HealthStory
5. w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD
Meaningful Use EHR Goals
Improve quality, safety, efficiency, and reduce
health disparities
Engage patients and families
Improve care coordination
Improve population and public health
Ensure adequate privacy and security
protections for personal health information
Largely aimed at driving healthcare organizations
to collect and report on quality and safety metrics
6. w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD
Meaningful use and the EHR
Facilitates the Transformation
Hospital Centric To patient centric
7. w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD
Meaningful Use ≈ Data Reuse
patient care
billing/claims
adjudication
research
quality reporting
clinical
decision
support
outcomes
analysis
Slide Courtesy of HealthStory
8. w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD
EMR Adoption Model (US)
0.8%
2.6%
3.2%
9.7%
50.2%
15.5%
6.8%
11.2%
n=5217
9. w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD
3 European Hospitals Awarded
Stage 6 Oct 1, 2010
Odense University Hospital, Denmark (DK)
The University Hospitals of Geneva (HUG)
ISMETT Hospital The Istituto Mediterraneo
per i Trapianti e Terapie ad Alta
Specializzazione (ISMETT) Sicily, Italy
10. w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD
Meaningful Use: Core Set
Vital signs – structured data
(>50%)
Problem List (1 entry for >80%)
Active Medication List (1 entry for
>80%)
Smoking status (>50%)
Drug/Drug and Drug/Allergy
Checking
e-Prescribing (>40%)
CPOE for medication (1 medication
>30%)
Medication Allergy (1 entry >80%)
Patient Demographics (>50%)
Electronic Exchange (1 test
exchange)
One clinical decision support rule
Implement privacy and security
Report Clinical quality Measures
through attestation in 2011
Generate Electronic Summary
(>50% within 3 days)
Provide e-copy to patients (>50%
within 3 days)
11. w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD
Meaningful Use – Menu Set
Medication Reconciliation (>50% of transitions of care)
Drug Formulary Checks (one internal or external formulary check)
Incorporate Labs as Structured Data (>40%)
Patients specific education (>10%)
Generate Lists of Patients by Condition
Summary of Care record (>50%)
Electronic Immunization Reporting (1 test submission)
Electronic syndrome surveillance (1 test submission)
Record Advance Directives (Hosp >50%)
Electronic submission of lab data (Hosp 1 test submission)
Patient Reminders for Preventative/f/u care (EP >20%)
Provide Patients with electronic access to Health Record (EP >105 within 4 days)
12. w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD
Quality Reporting Measures
Reporting Hospital Quality Data for Annual Payment Update
Acute myocardial infarction (AMI), Children’s asthma care (CAC), Heart failure
(HF), Surgical care improvement project (SCIP), Pneumonia (PN), Hospital
outpatient measures (HOP), Pregnancy and related conditions (PR), Venous
thromboembolism (VTE), Hospital-based inpatient psychiatric services (HBIPS),
Stroke (STK)
The Joint Commissions Core Measures
Acute myocardial infarction (AMI), Children’s asthma care (CAC), Heart failure
(HF), Surgical care improvement project (SCIP), Pneumonia (PN), Hospital
outpatient measures (HOP), Perinatal Care (PC) – replaced Pregnancy Related,
Venous thromboembolism (VTE), Hospital-based inpatient psychiatric services
(HBIPS), Stroke (STK)
Physician Quality Reporting Initiative (PQRI)
216 individual quality measures in the 2010 PQRI Program (this increases every
year)
13. w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD
Core Measures
Acute Myocardial Infarction
AMI-1 Aspirin at Arrival 1
AMI-2 Aspirin Prescribed at Discharge 1
AMI-3 ACEI or ARB for LVSD 1
AMI-4 Adult Smoking Cessation Advice/Counseling 2
AMI-5 Beta-Blocker Prescribed at Discharge 1
AMI-6 Beta-Blocker at Arrival 1
AMI-7 Median Time to Fibrinolysis
AMI-7a Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival 2
AMI-8 Median Time to Primary PCI
AMI-8a Timing of Receipt of Primary Percutaneous Coronary Intervention (PCI) 2
AMI-9 Inpatient Mortality
14. w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD
PQRI – Measure Groups
Diabetes Mellitus
Chronic Kidney Disease
Preventive Care
Rheumatoid Arthritis
Peri-operative Care
Back Pain
Hepatitis C
Heart Failure
Coronary Artery Disease
Ischemic Vascular Disease
HIV/AIDS
Community Acquired Pneumonia
CAD
Oral Antiplatelet Therapy Prescribed for Patients with CAD
Inquiry Regarding Tobacco Use (Preventive Care and Screening)
Advising Smokers and Tobacco Users to Quit (Preventive Care and
Screening)
Symptom and Activity Assessment
Drug Therapy for Lowering LDL-Cholesterol
IVD
Inquiry Regarding Tobacco Use (Preventive Care and Screening)
Advising Smokers and Tobacco Users to Quit (Preventive Care and
Screening)
Blood Pressure Management Control
Complete Lipid Profile
Low Density Lipoprotein (LDL-C) Control
Use of Aspirin or Another Antithrombotic
15. w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD
Unstructured
Data
Structured
Data
Dictation
and
Transcription
System
generated or
interfaced
data
Direct data entry,
not physician
Direct data entry,
physician
Handwritten
Current Methods for Data Capture
16. w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD
Perceived Barriers to Adoption
Major Perceived Barriers to Adoption of Electronic Health Records (EHRs) among Hospitals with Electronic-
Records Systems as Compared with Hospitals without Systems.
Hospitals with electronic-records systems include hospitals with a comprehensive electronic-records system and
those with a basic electronic-records system that includes functionalities for physicians' notes and nursing
assessments. P<0.01 for all comparisons except physicians' resistance (P=0.20). IT denotes information
technology, and ROI return on investment.
17. w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD
Survey Conducted with 1,000 Physicians
• 67% cited time associated with reliance on
keyboard and mouse to document within an EHR
as a major hurdle for adoption
• 97% selected narrative over structured data
entry as the more valuable documentation
method to treating patients
• 96% expressed concern that they may lose the
patient’s unique story with transition to point-and-
click EHRs
MDs resist point and click
18. w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD
EMR Use in Physician Practices
Source: Texas Medical Association
N=370, 4% response rate
19. w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD
EMR Use in Physician Practices
Source: Texas Medical Association
N=370, 4% response rate
3 to 5 minutes / patient
= 1 to 2 hours / day
= 1 to 3 fewer patients /
day
20. w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD
Health Story Project
Vision: Comprehensive electronic clinical
records that tell a patient’s complete health story.
Who We Are: A non profit alliance of healthcare
vendors, providers and associations
Mission: Pool resources to develop data
standards through HL7 for flow of information
between common types of healthcare documents
and EHR systems
Goals: Bridge the gap between the narrative
documents and structured data
21. w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD
Narrative
Text
Structured
Documents
Extracted, Coded
Discrete Data
Elements
EHR
Repository
HIM
Applications
Clinical
Applications
SNOMED CT
Disease, DF-
00000
Metabolic Disease, D6-
00000
Disorder of glucose metabolism,
D6-50100
Diabetes Mellitus, DB-
61000
Type 1, DB-
61010
Insulin dependant type IA,
DB-61020
Neonatal,
DB75110
Carpenter Syndrome,
DB-02324
Disorder of carbohydrate
metabolism, D6-50000
Meaningful Clinical Documents
22. w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD
Meaningful Clinical Documents vs. Text
Structured and encoded clinical content
enables…
pre-signature alerts,
decision support,
best documentation practices,
multiple output formats,
multi-media reporting,
data mining
Implements HL7 CDA4CDT standard
compliant document types
Increases quality of documentation
23. w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD
Current and Future Standards
HL7 Implementation Guides
Completed
History & Physical
Consultation
Operative Report
DICOM Imaging Reports
Discharge Summary (in publication)
Upcoming
Procedure Note (focus on Endoscopy Report)
CDA with unstructured body
Billing and Reimbursement Requirements
Progress Notes
w w w . h e a l t h s t o r y. c o m
24. w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD
Benefits of Health Story Project
Benefit Value
Retains patient story Maintains primary role of documentation to clearly
describe and communicate what is going on with patient.
Preserves physician time
for clinical care
Makes efficient use of physician time by enabling choice
of documentation methods
Supports meaningful use Implements HL7 CDA document standards for electronic
exchange of clinical information (Patient Summary Record)
Enables dual use of
information
Structured narrative enables better outcomes reporting,
data mining, and decision support
Collaborative approach Developed by a broad array of providers, vendors and IT
organizations
Balloted process supports harmonization
Better documentation Supports better coding, DRG optimization
= better reimbursement
25. w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD
What Health Story Offers You
Allows providers to choose preferred workflow
and documentation methods
Increases the value and usability of narrative
documents
Accelerates the implementation of interoperable
electronic health records
Allows intelligent and meaningful reuse of
information
Provides on-ramp to EMR system adoption
pre-populate EMR with structured documents
integrate legacy documents
26. w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD
Nick van Terheyden, MD Chief Medical Information Officer, Nuance Communications
Twitter http://twitter.com/drnic1
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E-Mail nvt@nuance.com, drnick@nuance.com, drnic1@gmail.com
GrandCentral (301) 355-0877
Where You Can Find Me
27. w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD
Meaningful Use and Quality
Measures and Healthstory
Nick van Terheyden, MD
Chief Medical Information Officer, Nuance
Executive Committee, Healthstory Project
Board of Directors, MTIA
October 16, 2010
Notes de l'éditeur
Meaningful use, in the long-term, is when EHRs are used by health care providers to improve patient care, safety, and quality.http://www.healthcareitnews.com/news/healthcare-it-chief-takes-meaning-meaningfulARRA HITECH Act and Meaningful Use brief overview
Complete patient record (the health story) in the center and all types of secondary uses coming from it Define notion of primary data and then secondary dataA critical, foundational component of MU is interoperability specifications, because they support data reuse and data aggregation.
Use of Electronic Health Records in U.S. Hospitals, New England Journal of Medicine, April 2009http://content.nejm.org/cgi/content/full/NEJMsa0900592Responses from 3,049 acute care hospitals in the U.S.
http://www.nuance.com/healthcare/physician-study/
What do physicians like about their EMRs? The OUTPUT. For the most part, physicians like using information in the EMR once it has been entered. (Note that electronic charting in this context refers to having access to notes electronically, not the actual act of charting)From sources other than this survey, we have seen the following EMR benefits noted:Finding and Retrieving NotesDoing RefillsFaxing Off PrescriptionsLooking Up Test ResultsDoing CalculationsDrug InteractionsMaking AppointmentsGenerating RemindersLooking Up ICD9s
What do physicians hate about their EMRs? The INPUT. For the most part, physicians dislike the user interfaces that slow down their ability to enter patient visit notes. We are starting to hear a common theme among physicians, that EMRs reduce their productivity considerably: it is taking from 3 to 5 minutes more per patient for visit documentation, which over the course of a workday translates to 1 to 3 fewer patients per day, or getting home 1 to 2 hours later. ( A recent survey by MGMA [March 2010, n=439] found that two thirds of respondents expected a PERMANENT decline in productivity with meaningful use, and fully one third expected declines of 10% or more). From sources other than this survey, we have seen the following EMR drawbacks noted:Dictating- Poor or NoneDocumenting an EncounterRestrictive TemplatesDirect Entry ErrorsComputer-generated NotesFaxing/Sending NotesReceiving NotesAutofeaturesElectronic ExchangeAccuracy DeclinesMalpractice Unknowns
Health Story members share the vision that all of the clinical information required for good patient care, administration, reporting and research will be readily available electronically, including information from narrative documents.Other key points:Active for three years (founded 2007 by AHIMA, AHDI, Alschuler, MTIA, M*Modal) Associate Charter Agreement: HL7Elected executive committee from member organizations provide direction- Members support project with active participation and annual membership dues