Guest post by Laura Kreofsky, Principal Advisor at Impact Advisors.
It is no surprise many hospitals and eligible professionals are “heads down” on meaningful use Stage 2 preparations. EHR upgrades, evaluating performance against increased thresholds for carry-over objectives from Stage 1, and delving into the technical, procedural and workflow complexities of many new objectives has caught many providers off guard, particularly those for whom meeting Stage 1 was a relatively easy goal.
Two very challenging areas for Stage 2 for most eligible hospitals (EHs) and eligible professionals (EPs) are the objective “Summary of Care Record at Transitions of Care (ToC)” and those that relate to Public Health reporting.
For these objectives, it is not necessarily the performance thresholds that present the challenge, rather the EHR functional requirements, the requirements-behind-the-requirements, or the workflows that are the cause of consternation. These objectives and their unique challenges are described below:
Summary of Care Record at Transitions of Care (ToC).
This objective is challenging on two fronts. First, the population and generation of the Summary of Care Record (the “Record”), and second, the actual transmission of that document at transitions of care to intended recipients.
The record requires an extensive set of data be captured and correctly populated into the C-CDA (the specified document architecture). The record, like several other Stage 2 measures, requires use of the “Common MU Data Set,” 16 specific data elements such as problems, medications and laboratory results. Many providers/staff will have to standardize and/or increase their documentation efforts and consistency to ensure the Record is populated with required data.
Several data elements in the Common MU Data Set require the use of specified vocabularies or standards. For example, for lab results, the Office of the National Coordinator for Health Information Technology (ONC) has adopted logical observation identifiers names and codes (LOINC) version 2.40 as the code set standard. Many healthcare systems are scrambling to ensure their LIS and/or EHR systems are correctly configured to use the LOINC code sets.
In some cases, especially for organizations with a 3rd party LIS interfaced to their EHR, ensuring the results are coded in LOINC is a costly and complex endeavor. Depending on the size of the enterprise and the configuration of lab data and systems, it can take months of effort. These efforts could possibly put reporting and attestation timelines at risk in 2014.
The actual transmission of the summary of care record at transitions to intended recipients also brings a host of challenges. CMS and ONC have specified transport protocols EHR vendors must comply with and that providers/organizations must ensure their individual systems are capable of using.
One means of transmitting the record is by using direct exchange. When using direct, organizations must have and use the services of a health information services provider (HISP). Depending on the EHR vendor, this can be the EHR vendor’s HISP product or a 3rd party HISP that must be selected, contracted and implemented. As a third option, healthcare providers can become their own HISP. Once a HISP is implemented, EHs and EPs must ensure their internal provider directories, the address books that enable the exchange via direct, are current and clean. These endeavors require a unique skill set and can put even more pressure on the ticking clock of Stage 2 preparations
For organizations with a heterogeneous EHR environment (i.e., an inpatient EHR from vendor X, and two ambulatory EHR products from vendors Y and Z), the magnitude of complexity increases rapidly and there may be multiple HISP solutions and strategies in play within the organization.
In some cases, organizations with a heterogeneous EHR environment have deployed internal Health Information Exchange (HIE) technology to support data routing. Depending on the organization’s unique strategy for meeting the ToC requirement, the HIE may have a potential role and the technical and workflow implications must be fully considered.
Public Health Reporting
In stage 2, public health (PH) reporting requirements are significantly more challenging, especially for hospitals. Ongoing immunization registry data submission is a core objective for both EPs and EHs and ongoing syndromic surveillance data and ongoing electronic lab reporting (ELR) are core objectives for EHs. Additionally, over the past two years, an increasing number of public health agencies have developed the capacity to support the types of electronic data submission required for meaningful use, so the “exemption” route is becoming less feasible.
The EHR and interface build for PH reporting requirements are complex in-and-of themselves requiring expertise that is often hard to find and expensive to secure. State and local regulations related to patient opt-in/opt-out must also be well understood and planned for. These can vary by patient age and/or by vaccine type. Additionally, staff communication and training is paramount as they need to understand the nuanced policies and communicate to each patient accordingly and adapt workflows according the patient response.
For large organizations with both EPs and EHs in a broad geographic region, there is a significant project/logistical management component. For example, a large IDN that covers a broad swath of Northern California must:
- Work with two regional immunization registry agencies who have similar but unique technology platforms, policies and procedures
- Work directly with the State for electronic lab reporting
- Work with individual counties for syndromic surveillance data.
Not all counties the IDN serves are capable of receiving syndromic surveillance data at this time. The IDN’s MU team must monitor each county’s status going forward and expedite the planning/implementation of the syndromic surveillance interface as counties become capable.
Counties may also contract with a 3rd party to support their syndromic surveillance data collection efforts. The IDN is now working with two unique third parties across the three counties in its service area now accepting syndromic surveillance data. As the number of counties able to accept the data grows, the number of unique 3rd party intermediaries will also likely grow.
The two objectives detailed here are representative of some of the more challenging requirements for MU Stage 2. Other objectives, such as providing patients/proxies with the ability to view, download and transmit their health information are equally complex.
Keys to success for tackling these challenges – and meeting MU Stage 2 – include:
- Fully understanding the functional (CMS Final Rule) and technical (ONC EHR certification criteria) and how they apply to your unique technical and clinical environment.
- Carefully managing the work effort and coordination for the most complex measures
- Consider assigning a project manager to focus just on the public health reporting and/or summary of care at transition of care requirements. As evidenced above, these can quickly become projects-within-projects.
- Working closely with your EHR vendor(s) and leveraging their expertise. Also, network within the vendor’s client base to see how other like organizations are addressing the pain points.
- Ensure that within your organization, the task force(s) addressing the more complex measure includes representation from clinical (nursing and physician), legal, technical/IS, security and privacy, training and communications.
Although Stage 2 has already commenced for some eligible hospitals, most providers are still working diligently to prepare. Focusing on key challenges – and the requirements-behind-the-requirements – inherent in many of them is essential to ensuring the objectives and timelines can be met.