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What Is An EHR That Supports Meaningful Use -University Degrees Online

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What Is An EHR That Supports Meaningful Use -University Degrees Online Powered By Docstoc
					Healthcare IT for Quality, Safety and Efficiency:
        It’s More Than Meaningful Use

                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 Raise threshold to >60% for medication orders and include at least one lab order
order have at least one med order entered     using CPOE for >60% of unique patients who have at least one lab test result; at least
using CPOE                                    one radiology test is ordered using CPOE (unless no radiology orders)

Implement drug-drug and drug-allergy           Employ drug interaction (drug-drug, drug-allergy) checking; Providers have the ability
interaction checks (enabled functionality)     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]
EP: Generate and transmit permissible          50% of outpatient medication orders and 10% of hospital discharge medication orders
prescriptions electronically for >40% of       transmitted as eRx
prescriptions
>50% of all unique patients have               80% of patients have demographics recorded and can use them to produce stratified
demographics recorded as structured data.      quality reports; for stage 3, use more granular demographic categories per IOM report
(preferred language, gender race ethnicity,    (HITSC needs to work on standards for granular demographics)
DOB, date and preliminary COD- EH ONLY).


Report CQM as per CMS attestation              Report CQM electronically as per CMS

Maintain an up-to-date problem list for >80%   Maintain problem list (80%)
of all unique patients
          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 Maintain active med list (80%)
patients
Maintain active med allergy list for >80% of all Maintain active med-allergy list (80%)
unique patients
Record and chart vital signs for >50% of all      80% of patients have vital signs recorded during the reporting year; change age for
unique patients age 2 and over                    peds BP from 2 yrs to 3 yrs


Record smoking status for >50% of all unique      80% of patients have smoking status recorded [stage 3 add new field in certification for
patients 13 years or older                        secondhand smoke]

Implement 1 clinical decision support rule        Use CDS; HITSC: Suggest changing certification criteria definition as indicated on
relevant to specialty or high clinical priority   comment summary
along with ability to track compliance

Menu: Implement drug-formulary checks with Move to Core: Implement drug formulary checks according to local needs (e.g., may
access to at least one drug formulary      use internal or external formularies, which may include generic substitution as a
                                                  “formulary check”)
Menu: Record AD for 50% of all unique             Move to Core: For hospitals (inpatient), 50% of patients 65 years and older have
patients 65 years and older                       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 Move to Core: Incorporate lab results as structured data (40%); HITSC: Use LOINC
structured data for more than 40% of all lab    where available
tests results ordered
New                                          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)
Menu: Generate at least one report listing   Move to Core: Generate patient lists for multiple patient-specific parameters
patients by specific conditions

Menu: Send an appropriate reminder for           Move to Core: EPs:10% of all active patients are sent a clinical reminder (reminder for
preventive/follow up care to more than 20% of existing appointment does not count)
all unique patients 65 years or older or 5 years
or younger

New                                          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]

New                                          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)

New                                          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               (combined with other objectives)
electronic copy of health information

EH: Provide >50% of all discharged        Hospitals: ≥ 25 patients receive electronic discharge instructions at time of discharge
patients patients with an electronic copy
of their discharge instructions
New                                         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
Menu: Provide >10% of all unique            Move to Core: EPs: >10% of patients/families view & have ability to download their
patients with timely electronic access to   longitudinal health information; information available to all patients within 24 hours of an
health information (EP)                     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]
Provide Clinical Summaries to patients      EPs: patients are provided a clinical summary after 50% of all visits, within 24 hours (pending
for >50% of all office visits within 3      information, such as lab results, should be available to patients within 4 days of becoming
business days                               available to EPs; (electronically accessible for viewing counts)
Menu: Use certified EHR technology to       Move to Core: Both EPs and hospitals: 10% of patients are provided with EHR-enabled
identify patient-specific educational       patient-specific educational resources; make core; take out “if appropriate” instead of raising
resources and provide to patient if         threshold
appropriate for >10% of all unique pts.
New                                         EPs: patients are offered secure messaging online and at least 25 patients have sent secure
                                            messages online
New                                         EPs: Patient preferences for communication medium recorded for 20% of patients

New                                         Stage 3: Provide mechanism for patient-entered data (supply list); consider “information
         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       ELIMINATED IN FAVOR OF USE CASE OBJECTIVES BELOW
information – Perform at least one test




Menu: Perform medication                   Move to Core: Medication reconciliation conducted at >50% of transitions by receiving
reconciliation for >50% of transitions for provider
receiving provider


Menu: Provide summary of care record Move to Core: Summary of care record. EH: 10% of all discharges have summary and care
for >50% transitions of care for the plan sent electronically to EP or post-acute care facility. EP: at least 25 transactions sent
referring EP or EH                   electronically (if exclusion for lack of electronic recipients, then must send on paper) [Need
                                          HIE preamble.]
New                                       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)
New                                       (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 EH and EP: Submit immunization data (attest to at least one) in accordance with applicable
immunization registries or immunization law and practice; move to core for both EH and EP [In Stage 3, view cumulative
IS – Perform a test                     immunization record and recommendations]

EH: Capability to submit electronic lab    EH: Submit reportable lab results (attest to submitting to at least one organization) in
data on reportable lab results to public   accordance with applicable law and practice; move to core
health agencies – Perform a test

Capability to submit electronic            EH: Submit syndromic surveillance data (attest to at least one) in accordance with applicable
syndromic surveillance data to public      law and practice; move to core
health agencies - Perform a test

CMS to Consider                            EP: Submit syndromic surveillance data (attest to at least one) in accordance with applicable
                                           law and practice

CMS to Consider                            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)


New for Stage 3                            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           Perform, or update, security risk assessment and address deficiencies.
analysis and implement security             Address encryption for data at rest and attest to policy (not required for all but need policy).
updates as necessary and correct
identified security deficiencies as part of
the its risk management process
   The Standards Work this Summer
June
•Metadata recommendations
•Provider Directory recommendations
•Patient Matching preliminary recommendations
•Vocabulary recommendations

July
•Patient Matching recommendations
•ePrescribing of discharged medications recommendations
•Syndromic Surveillance recommendations
•Quality Measurement recommendations
  The Standards Work this Summer
August
• Simple Lab Results recommendations
•Transitions of Care recommendations
•CDA Cleanup recommendations
•NwHIN preliminary recommendations

September
•NwHIN recommendations
•Summary of all recommendations from Summer
Camp
BIDMC’s post HITECH
     strategy
• New health information exchanges
• Capturing the value of unstructured data
• Empowering the users with new
  analytics
• Embracing novel sources of data
• Genomics
   “Pull” Healthcare Information Exchange

                                        Needham                                       BIDMC
                 Atrius Epic                                 eClinicalWorks
                                        Meditech                                     webOMR

                                        “Needham Magic       “eCW Magic Button”      “webOMR Magic
Atrius Epic              X               Button” went live
                                           March 2011
                                                              being developed in
                                                                     2011
                                                                                     Button” went live
                                                                                      January 2010



                   “Reverse Magic
 Needham                                                     “eCW Magic Button”     “Careweb” enables
                    Button” go live
 Meditech         enables us to plan
                 Meditech integration
                                              X               being developed in
                                                                     2011
                                                                                   viewing of all BIDMC
                                                                                     and Meditech data



                  “Reverse Magic
                                        “Needham Magic                               “webOMR Magic
                   Button” go live
eClinicalWorks   enables us to plan
                  eCW integration
                                         Button” went live
                                          January 2010
                                                                    X                Button” went live
                                                                                      January 2010




  BIDMC            “Reverse Magic       “Needham Magic       “eCW Magic Button”

 webOMR
                   Button” went live
                     March 2011
                                         Button” went live
                                          January 2007
                                                              being developed in
                                                                     2011
                                                                                           X
                                          “Push” Health Information Exchange

                      Local Gateway Participant
                                                                                                                                                              Local Gateway Participant
    EMRs and Other Enterprise Interface Engine                                  Published Patient Data                                      Published Patient Data                                  Interface Engine      EMRs and Other Enterprise
           Systems                or Portal                                                                                                                                                             or Portal                Systems
                                                            Local Provider Directory                                                                                 Local Provider Directory




                                                             HIE Application Server /                                                                                HIE Application Server /
                                                                    Gateway                                                                                                 Gateway
                                                                                                               CCD Standard Messages,
                                                                                                                  ail
                                                                                                               e-m or fax encapsulation




Secondary Local System             E-Mail Server                W eb Server                  Fax Server                                          Fax Server                    W eb Server                E-Mail Server        Secondary Local System
 •Local gateway users control integration, etc.
 •Can leverage infrastructure for internal integration
 •Interfaces can be direct or use interface engine or similar tools
                                                                                    Summary / Results Viewer                                                                     Summary / Results Viewer

                                                                                                                  Internet /
                                                                                                                   Netw ork
                                                                                E-m fax or
                                                                                    ail,                                                  CCD Standard Messages, HTTP encapsulation
                                                                              HTTP encapsulation




                             Network Subscriber                                                                                                                               Hosted Portal
           Summary / Results
               Viewer                                                                                                                                                                           Published Patient Data

                                                   W eb Server                Fax         E-Mail Server             External
                                                                                                                                                                                                       Community Provider Directory
                                                                                                                    Networks
            Printer                                                                                                                           HIE Application Server /
                                                                                                                                                       Gateway
                                                                                                                                           •Hosted by service provider (MA-SHARE)
 •No infrastructure support requirement – just Internet connection, fax or e-mail
                                                                                                                                           •Provides document / data storage, HTTP viewing for subscribers, and common provider index for
                                                                                                                                           dissemination to local gateway participants

                                                                                                                                                                                                              14
Capturing the value of unstructured
               data
Natural Language Processing (NLP)

    Natural Language Processing is about
    getting a computer to “understand” (in the
    sense of “do something useful with”)
    human languages
    It is no longer just an esoteric part of
    Artificial Intelligence research or Science
    Fiction movies

1
NLP – Something Millions Use Every Day

    Try asking Google: What is the height of
    the empire state building?
    Try asking Ken Jennings: Can computers
    really understand English?
    Applying NLP to medical problems is an
    extremely active area – over 500,000
    Google hits for “medical natural language
    processing”

2
         NLP – Some thoughts are best
              expressed in words

Physician insight into patient’s opinions and
concerns
    “Patient is afraid of needles.”
    “Patient fears weight gain with metformin.”
    “Patient expresses concern about becoming
    addicted to pain meds.”


4
Not So Simple Structured Data Extraction
• MEDICATIONS:
 1. He currently takes 3% hypertonic saline nebs
    twice daily.
 2. Pulmozyme 2.5 mg nebs twice daily.
 3. He takes Bactrim 5 mL twice daily every
    Friday, Saturday, Sunday for PCP prophylaxis.
 4. He takes Zithromax 2.5 mL once daily every
    Friday, Saturday, Sunday for neutrophil
    modulation.
   5. He takes Zyvox 600 mg one tablet twice daily
11    but is stopping on 9/12.
   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
       Privacy protections
• No central database
• 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
   Embracing novel sources of
             data
•Regional aggregated databases from
 regional healthcare IT extension centers
•Surescripts/Rx Hub
•Labs compliant with national standards
•Social Security Administration/Megahit
•Centers for Disease Control/Biosense
   Embracing novel sources of
             data
•Medical societies
•Departments of Public Health
•Consumer Healthcare Devices (Continua)
•PHRs - tethered, payer, employer-
 sponsored and vendor-based
•Google Trends
Genomics




           30
             My Genome
•   Charcot Marie Tooth IV
•   Severe Combined Immunodeficiency
•   Susceptibility to Tuberculosis
•   2x risk of Prostate Cancer
•   Negative Kell Antigen
•   Glaucoma



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




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