EHR Meaningful Use Stages 1 and 2 What They Mean To You · Developing EMRs and EMR Integration since 1997 Rapid and accurate software development and customer implementation Our Customers

EHR Meaningful Use Stages 1 and 2

What They Mean To You

Pat Wolfram

What We’ll Cover

Update on Meaningful Use Stages 1 and 2

EMR Trends and Learnings During MU Stage 1

But It’s Really More Than Just Meaningful Use

− The Practice’s Expectations

− What The EMRs Can Do

− What You Can Do

Our Mission

Enhance the physician’s ability to make timely and accurate diagnostic

decisions

Enhance our lab and imaging partners’ services through integration within the

practices’ EMR workflow

Our Company

Focus on physician-centric interoperability

Developing EMRs and EMR Integration since 1997

Rapid and accurate software development and customer implementation

Our Customers

18,000 users, 6000 physicians on EMRs using EMR-Link today

Over 300 practices use EMR-Link for lab and radiology integration

Over 100 labs and radiology systems supported across US

2,000,000 clinical transactions per quarter

EMR-Link is Deployed Nationwide through cloud-based SaaS

Orders

Results

EMR with HL7 only

Lab

Radiology

300 + Practices 100 + Labs 6000 + Providers

No EMR: Web-based OrdersAnywhere

EMR with workflow integration

Orders

Results

HIE, public health reporting, etc.

HL7 –

EMR-Link Hub Lab-to-Practice Connectivity

EMR

EMR

EMR

No EMR: Web-based OrdersAnywhere

EMR with workflow integration

EMR with HL7 only

Lab

Radiology

OK

About Meaningful Use

It’s Complicated

Meaningful Use Goals

• Improve quality, safety, efficiency of health care

• Engage patients and families

• Improve care coordination

• Improve population and public health

• Ensure adequate privacy and security

protections for personal health information.

Through incentive payments the HITECH Act promotes the adoption of

EHR technologies with the goal to:

$18,000,000,000 in total $44,000

per care provider

MU Certification Stage 1 – For Labs

1. Lab Test Results

An optional menu item (one of 10 menu items)

Incorporate 40% of clinical lab test results as structured data

2. Computerized Physician Order Entry (CPOE)

Not required for phase one

But a likely requirement for phase two, starting 2014

Not great for labs….

Orders can be on paper

In the absence of orders, results are less robust

(patient chart mismatches, provider ID mismatches, order

reconciliation, …..)

MU Stage 2 – For Labs (Proposed Rule)

1. Lab Test Results

Becomes a CORE item (now required)

55% structured data requirement

2. Computerized Physician Order Entry (CPOE)

- Core item

>60% of orders (labs, meds, imaging, …) must be

placed/documented in the EMR

- Must be entered by the care provider making the

decision to order the test.

- Order does not have to be sent electronically

3. HL7 v2.51

4. LOINC Support – It’s part of the standard set

HUGE workflow impact to the practice

Orders, Orders, Orders……

About The MU Stage 2 Process

• Notice Of Proposed Rule Making Comments due May 7, 2012

• Rules will likely be relaxed again.

• MU 1 --- about 20% of rules were relaxed, as was

the timing.

• HL7v2.51 and LOINC compliance are going to be

difficult.

• First attestation in 2014

EMR Trends

…and Learnings from the MU Stage 1 period.

EMR Adoption

Includes structured

lab results

Source: CDC/NCHS, National Ambulatory Medical Care Survey. Electronic Medical Record/Electronic Health Record

Systems of Office-based Physicians: United States, 2009, and Preliminary 2010 State Estimates


EMR Innovation was frozen for two years

Vendors had to comply with MU measures

So, EMR Orders did not get better (this will hurt the labs in 2014)

EMR Vendors multiply

35 EMR vendors in 2009

435 Certified EMRs and/or modules in 2011

1321 Certified EMRs and/or modules as of March 2012

Greater EMR Adoption Volume

Ignis integration projects starts with current labs rose 70%

More labs came to us for outreach

Thinned out EMR integration talent – implementations are slower

Long waiting periods for all new EMRs to kick off projects

Some Positive Notes

Consolidation Starts

Some IT vendors have dropped lower volume EMRs that haven’t gotten

traction

Many smaller EMRs silently stop showing up

The Market Nudges Back To Normal

Late Majority initially acts uncharacteristically

Late Majority makes an adjustment

A Normal Product Adoption Curve

At 25% adoption,

we’d typically still be

in the Early Majority • EM is willing to deal

with newer technology

• Resilient. Don’t need

referrals, or cookie

cutter approaches.

But Because Of Stimulus Dollars……..

…..adoption moves

into the late majority

The Late Majority Wiggles A Bit

Initially

LM adopted earlier than

they’re accustomed

--- MU $$

Chose new low-cost EMRs

Difficult projects for lab

integration

Backed-up queues for lab

result interfaces

Today

Trending back to normal

LM conservatively choosing

vetted products

Seeing mostly top tier EMR

vendors now

Beginnings of EMR

consolidation


Physicians qualifying for MU checks were low

91% of physician qualified for MU program, based on Medicare billings

Yet, only 11% had qualifying EMRs and applied.

……….SO, MORE VOLUME IN 2012.

For mature EMRs users, MU was a small bump in the road.

2011 EMR User Group --- 50% of papers were about MU

2012 EMR User Group – Less than 10% of papers were about MU

Now, they’re gearing up for MU 2….and more..

………. GET READY FOR ORDERS!!!

………. GET READY FOR PATIENT CONNECTIVITY!!!

2012 EMR User Group – WE WANT RULES BASED ORDERS

2012 EMR User Group – WE WANT PATIENT CONNECTIVITY

So, You’re Adopting EMR

Pre MU – A Practice Adopts EMR………

Office Communication

• Phone notes • Virtual “to do” list • Office efficiencies

Full Encounter Documentation

• Face sheet documentation • E&M Compliance • Billing efficiencies • Disease management

Orders

• CPOE requirement • Complete EMR

workflow

EMR Function Adoption Timeline

View and Sign

• Minimal workflow impact • Populates chart with clinical data; lab results and transcription • Chart review from home

Medication Management

• Script legibility • Interaction checks • Formulary compliance

In

vestm

en

t (ti

me,

too

ls,

etc

…) Lab results at

Step 1

Required in 90%

of EMR go-lives

Orders come later. More difficult to set up. Workflow impact is greater.

Usually begin with low impact, high value modules; then “move up”

View and Sign

MU Stage 1 Compresses Adoption Timeframe




Still a later step



Orders

View and Sign


Lab Results:

Still step 1


In

vestm

en

t (ti

me,

too

ls,

etc

…)

• Forced EMR vendors

to change their

deployments

• Results are still job 1

View and Sign

MU Stage 2. To The Practice It’s All About Orders




Still a later step



Orders

View and Sign


No big deal moving from

40% to 55% structured


In

vestm

en

t (ti

me,

too

ls,

etc

…)

• Results – no big deal

• Orders are now in play.

• This will be tough for

practices new to EMR

Buyers Of Seasoned EMRs Expect This……

Lab Clinic Lab Order

Completion

Accessioning

&

Testing

EMR Chart Matching

Provider Lab Review

Provider Ordering

• AOE questions

• Minimize data

entry

• Results match to

charts.

• Results into the

flowsheet

• Desktop notification

• Updates the order

status

•Easy to order

•ABN validated

• Verify insurance

• Verify ABN

• Minimize data

entry

Patient ID

Provider ID

Order ID

• Lab reports to the

patient

And Support For Multiple Labs

Clinic Lab Order

Completion

Accessioning

&

Testing

EMR Chart Matching

Provider Lab Review

Provider Ordering

• AOE questions

• Minimize data

entry


charts.


flowsheet



status

•Easy to order

•ABN validated

Patient ID

Provider ID

Order ID

Lab

Lab

Lab


patient

Stage 1 MU


Completion

Accessioning

&

Testing

EMR Chart Matching

Provider Lab Review

Provider Ordering

• AOE questions

• Minimize data

entry


charts.


flowsheet

•Easy to order

•ABN validated


• Verify ABN

• Minimize data

entry

Patient ID

Provider ID

Order ID

X

X

X

X



status

• Patient friendly lab

reports

X X

Stage 2 MU


Completion

Accessioning

&

Testing

EMR Chart Matching

Provider Lab Review

Provider Ordering

• AOE questions

• Minimize data

entry


charts.


flowsheet

•Easy to order

•ABN validated


• Verify ABN

• Minimize data

entry

Patient ID

Provider ID

Order ID

X

X

X



status

• Patient friendly lab

reports

X X

X X

The Types Of EMRs We’re Dealing With

Four Basic EMR Types

……..when discussing lab integration

1. Strong EMR that creates clean orders and

receives results

2. Moderate EMR with good integration “hooks”

3. Moderate EMR with no integration hooks

4. Weak EMR

Strong EMR

Lab Clinic’s

EMR

Order tests

•Order Entry Questions •Requisition printing •ABN printing •Label printing

•ABN validation •Rules checks •Redundancy checks

• Provider lab review

• Patient view Result review

Draw and

order completion

Physician orders in the EMR

Medical necessity checked

AOEs are complete

Specimen collection in the EMR

Clean orders sent to the lab

Results returned and managed well

ORM

ORU

Moderate EMR Orders – Good Integration Hooks

Lab Clinic’s

EMR

Order tests




• Patient view Result review

Draw and

order completion

Physician orders in the EMR

ABN checks in the background

Specimen collection in the Portal

Clean orders sent to the lab

Results returned

Patient friendly reporting via Portal

ORU

…Provider-friendly report

…. Patient-friendly report

Typical EMR – weak orders, simple HL7 interface

Lab

EMR

Draw and

order completion

• Patient view

•Receives clean and complete orders

•No data entry

Result review

• Nice HTML view

• Or CCD, or…

HL7 ORM

Orders in EMR

Physician orders in the EMR, but no rules checked

Specimen collection managed outside the EMR

Results returned

A Weak EMR

Lab

EMR

Draw and

order completion


Result review

• Nice HTML view

Orders entered in

Lab portal

Order placed outside the EMR

Specimen collection managed outside the EMR

Results returned

ADT

But Practices Want All Of This…….


Completion

Accessioning

&

Testing

EMR Chart Matching

Provider Lab Review

Provider Ordering

• AOE questions

• Minimize data

entry


charts.


flowsheet



status

•Easy to order

•ABN validated


• Verify ABN

• Minimize data

entry

Patient ID

Provider ID

Order ID


patient

.

An Approach To

Satisfying The Practice

……..Fill The EMR Workflow Gaps

The Challenge

The Difficulty Will Be With Orders Workflow

Most EMR Vendors Will Struggle

Orders workflow is much tougher than meds, or lab result

review

Interface Engines Can’t Help With Orders Workflow

Surround the EMR With Order/Result Functions. Fill It’s Gaps……..

…Provider-friendly report

…. Patient-friendly report

Specimen

collection

Orders

Results

Tests

ordered

Result

review

Practice’s

EMR Flowsheet

Lab

The Strong EMR

Lab Clinic’s

EMR

Order tests Draw and

order completion

•ABN validation Orders

Results


•No data entry

Result review

• Single Lab Connection

• Simple HL7 interfaces

• No Gap Filling Needed.

The Moderate EMR Orders, with integration hooks

Lab Clinic’s

EMR

Order tests Draw and

order completion



Orders

Results


• Patient view


•No data entry

Result review

Provider Network for

Clinical Interoperability

Patient Portal

HIE

Public Health

• Same single Lab Connection

• ABN checking in the background

• One click to Draw application

• Link to patient friendly reporting

The Moderate EMR Orders, No integration hooks

Lab

EMR

Draw and

order completion

Orders

Results • Provider

lab review

• Patient view


•No data entry

Result review

HL7 ORM

Orders in

The EMR

Patient Portal

HIE

Public Health




• Draw app in the Portal

• ABN checking at draw by

nurse/phlebotomist

• Patient friendly reports in

the portal

Weak EMR Orders --- Enter Order in the Portal

Lab

EMR

Draw and

order completion

Orders

Results • Provider

lab review

• Patient view


•No data entry

Result review

ADT feed

Decision to order….

Patient Portal

HIE

Public Health




• Order in the Portal

• Draw in the Portal

• Patient friendly reports in

the portal

Summary of EMR Meaningful Use

It’s More Than Just HL7 Interfaces Now

Get Ready For Orders

MU 2 will require a major overhaul of the EMR vendor capabilities

Get Ready For Patient Connectivity

Mature EMR Vendors Are Going Well Beyond MU

They’re demanding workflow integration

They’re demanding full bi-directional integration

We’ve Just Started

Only 11% have attested so far. 80% more to go.

Lab Setup and Maintenance

Beyond MU --- EMR Setup and Maintenance

Ideally the EMR team and processes will

− Build a flow-sheet from your utilization report

− Map from your result codes to the EMR’s codes (LOINC?)

− Load your DOS (directory of services) in an automated

fashion.

− Load your ordering rules (requisition splitting, AOE questions,

specimen requirements, ..).. from a compendium.

− Use your utilization report to create custom order lists

Or is setup customized?

− Customized order lists. Great for a practice’s unique

workflow and a valuable EMR feature.

− But, some EMRs build this from the ground up with

templates.

Part of repeatable process

Your Lab Information System Setup and Maintenance

Evaluate your LIS

Can it provide a compendium with a full directory of

services (DOS)?

Will that compendium include ordering rules,

specimen data, ABN cost data

Can your LIS provide a utilization report?

History of tests for this practice

Evaluation your resources. Can they

Set up the orders categories in the EMR?

Set up the custom order list in the EMR?

Set up the flow sheet views in the EMR?

Set up the cross-reference files for the result codes

Part of repeatable process

EMR Integration Maintenance

Results maintenance

When you update a results code, what happens in the EMR?

Orders maintenance

When you update an order code, what happens in the EMR?

Who troubleshoots a missing lab result?

Recommendations

The Situation

More and Different EMRs

Adoption rate increases

Installing at practices that are less prepared

Less savvy EMR consultants

Here are some approaches …….

For your lab

As an industry group

Your Plan: Review Your Resources

Look at your LIS capabilities

Can your LIS provide a utilization report?

Can your LIS provide a compendium with your lab ordering

rules?

Can it accept an electronic order from an outpatient EMR?

Must it receive a registration event from the HIS first? Is this

really a show-stopper? (it’s not for the reference labs)

Your interface engine (or middleware) capabilities

Is your team ready for 2X the volume?

Can you map to the result codes of the EMR

Can you map to LOINC?

Look at your processes for providing lab-to-EMR

integration *you’re welcome to use the Ignis project plan as a starting point.

Your Plan: Get Involved in the EMR Selection

Conduct your own EMR assessment

Ask your interface team to rank the EMR that were easiest to

deploy and support.

Ask your middleware vendor to rank EMRs for integration

(have them to plan bandwidth for your upcoming projects)

Partner with your practices. Create an RFP they

can use for EMR selection (use the Results and Orders checklist in this presentation)

Help Your Practices Choose An EMR

Results Checklist

Does the EMR have its own result code database?

Does the vendor provide result code mapping services?

How are mismatched results dealt with?

How are result codes maintained?

Can the EMR support results from multiple labs?

Will the result codes from the various labs import to the same flow-sheet?

EMR Orders Checklist

Orders Checklist

Can an HL7 electronic order (HL7) be sent to the lab (or to outreach product)

Is ordering easy to use for the physician? If it’s installed ,is it being used?

Is medical necessity being checked when physician places the order?

Lab specific AOE support

Can lab specific requisitions be printed?

Can the EMR support orders to multiple labs?

Must the physician choose the correct lab, or can they choose from a single list and the EMR route to the right lab?

Is the staff ordering workflow easy to use?

Is the setup automated? Is it derived from lab’s utilization report and directory of services?

Are order and result codes easy to set up and maintain?

Your Plan: Reach Out To The Practices

Host an EMR open house

Tell them you’ll help with meaningful use

Offer to assist them in the evaluation

Give them your EMR integration “report card”

Thank You!

Pat Wolfram

Documents

EHR Meaningful Use Stages 1 and 2 What They Mean To You · Developing EMRs and EMR Integration since 1997 Rapid and accurate software development and customer implementation Our Customers