Getting to Stage 1
Editor’s note: the cover story in this month’s print issue reviews the industry’s experience to date with stage 1 of the meaningful use program. The first providers in the water typically have been those with mature health IT systems in place. For them, the sailing has been smoother, though most are experiencing common challenges around several program requirements.
Here, Bill Spooner, senior vice president and chief information officer of Sharp HealthCare in San Diego, continues that discussion by sharing a large integrated delivery network’s experience with the stage 1 criteria.
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For some healthcare providers, meaningful use is a carrot being offered in reward for implementing an EHR system. For other organizations, however, meaningful use is affirmation that their EHR strategies—often devised before the HITECH Act and meaningful use program—are on the right track to enhance the quality and efficiency of patient care.
With ambulatory and hospital-based EHR technology already in place, Sharp HealthCare in San Diego was in compliance with many of the meaningful use stage 1 requirements from the day the final rule was published.
That’s not to say that conforming to all of the criteria is proving to be a breeze. Many components such as patient discharge summaries and quality measures reporting were not intrinsic capabilities of Sharp’s ambulatory EHR when it deployed the software. Working to meet these criteria has required changes to IT systems as well as the workflows and protocols across the enterprise.
From EHR Deployment to Stage 1 Compliance
Sharp HealthCare is a not-for-profit integrated, regional healthcare delivery system with approximately 2,000 beds spread throughout four acute-care hospitals and three specialty hospitals. The organization also boasts two affiliated medical groups with more than 1,000 physicians, a health plan, and a full complement of other healthcare services. Sharp has been recognized with the prestigious Malcolm Baldrige National Quality Award, the nation’s highest presidential honor for quality and organizational performance excellence.
In 2006 Sharp began rollout of an EHR technology in its two multi-specialty medical groups. Two years later, it followed that with implementation of an in-patient system at its hospital sites. This decision was motivated by a desire to ensure doctors had a powerful and user-friendly tool for computerized physician order entry (CPOE) and clinical documentation, bringing these caregivers up to speed with the nursing staff, who had been documenting patient encounters electronically for many years.
After a slow start, physicians have become very comfortable with the technology and Sharp is able to boast that 80 percent of physician orders are captured with the technology, well over the 30 percent threshold required by meaningful use. Separate platforms in the hospitals and medical groups provide each setting with the system optimally supporting its workflow. The rapid CPOE adoption, critical to meaningful use, has been an early benefit of this strategy.
Naturally, the organization looked to integrate these systems in order for patient data to flow seamlessly to the point of care across the system as well as with community physicians. And with meaningful use guidelines articulated and stage 1 deadlines looming, leadership selected a semantic interoperability platform to integrate the patient data housed in the disparate EHR systems. This would prove beneficial to patients and individual providers alike by streamlining access to individual records and elevating patient safety.
In early 2011 Sharp began deployment of the interoperability technology, which semantically harmonizes data stored in the ambulatory and hospital EHR systems so providers can access and act upon the information whether at the bedside or in the exam room. The information is available within providers’ familiar workflow without the need to exit from one system to log onto another.
This simplicity and convenience encourages caregivers to utilize the wealth of information previously out of reach and has resulted in accelerated progress towards demonstrating meaning use of technology.
Gaining Physician Buy-in
In both the hospital and physician practice settings, Sharp has gained physician buy-in to its technology deployments through the efforts of its chief medical information officer and the director of medical informatics. These professionals were charged with reaching out to physician champions as well vetting EHR configuration alternatives to make sure the technology falls in line with physicians’ workflow patterns.
These efforts were undertaken to involve physicians while sparing them time spent discussing decisions that could be processed quickly and informally through each facility’s executive management committee. Yet it is still among the IT department’s chief goals to provide the most workable solution for physicians that is configured to operate within their workflow to the greatest extent possible. Through its efficient approach to dialog, Sharp has found a balance that has paid off in terms of high physician buy-in and satisfaction with the technologies.
Working through Stage 1 Challenges
While Sharp is well on its way to stage 1 compliance, it still has some challenges to overcome. Among them are problem lists—designed to include information in the patient record such as disease state diagnoses, prior surgeries, and important tests via ICD-9 or SNOMED designations.
Sharp is still weighing if the responsibility of recording information in the problem list should fall to the nurse or physician, as there are pros and cons to both. Direct physician entry would streamline the documentation process for the patient and eliminate the need for information to flow to a third-party for inclusion in the electronic record. However, it potentially disrupts doctors’ workflow, limiting the number of patients they could have contact with on a given day.
Sharp has not reached an consensus across the entire enterprise; it determined to leave the decision up to the individual hospitals and physician practices based on would work best for their particular situations.
Sharp is in the early stages of standardizing problem lists and related documentation. This is somewhat facilitated by meaningful use as the reporting requirements drive standardization within the certified EHR.
Discharge instructions and clinical summaries are another issue that Sharp has had to work through. Stage 1 calls for healthcare organizations to provide patients with electronic copies of their health information, including discharge instructions (hospitals) and clinical summaries (physician practices). The challenge for Sharp and other provider organizations is to determine how best to meet the requirements with as little disruption in workflow for nurses and physicians as possible, while eliminating as much paperwork and manual effort as well.
With responsibility for providing copies of the chart traditionally falling to the HIM department, new workflow is required to similarly enable staff to provide patients with electronic copies. The process for giving patients discharge instructions or visit summaries is less obvious. The hospital might assign the task to the bedside nurse, discharge coordinator, or others along the discharge pathway. The clinic physician might personally hand the patient a flash drive or push the document to the portal, or the nurse or other office staff could be assigned this responsibility. The optimal solution will vary on the facility.
In order to facilitate the discharge summary process, Sharp plans to leverage the patient portal that it implemented in early 2010. Containing select patient data on approximately 58,000 patients, the portal can be used as a platform from which patients could read or download their discharge instructions at their convenience.
Of course, the organization understands that a large percentage of patients would rather leave the hospital with orders in hand—whether on paper or an electronic file written to a CD or flash memory drive—and Sharp is currently gearing up to handle these requests.
Discharge summaries also are a factor in the ambulatory setting as each clinic must decide whether it should be a part of the doctor’s examination routine or if it is best to make the summary available at the nurses’ station or front desk when the patient leaves. While Sharp has decided to let every physician or hospital make its own decision on what path to choose, the organization advises a centralized process managed by a nurse or ward secretary for optimal convenience.
The third and perhaps most difficult requirement is the reporting of quality measures and public health information. At issue is the effort required to ensure its clinicians are recording data that will populate reports delivered to CMS demonstrating that the organization is meeting the threshold requirements. Sharp is still working through the operational protocols for how the quality data are monitored.
Sharp’s HIM professionals participate in the meaningful use work groups. They are integral in establishing both the workflow and documentation standards of the electronic documents.
One alternative would be to have a nurse or group of nurses take charge of quality reporting and check each patient record to validate that it contains the correct data. A second option would be to integrate it within the workflow of the nurse who is providing the patient’s care at the time. Again, the right course of action will be left to the individual hospitals or physician groups to decide.
Decisions like this are particularly difficult on the ambulatory care side. In spite of the fact that Sharp’s affiliated physician practices operate as a coordinated, multispecialty medical group, meaningful use attestation, validation, and payment occurs on a doctor-by-doctor basis. And while it is easy for the hospital to collectively achieve the 30 percent CPOE threshold (since not every doctor must collect all necessary reporting data), if an individual ambulatory physician is not collecting the right data, he or she will not get paid.
To ensure that data are correctly captured in the quality report, Sharp leverages dashboards that help elevate the accuracy of its reporting, not only for meaningful use but also to ensure its patients are receiving the best care possible. For example, if patients indicate that they smoke and it is noted in the medical record, Sharp has the ability to search for these individuals and target a medical or preventive care activity.
The dashboards display at a summary level the percentage compliance of each indicator. They display the relevant indicators for each patient to determine whether the desired function was performed and recorded.
What Stage 2 Has in Store
Providers must meet 15 criteria in order to prove they are meaningful users of the technology under stage 1 requirements. Ten additional items—at least five of which must be demonstrated—are optional. While organizations are not yet privy to the final requirements of the program’s second stage, it is widely assumed that all the menu set items will become mandatory. Sharp is tracking the known menu set items and promoting their adoption among its caregivers. This will lessen the overall transition as additional stage 2 measures become known.
The industry also anticipates an increase in the number of quality measures healthcare providers will need to report. Like some other aspects of meaningful use such as the discharge summary requirements, electronic quality measure reporting is new territory for healthcare providers and the EHR vendor community. However, as a development partner with its EHR vendor for a new quality reporting module, Sharp believes it is well positioned to integrate stage 2 compliance with the efforts it is currently undertaking for stage 1.
Sharp’s meaningful use compliance efforts center around the deployment of advanced healthcare IT solutions. The organization has applied a best-of-breed approach to its strategic IT plan, implementing the technology it believes will help achieve the best medical outcomes by balancing healthcare cost, quality, and access. To help protect the significant investment it has made in these enabling systems, Sharp, like many other healthcare providers, is deploying technology to provide the interoperability by which data can be easily understood by disparate EHR technologies.
With stage 1 under way and stage 2 on the horizon, Sharp is fully on board with guidelines that are intended to create a pathway by which all healthcare organizations can inject efficiency and safety in the care delivery process.