Meaningful Search

What constitutes “meaningful use” and “certified EHR?” No one yet knows for sure. But understanding key features and functionalities can make your EHR search more meaningful while the ONC works out the details.

The announcement in early 2009 of incentive payments targeted for providers adopting EHR has certainly accelerated the action in the EHR industry. Providers who previously had been sitting on the fence now see the Stimulus money looming on the horizon and suddenly want to select and implement an EHR system. However, along with the excitement, have come some valid questions. The Stimulus Bill requires that in order to be eligible for incentive monies, a provider must show “meaningful use” of a “certified EHR.” The meaningful use definition is being further defined by the Office of the National Coordinator (ONC). Still, many believe the criteria will include electronic prescribing, information exchange, and quality measures reporting.

A bigger question is how and when will the government determine what constitutes a “certified EHR.” This question is also being examined by the ONC and definitions will be forthcoming. However, over the past 3 years, there has been a good start on this by the Certification Commission for Healthcare Information Technology (CCHIT). This organization has taken on the role of both developing functional criteria for electronic health records vendors and performing the actual certification testing of those systems. CCHIT has grown into a sophisticated certifying body whose criteria are used by health care organizations acquiring EHR technology; its certification is recognized by many vendors as being crucial to their adoption efforts. It has not been determined at this point to what extent CCHIT will be utilized by the ONC in their incentive program, or whether CCHIT will be used at all. But the one thing that CCHIT’s certification work has taught us is that there are a growing number of core features and functions that need to be integrated into an EHR in order to provide real benefit.

Space constraints won’t allow me to discuss all the features and functions crucial to an EHR. But, as a member this past year of the CCHIT Ambulatory Work Group, my goal here is to get you to think about a few major areas to evaluate as you research potential EHRs. This should put you ahead of the game as you prepare to benefit from the Stimulus.

Health Information Exchange

EHR systems should provide clinical templates that let you input structured or discrete data.

Whether you’re a medical practice or group sharing encounter information, a hospital sharing lab results and ADT information, or an imaging center sharing reports and images, certified EHR systems must be able to support this import and export of data between systems.

The interoperability world is moving much closer to standards for this data interchange and, in fact, CCHIT is leading the way in adopting these evolving criteria for EHR certification. Organizations with EHRs that can’t import and export to other systems will be at a disadvantage. I have been working with Health Information Exchanges, and the idea of producing quality reporting and outcomes for a community, based on the sharing of information from disparate EHR systems, is one that the government is very interested in. In regard to “meaningful use” of EHR technology as it relates to the Stimulus Package, this capability is one of the core functions defined in the bill.

Clinical Documentation

Having attended hundreds of electronic health records vendor demonstrations over the years, one of the most important components is that of the clinical note. One of the touted benefits of EHR is the ability to save a provider time documenting a patient encounter. Therefore, how a system is designed to facilitate this is of much interest. Of course, the actual look and feel of the electronic note is subjective and can be determined by seeing how the system documents various scenarios. But there are certain functionalities within the note that should be addressed and understood.

Most importantly, the system should provide clinical templates that allow you to input structured or discrete data. I have had many clients come to me, excited about an EHR system, only to find when I drilled down further that data was only in the form of dictation or input text. In order for the information such as HPI, diagnoses, and procedures to be reportable, searchable, and automatically billable, it must be in the form of individual data elements known as structured or discrete data.

A system must also allow different modes of input as options since every observation might not lend itself to be captured in a structured way. Therefore, a template must have the capability, in addition to “point and click,” to input information via voice recognition, text input, and handwriting recognition.

I had a client whose providers were split between the ones willing to change their workflow and embrace all the benefits of electronic health records and those who really were hesitant about changing the way they were doing documentation. Because the templates, in addition to allowing input of structured data, allowed voice recognition, the providers who were a little slower at embracing the new technology were actually able to dictate into the note. After getting used to the system, they later moved to entering the data in a structured format.

Also, when entering information such as vitals into the note, the system must have an ability to check for errors. These would be measurements that fall outside the range as specified by an authorized user. Vitals should be able to be accepted from various devices. That, in turn, cuts down on errors generated from manual input and saves time.

Many clinicians get interrupted during the day, and it might not be possible to finish a note at the point of encounter. In addition, even if you have finished your note, there might be reason to go back in at a later time to modify some of the information. So, this leads to two important features. First, you must have the ability to save a note without signing off or finalizing it with the ability to come back at some point and continue where you left off. At the same time, there must be a capability to append information to a finished note, and most importantly, in this case, the system must keep track of who appended the note and the time and date this took place.

Finally, in terms of clinical documentation, clinical templates are key. When I have clients that implement electronic health records systems, they typically don’t just fire it up and use it out of the box. Therefore, a system must have the capability to customize the templates based on the way you do your documentation. You need the ability to add structured fields to your template as well as revise the format and look and feel so it is easier for you to use. Remember, the purpose of a well-designed electronic note, in addition to the efficiencies you get from the data, is to allow you to document faster and more efficiently.

Medication Ordering

Even providers who have been hesitant to begin using electronic notes agree that one of the most powerful features of an electronic health records system is the level of efficiency they bring to prescribing medications and the workflow process surrounding medication ordering. In terms of features and functionality that are necessary for electronic health record-based prescribing, let’s cover a few of the main areas that you need to look at when evaluating this technology.

First of all, there is much confusion surrounding the difference between automatic electronic faxing of prescriptions and true electronic prescribing. Most systems allow you to prescribe medications for a patient using your EHR and then have the prescription automatically faxed to the pharmacy. However, in this day of EHR certification, this is not good enough. You’ve probably heard recently about reimbursement for use of electronic prescribing, and this eRX requirement should follow through to the incentives under the Stimulus Package. Electronic prescribing is the ability of your system to electronically send your prescription so that the order winds up in the system of the patient’s preferred pharmacy. And once the technology on the pharmacy side is fully developed, your EHR system should be able to know if, and when, a prescription was picked up. So, in addition to being able to electronically fax prescriptions to a preferred pharmacy, it will be a requirement that your EHR system performs electronic prescribing (ePrescribing).

Guidelines, Protocols, Care Plans, and Disease Management

Having information at your fingertips for decision-making is an area that EHR vendors have focused on over the past couple of years, and related features are being incorporated into “must have” criteria. These powerful modules give a provider the ability to provide access to standard care plan, protocol, and guideline documents when requested at the time of the clinical encounter. There are a number of ways to get to this information. It can reside internally on a database that is developed and edited by the provider or practice. In addition, the information can come from a trusted outside source. Many providers go to links and Web sites on their own to get this information, and the ability to incorporate this into an encounter as you’re documenting it is a feature that is becoming more standard.

Of course, if you’re going to have this capability to access standard care plans, protocols, and guidelines based on observations and diagnoses, then you need the ability to update the content and define and edit the rules utilized to generate this information. The features should allow you to create practice-specific care plans, protocols, and guidelines, as well as provider-specific content.

To take patient care a step further, certifying criteria have been expanded to include disease management. Because a patient’s record is in the form of structured or discrete data, it is fairly straightforward to use clinical guidelines and rules for disease management, preventive, or wellness services. The EHR should be able to update disease management guidelines and any associated reference material. Based on this content and associated rules, the system should have the ability to both display alerts for overdue services as well as automatically generate reminder letters and possibly HIPAA-compliant online reminders for patients who are due or are overdue for disease management, preventive, or wellness services. Finally, the system should provide reports on patients who are overdue for various services.

Where Do We Go From Here?

The feature/functionality areas described above are just the tip of the iceberg when it comes to recognizing criteria that will be used to certify EHR technology. There are numerous additional areas that need to be explored when evaluating an EHR. As mentioned, at this point, we don’t know all the features and the functionality that the government will require under the ARRA bill. The one thing we do know though is that for the past 3 years the Certification Commission for Healthcare Information Technology has been the leading certification body in the industry. Recently, CCHIT has made presentations to the Office of the National Coordinator on the value of not reinventing the wheel, but rather leveraging work that has been done and the structure and processes already set up as a basis for the future.

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Michael Uretz is an authority on health IT selection and contract negotiation. His specialty is representing health care organizations in health IT vendor selection, contract negotiation, and project implementation. Contact: ; www.ehrgroup.com.