Peter Muir MD Springfield Center for Family Medicine Collaborating Communities Health Information Exchange HealthBridge Tri-State Regional Extension Center June 2010

Introduction Family doc In practice 30 years Office 4 days a week, hospital rounds, 24x7 call SCFM 6 doc FP group Computers since 1980 EMR since 2003 w transcription since 2000

Quick survey How many on: Paper charts? EMR? eRx? Meet all 25 meaningful use criteria (swap seats)?

Meaningful use for PCPs Initial read of the criteria is overwhelming Any practicing PCPs on the steering committee? 80% computerized physician order entry?!? (1) BPs on 2 yr olds?!? (8) How do we communicate between offices? We need a Health Information Exchange

Complicated and Expensive Issues drug-formulary checks (2) eg RxHub, multiple drug plans, locations, etc checking insurance eligibility electronically on 80% patients (15) timely electronic access to health information lab results, problem list, medications, allergies on 10% of all unique patients (18). How to quantify and report? initial cost and sustainable cost considerations Final rule still pending

Narrow line between meaningful use and useless meaning Rx compliance by pharmacy or claims data - does not include samples, half tabs, etc - interferes with work flow, - pharmacy timing rather than at pt intervention, - use lab results and medication reconciliation

Narrow line between meaningful use and useless meaning - patient becomes diagnostician - security concerns - time consuming - not recognized under fee for service plans

Narrow line between meaningful use and useless meaning Timely electronic access 10% unique patients (18) - some patients still on rotary dial phones - doc, what does this mean??? - glucose meter automated reporting vs manually recording - not recognized under fee for service plans

Signal to Noise Ratio In the old days, a fax was important. Now, it is spam due to the flood of info. Electronic records can make it too easy to overwhelm the most critical interface - the clinician. Need to filter out less important info and amplify any important info (format, duplication, reports)

How to get started? Start somewhere Look at work flow Follow the information Make it work for you and your office You are the expert for your office

Who Office leadership: clinical & clerical teams authority to make it happen be consistent & persistent Seek assistance from REC

What Look at work flow: reduce repetitive effort eg allergies, date/time (caution re MMSE, lose orientation x2) reduce errors eg record ht as ft/in vs in from tape PQRI opportunities

Why Hurts the first year, but then life gets better Have access to your own data Compliance and outcome analysis ARRA REC

Where Many items easier with an 'annual' risk assessment checklist approach Practice and disease management - graphing vitals makes impact - tracking microalbumins, colonoscopy, etc Medication management & reporting (recalls)

When If on paper, start with pt summary forms, flow sheets Save transcription files by patient to import Timeline, need to implement 2010 or 2011 for maximum benefit

[1] Use CPOE Computer Physician Order Entry Measure: CPOE is used for at least 80 percent of all orders. Response: Placing orders by LabMaster, Radiology and Rx covers >80% of orders.

[2] Implement drug-drug, drug- allergy, drug-formulary checks Measure: The EP has enabled this functionality. Response: RxModule has drug-drug, drug-allergy checks. Drug-formulary via Epocrates, Add formularies with new servers.

[3] Up-to-date problem list current & active Dx ICD-9 or SNOMED Measure: At least 80 percent of all unique patients seen by the EP have at least one entry or an indication of none recorded as structured data. Response: Dx list (ICD-9) maintained by IM Assessment. Problem list and PHx provide more detail.

[4] Generate & transmit permissible prescriptions electronically (eRx) Measure: At least 75 percent of all permissible prescriptions written by the EP are transmitted electronically using certified EHR technology. Response: eRx targets require extra effort by MD & billing. Recommend print weekly totals for MD.

[5] Maintain active medication list Measure: At least 80 percent of all unique patients seen by the EP have at least one entry (or an indication of “none” if the patient is not currently prescribed any medication) recorded as structured data. Response: Rx module maintains active list. All users should set preferences for active list. Use stop dates for temporary Rx. MDs need to delete inactive Rx. SEE 21

[6] Maintain active medication allergy list Measure: At least 80 percent of all unique patients seen by the EP have at least one entry (or an indication of “none” if the patient has no medication allergies) recorded as structured data. Response: Allergy module maintains active allergy list. Nurses must check appt slip against pt chart & verify with patient.

[7] Record demographics Measure: At least 80 percent of all unique patients seen by the EP or admitted to the eligible hospital have demographics recorded as structured data. Response: NextGen does at patient registration.

[8] Record and chart changes in vital signs Measure: For at least 80 percent of all unique patients age 2 and over seen by the EP, record blood pressure and BMI; additionally, plot growth chart for children age 2 to 20. Response: Nurses must record BP starting at age 2. Print Ht/Wt/BMI pediatric growth charts at well checks/annually. SEE 23

[9] Record smoking status for patients 13 years old or older Measure: At least 80 percent of all unique patients 13 years old or older seen by the EP “smoking status” recorded. Response: MDs need to have smoking status recorded on social hx or cold template for all patients. Add to float nurse protocol

[10] Incorporate clinical lab-test results into EHR as structured data Measure: At least 50 percent of all clinical lab tests results ordered by the EP or by an authorized provider of the eligible hospital during the EHR reporting period whose results are in either in a positive / negative or numerical format are incorporated in certified EHR technology as structured data. Response: Have lab/rad results as structured data from 2009 Implement results interface via Rosetta or Mirth on new servers - MUIR.

[11] Generate lists of patients by specific conditions Measure: Generate at least one report listing patients of the EP with a specific condition. Response: Need to modify diabetes selection Crystal Report (select by ICD9 range) - MUIR

[12] Report ambulatory quality measures to CMS or the states Measure: For 2011, an EP would provide the aggregate numerator and denominator through attestation as discussed in section II.A.3 of this proposed rule. For 2012, an EP would electronically submit the measures are discussed in section II.A.3. of this proposed rule. Response: Select criteria (HTN, DM, lipids, CHF). Review II.A.3 for reporting PQRI - MUIR.

[13] Send reminders per patient preference for preventive/follow-up Measure: Reminder sent to at least 50 percent of all unique patients seen by the EP that are 50 and over. Response: Could create report on active pts >50 without annual exam in past 12 months. - MUIR MDs need to flag annual assessment. COST

[14] Implement 5 clinical decision rules, orders, & track compliance Measure: Implement five clinical decision support rules relevant to the clinical quality metrics the EP is responsible for as described further in section II.A.3. Response: Select 5 support rules (Hba1c, microalbumin, lipids, etc) Need to review II.A.3 reporting PQRI - MUIR.

[15] Check insurance eligibility electronically public private payers Measure: Insurance eligibility checked electronically for at least 80 percent of all unique patients seen by the EP. Response: Check via CCHIE? GBS? How to automate? COST

[16] Submit claims electronically to public and private payers Measure: At least 80 percent of all unique patients seen by the EP or admitted to the eligible hospital have demographics recorded as structured data. Response: NextGen does.

[17] Provide electronic copy of health info: Dx, Rx, allergy, results Measure: At least 80 percent of all patients who request an electronic copy of their health information are provided it within 48 hours. Response: Could comply by print to pdf and burning CD. Anticipate low volume (pt request). Minimal cost.

[18] Timely electronic access to health info: Dx, Rx, allergy, results Measure: At least 10 percent of all unique patients seen by the EP are provided timely electronic access to their health information. Response: Could do via NextGen Next MD. Any potential for CCHIE? This one is problematic (10% of all active patients) COST +++

[19] Provide clinical summaries to patients for each office visit Measure: Clinical summaries provided to patients for at least 80 percent of all office visits. Response: Could print office visit note on all patients (could auto-print each time generated) PAPER COST

[20] Exchange key clinical info with providers electronically Measure: Performed at least one test of certified EHR technology's capacity to electronically exchange key clinical information. Response: CCHIE can do this by sending visit note/exam. Most offices can not receive other formats except pdf. SEE 22.

[21] Perform Rx reconciliation at relevant encounters Measure: Perform medication reconciliation for at least 80 percent of relevant encounters and transitions of care. Response: Rx module maintains active list. All users should set preferences for active list. Use stop dates for temporary Rx. MDs need to delete inactive Rx. SEE 5.

[22] Provide summary care record for transition of care & referrals Measure: Provide summary of care record for at least 80 percent of transitions of care and referrals. Response: CCHIE can do this by sending visit note/exam. Most offices can not receive other formats except pdf. SEE 20.

[23] Submit electronic data to immunization registries Measure: Performed at least one test of certified EHR technology's capacity to submit electronic data to immunization registries. Response: OHIO does not have capability of electronic submission/transmission.Might meet criteria by checking OH vaccine website for all pediatric well checks. SEE 8.

[24] Provide electronic syndromic surveillance data to public health Measure: Performed at least one test of certified EHR technology's capacity to provide electronic syndromic surveillance data to public health agencies (unless none of the public health agencies to which an EP or eligible hospital submits such information have the capacity to receive the information electronically). Response: OHIO does not have capability of electronic submission/transmission. CCHIE?

[25] Protect electronic health info by certified EHR technology Measure: Conduct or review a security risk analysis in accordance with the requirements under 45 CFR (a)(1) and implement security updates as necessary. Response: New edge security server threat management gateway and domain restructuring is part of server upgrade. - MUIR