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1 Copyright All Rights Reserved. No part of this document may be reproduced or shared with anyone outside of your organization without prior written consent from the author(s). You may contact us at /

2 MU 2014 Standards: A Big Jump? 1-2 pm CT 6/13/2012 Virginia Lorenzi 2

3 Speaker Bio Virginia Lorenzi has over 20 years experience in HIT. She joined the NewYork-Presbyterian Hospital IS department in Her specialties are interoperability, HIT Standards, and HIT related regulations. Virginia also serves on the faculty of Columbia University in the Department of Biomedical Informatics, teaching applied clinical information systems and standards. She has a long history of HIT Standards involvement. She teaches nationally and internationally for HL7 and is the recipient of the HL7 Volunteer of the Year Award and the HL7 Fellow Award. She has directly participated in federal efforts in HIT Standards adoption including HITSP and the S&I Framework and has been called to Washington on several occasions to testify on topics related to HIT Standards. vlorenzi@nyp.org Please note that opinions expressed in this presentation are my own and not necessarily my employers. 3

4 NewYork-Presbyterian Hospital Hospital system of Cornell and Columbia Universities 5 campuses, 2300 beds, 5600 physicians, 1700 residents Affiliate system of about 40 additional healthcare facilities Number 6 on US News & World Report Honor Roll for the past 5 years CIO Magazine: CIO 100 List, 2010 Information Week: #23 in Information Week 500,

5 Survey Participation 52 entries Removed blanks and duplicates 28 entries, each representing distinct healthcare facilities within the Scottsdale Community. 11 participants only answered the when will you attest to Stage 2 question. Thank You to All the Participants! 5

6 Why this Survey? Theory: Proposed Rule + Current Environment = Gap Timeline + Workload = Feasibility Concern The purpose of the survey is to test the above theory, and if true expose the gap and concerns. Plus, its an icebreaker 6

7 The link between certification and standards All EHR technology must be certified according to the NPRM regulations. Many certification criteria name/require standards to be implemented as part of the criteria. 7

8 Planning Ahead: 2014 Certified Systems and Stage 2 Regulation says all EHRs must be upgraded to 2014 certified system for providers to attest in 2014, no matter what stage. Based on regulations, official data collection for EHs attesting to Stage 2 in 2014* must begin October Official data collection for EPs attesting to Stage 2 in 2014* must begin January Nothing is definite until the final rules are published summer Install Configure Test Change workflow Practice data collection to ensure clean data/correct metrics during official collection *This deadline is for EHs and EPs that have already done a 90 day attestation. 8

9 Stage 2 Attestation: Survey Says What are your plans for applying for Stage 2 Meaningful Use? Please check ALL that apply: 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% First Inpatient Stage First Inpatient Stage 2 in 2015 First Ambulatory Stage 2 in 2014 First Ambulatory Stage 2 in 2015 First Inpatient Stage 2 later than 2015 First Ambulatory Stage 2 later than

10 Lab Results - Regulations Say: MU Objective Incorporate clinical laboratory test results into Certified EHR Technology as structured data Edition EHR Certification Criterion (b)(5) (Incorporate laboratory tests and values/results) Standards and Implementation Specifications (k) (HL and HL7 Version Implementation Guide: Standards and Interoperability Framework Lab Results Interface, Release 1 (US Realm)); and (g) (LOINC version 2.38) *Also used for Inpatient Setting MU Objective: Provide structured electronic laboratory 10 results to eligible professionals. LOINC used in Patient Summaries.

11 Do you use HL7 Version 2 on your LIS system(s)? Do you use HL7 V2.5.1 on your LIS to send lab results? Do you use LOINC in your LIS? Does your LIS vendor system have support HL7 V2.5.1 results? Does your LIS vendor system support LOINC? LIS Systems: Are We Ready? 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% HIT standards for lab results on your LIS systems. Please check all that apply: Axis Title Series1 11

12 Does your EHR use HL7 V2 to receive labs? Does your EHR use HL7 V2.5.1 to receive labs? Do you use LOINC in your EHR? Does your EHR support HL7 V2.5.1? Does your EHR support LOINC? EHRs: Are we Ready? HIT standards for lab results on your EHR system. Please check all that apply: 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 12

13 The unspoken truth about HL7 used in our hospitals today 40.0% What versions of HL7 V2 lab results messaging do you have employed at your site(s)? Please check all that apply: 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% V2.1 V2.2 V2.3 V2.3.1 V2.4 V2.5 V2.5.1 V2.6 V2.7 13

14 Currently on LIS Currently on EHR Currently on Terminology Server Plan to store on EHR Plan to store on LIS Plan to store on Terminology Server Other Are we prepared to manage LOINC? Please specify where you maintain LOINC mappings to local codes (i.e., terminology server, EHR, LIS, etc.) or have future plans to do these mappings. Please check all that apply: 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% it is all a manual process LIS is an integrated module 14 within our EHR

15 Diagnoses -Regulations Say: MU Objective Maintain an up-to-date problem list of current and active diagnoses Edition EHR Certification Criterion (a)(5) (Problem list) Standards (a)(3) (SNOMED CT International Release January 2012) *Also used in Patient Summaries 15

16 Our EHRs provide the capability Does your EHR provide the ability to use SNOMED-CT? 6.3% Yes No 93.8% 16

17 Actual Active Use Do you actively use SNOMED-CT in your EHR to represent problems? 43.8% 56.3% Yes No 17

18 SNOMED-CT Not just for problems Do you currently or do you have plans to use SNOMED-CT on any other application in your organization and/or for any other purpose? 37.5% No Yes 62.5% Our Pathology system uses Snomed II Map ICD-9 diagnoses and commonly used observations. Working on mapping lab organisms on our terminology server - maps local codes to Snomed 18 Microbiology organism identification and Pathology for stage 2

19 66% of those who use Snomed-CT map them to local codes Reasons for Local Mapping: Autocoding of diagnoses. Not local per se, but to vocabulary defined by Intelligent Medical Objects. We map the SNOMED-CT codes to our local codes within our data dictionary on terminology server Mnemonics that identify national lab procedures within our LIS/EHR system We map to Children's defined problems used for improved problem reflection. 19

20 Encounter Diagnoses and Procedures: Regulation Says For encounter diagnoses and procedures, we propose the use of ICD-10 (ICD-10-CM and ICD-10-PCS, respectively). *Used in Patient Summaries. 20

21 Survey Says - Does your EHR use ICD-10 for Procedures and/or Encounter Diagnoses? Please check all that apply: 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Our EHR has the capability of storing procedures and diagnoses as ICD-10. We store ICD-10 codes for procedures and diagnoses in our EHR. We already plan to have Do you use ICD-10 to ICD-10 for procedures represent diagnoses and and diagnoses in our procedures for patient EHR within the next year. engagement and transitions of care use cases (CCD/CCR)? 21

22 MU Objective Medications - Regulations Say: Generate and transmit permissible discharge prescriptions electronically (erx) Edition EHR Certification Criterion (b)(3) (Electronic prescribing) Standards (b)(2) (NCPDP SCRIPT version 10.6) and (h) (RxNorm February 6, 2012 Release) *Used in care summaries as well. 22

23 EHR currently uses a coding system that does NOT map to RxNorm. EHR uses a coding system that maps to RxNorm. EHR uses RxNorm to represent medications in prescriptions EHR uses RxNorm to represent medications for Patient Engagement or Transitions of Care use cases (CCD/CCR generation and/or EHR sends medication information coded using RxNorm Pharmacy Information System uses RxNorm. EHR has capability to store medications represented using RxNorm Pharmacy Information System has capability to store medications using RxNorm. Survey says: What is the current status on Medication terminology on your systems? Check all that apply. 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 23

24 Other uses for RxNorm Do you currently or do you have plans to use RxNorm in any other application in your organization and/or for any other purpose? 6.7% No Yes 93.3% Terminology Server and Enterprise Data Warehouse 24

25 Provide Patient Summaries at TOC MU Objective Regulations Say: The EP, EH, or CAH who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide summary care record for each transition of care or referral Edition EHR Certification Criteria (b)(1) (Incorporate summary of care record) (b)(2) (Create and transmit summary care record) Standards (a)(3) (Consolidated CDA); (f) (OMB standards for the classification of federal data on race and ethnicity); (j) (ISO 639-1:2002 (preferred language)); (l) (smoking status types); (a)(3) (SNOMED-CT International Release January 2012); (m) (ICD-10-CM); (b)(2) (HCPCS and CPT-4) or (b)(3) (ICD-10-PCS); (g) (LOINC version 2.38); (h) (RxNorm February 6, 2012 Release); and (a)(1) (Applicability Statement for Secure Health Transport); (a)(2) (XDR and XDM for Direct Messaging); and (a)(3) (SOAPBased Secure Transport RTM version 1.0) 25

26 View/Download/Transmit - MU Objective: EPs Regulations Say: Provide patients the ability to view online, download, and transmit their health information within 4 business days of the information being available to the EP. EHs and CAHs Provide patients the ability to view online, download, and transmit information about a hospital admission Edition EHR Certification Criterion (e)(1) (View, download, and transmit to 3rd party) Standards (a) (Web Content Accessibility Guidelines (WCAG) 2.0, Level AA Conformance ); (a)(3) (Consolidated CDA); (j) (DICOM PS ); (f) (OMB standards for the classification of federal data on race and ethnicity); (j) (ISO 639-1:2002 (preferred language)); (l) (smoking status types); (a)(3) (SNOMED-CT International Release January 2012); (m) (ICD-10-CM); (b)(2) (HCPCS and CPT-4) or (b)(3) (ICD-10-PCS); (g) (LOINC version 2.38); (h) (RxNorm February 6, 2012 Release); (a)(1) (Applicability Statement for Secure Health Transport) and (a)(2) (XDR and XDM for Direct Messaging); and (g) (synchronized clocks) 26

27 Survey says: Use of NHIN Direct Transport Standard Do you currently use the NHIN Direct standard? 7.1% Yes No 92.9% 27

28 Survey says: Use of SOAP (Simple Object Access Protocol) Do you use SOAP in your organization for any clinical information exchange? 21.4% No Yes 78.6% Uses: E-Prescribing We use SOAP to exchange using: Medicity, NOVO, point-to-point HIE exchange Web services for EMPI queries (IHE PIX/PDQ) and to deliver CCR documents to a PHR 28

29 Care Summary Survey Says Do you provide your patients with a mechanism to download their clinical information in the CCD standard? 57.1% 42.9% Yes No 29

30 Care Summary - Survey Says Do you provide your patients with a mechanism to download their clinical data in the CCR standard format? 28.6% Yes No 71.4% 30

31 Public Health - Regulations Say: Communicate reportable results, immunization, syndromic surveillance, and cancer cases using the following standards: Reportable Results: Electronic transmission of lab results to public health agencies. Standard. HL (incorporated by reference in ). Implementation specifications. HL7 Version Implementation Guide: Electronic Laboratory Reporting to Public Health, Release 1 (US Realm) with errata (incorporated by reference in ). Immunizations: HL (incorporated by reference in ). Implementation specifications. HL Implementation Guide for Immunization Messaging Release1.3 (incorporated by reference in ). Syndromic surveillance: HL (incorporated by reference in ). Implementation specifications. PHIN Messaging Guide for Syndromic Surveillance: Emergency Department and Urgent Care Data HL7 Version (incorporated by reference in ). Cancer information. HL7 Clinical Document Architecture (CDA), Release 2 (incorporated by reference in ). Implementation specifications. Implementation Guide for Healthcare Provider Reporting to Central Cancer Registries, Draft, February 2012 (incorporated by reference in ). 31

32 Do you currently exchange immunization information with a public health authority using the HL7 V2.5.1 Implementation Guide for Immunization Registries? 42.9% 57.1% Yes No Explanation of No s: If/when it becomes a requirement for MU, we will. So, possibly within 2 yrs. We are exchanging using and will upgrade if required for 2014 criteria Plan to do so as required and registries are available to connect with We are using HL7 v and don't have a timeline for moving to v2.5.1 Starting to use in

33 Do you currently exchange reportable lab results with a public health authority using HL7 V2.5.1 Implementation Guide: Electronic Laboratory Reporting to Public Health, Release 1? 42.9% 57.1% Yes No Explanation of No s:: By 2013 By end of 2012 Plan to do so as required and registries are available to connect with When states are ready to accept data Looking at the possibility in By 2013

34 Do you currently exchange emergency room/urgent care syndromic surveillance information with a public health authority using PHIN Messaging Guide for Syndromic Surveillance: Emergency Department and Urgent Care HL7 V2.5.1? 35.7% Yes No 64.3% 34

35 Do you currently - or within the next year - plan to exchange syndromic surveillance data for EPs with a public health authority? 50.0% 50.0% Yes No 35

36 Do you exchange information with a central cancer registry? 28.6% No Yes 71.4% Explanation of Yes s : The Commission of Cancer (CoC) of the American College of Surgeons and the Illinois State Cancer Registry. We follow, and are in full compliance, w/the CoC standards. We also received the Outstanding Achievement Award from the CoC. Undetermined manual process 36 Data is currently manually loaded into registries

37 MU Objective Infobuttons - Regulations Say: Use clinically relevant information from Certified EHR Technology to identify patient-specific education resources and provide those resources to the patient Edition EHR Certification Criterion (a)(16) (Patient-specific education resources) Standard (b)(1) (HL7 Context-Aware Knowledge Retrieval (Infobutton) Standard, International Normative Edition 2010) *Also used for MU Objective Use clinical decision support to improve performance on high-priority health conditions in Clinical Decision Support 37

38 Survey says Do you currently provide the ability for patients to refer to knowledge resources in context using the HL7 Context- Aware Knowledge Retrieval (Infobutton) standard? 21.4% Yes No 78.6% 38

39 Regulations Say: Electronically capture, calculate, and report Quality Measures MU Objective N/A (now separate from objectives) 2014 Edition EHR Certification Criteria (c)(1) (Clinical quality measures capture and export) (c)(2) (Clinical quality measures incorporate and calculate) (c)(3) (Clinical quality measures reporting) Standard (c) (NQF Quality Data Model) 39

40 Survey Says: What? Does your organization implement the NQF Quality Data Model in your EHR or in any other application? 7.1% No Yes 92.9% 40

41 I Apologize to the Standards I left out of the survey The survey and this presentation did not cover all the standards in the proposed rule or all their uses. Omitted standards included the following: Accessibility: WCAG 2.0, Level AA Conformance Small value sets for Race/Ethnicity, Smoking Status, Primary Language, Cause of Death, etc. Security and Privacy Standards Images: DICOM Guidelines for usability and for software methodology best practices. Possibility for CQM QRDA standard, HL7 Pedigree standard, patient safety event AHRQ format 41

42 In Closing, Survey Says Behavioral and mental health EHR technology should be certified to meet the same standards that exist for other EHR technology now under ARRA/HITECH. We would support a dual standard for Problems rather than limiting it to ICD-10 as we are already mapped to SNOMED. It is important than minimum standards be set for everything to allow organizations a reasonable migration path. The Sure Scripts monopoly is costly to implement for insurance formulary checking. Is there any alternative? LIS vendors and EHR vendors should come with LOINC Codes already mapped for this to be sustainable. In addition, there needs to be further refinement of LOINC to reduce ambiguity and the need for vetting large numbers of codes to determine which are most appropriate. There needs to be a 1:1 relationship between codes and tests, especially when it comes to panels, etc. 42

43 And Says - The vendors may have ICD-9 and 10 and Snomed but if the system cannot make use of the cross walk functionality, this does not result in easier workflows for the users. Not sure if our infobutton is using the HL7 standard. Not sure of our ICD-10 conversion plans due to announced delay from the gov't. Large mapping effort needed. We do not have a way currently to automatically map SNOMED codes to our ICD-9 procedures and ICD-9 diagnosis codes. In our EHR Human readable version of the CCD neither LOINC nor RxNorm codes are displayed or printed. 43

44 My Own Conclusion Based on The NPRM and the Survey Results Significant Gap does exist There IS a Large Workload and Tight Timeline for Hospitals And for their Vendors 44

45 Questions and Discussion Any questions after the presentation can be directed to SI or to my 45