Using Electronic Health Records (EHRs) for Improving Chronic Disease Care Margaret O. Casey RN MPH NACDD CVH Council Con

1. Using Electronic Health Records (EHRs) for Improving Chronic Disease Care Margaret O. Casey RN MPH NACDD CVH Council Consultant

2. Outline • Background and pertinent legislation • “Meaningful Use” • Alphabet soup • Recommended EHR components • Role of public health

3. “Our recovery plan will invest in electronic health records and new technology that will reduce errors, bring down costs, ensure privacy, and save lives.” -  President Obama, Address to Joint Session of Congress, February 2009

4. Background • 2000 – IOM report released – To Err is Human: Building a Safer Health System • 98,000 Americans die each year from medical errors • Health care delivery system was fragmented and decentralized • Outlined principles for computerized health records • Became basis for future certifications Insert

5. Pertinent Legislation • 2004 Executive Order 13335 • Widespread adoption of EHRs by 2014 • Creation of a position for the National Coordinator for Health Information Technology • 2009 American Reinvestment and Recovery Act (ARRA) • Health Information Technology for Clinical and Economic Health (HITECH) Act • Office of the National Coordinator for Health Information Technology (ONC) given statutory permanence • Funding for “meaningful use” (MU) of certified EHR technology

6. Office of the National Coordinator(ONC) • Developed a Federal Health IT Strategic Plan; initial framework: • Inform clinical practice • Interconnect clinicians • Personalize care • Improve population health • Administers MU incentive program with the Centers for Medicare and Medicaid Services (CMS)

7. What is Meaningful Use? Using certified EHR technology to: • Improve quality, safety, efficiency, and reduce health disparities • Engage patients and families in their health care • Improve care coordination • Improve population and public health  While maintaining privacy and security

8. MU Incentive Programs • Medicare EHR Incentive Program • Medicaid EHR Incentive Program Comprised of three regulations • Certification standards and criteria that EHR technology must embody • Certification process • Measures of use and quality to achieve CMS-specified objectives

9. MU Incentives • Through HITECH – Incentive payments totaling up to $27 billion over 10 years • Medicare – Up to $44,000 per clinician over 5 years • Medicaid – Up to $63,750 per clinician over 6 years • Medicare/Medicaid – $2M+ per hospital • After 2015 – Medicare reimbursement payment adjustments • No payment adjustments for Medicaid

10. MU Stage 1 Eligible Professionals must : • Complete15 core objectives • Complete 5 objectives out of 10 from menu set • Report 6 total Clinical Quality Measures • 3 core or alternate core, and 3/38 from menu set • 2011 – submit via attestation • 2012 – submit electronically • Current rules define requirements for stage 1 of 3 stages

11. MU Core Objectives Computerized provider order entry (CPOE) E-Prescribing (eRx) • Report ambulatory clinical quality measures to CMS/States Implement one clinical decision support rule • Provide patients with an electronic copy of their health information, upon request • Provide clinical summaries for patients for each office visit • Drug-drug and drug-allergy interaction checks • Record demographics

12. MU Core Objectives (cont’d) • Maintain an up-to-date problem list of current and active diagnoses • Maintain active medication list • Maintain active medication allergy list • Record and chart changes in vital signs • Record smoking status for patients 13 years or older • Capability to exchange key clinical information among providers of care and patient-authorized entities electronically • Protect electronic health information

13. MU Menu Set • Incorporate clinical lab test results as structured data • Generate lists of patients by specific conditions • Drug-formulary checks • Medication reconciliation • Send reminders to patients per patient preference for preventive/follow up care • Provide patients with timely electronic access to their health information • Use certified EHR technology to identify patient-specific education resources and provide to patient, if appropriate • Summary of care record for each transition of care/referrals • Capability to submit electronic data to immunization registries/systems* • Capability to provide electronic syndromic surveillance data to public health agencies* * At least 1 public health objective must be selected.

14. MU Clinical Quality Measures – Core Set • Hypertension: Blood Pressure Measurement (NQF 0013) • Preventive Care and Screening Measure Pair: • a) Tobacco Use Assessment • b) Tobacco Cessation Intervention (NQF 0028) • Adult Weight Screening and Follow-up (NQF 0421, PQRI 128)

15. MU Clinical Quality Measures – (Selected) Menu Set • Controlling High Blood Pressure • Ischemic Vascular Disease (IVD): Blood Pressure Management • IVD Complete Lipid Panel and LDL Control • Coronary Artery Disease (CAD): Drug Therapy for Lowering LDL-Cholesterol • IVD: Use of Aspirin or Another Antithrombotic • CAD: Oral Antiplatelet Therapy Prescribed for Patients with CAD • Smoking and Tobacco Use Cessation, Medical Assistance • Diabetes: Low Density Lipoprotein (LDL) Management and Control • Diabetes: Blood Pressure Management • Diabetes: Hemoglobin A1c Poor Control • Diabetes: Hemoglobin A1c Control (<8.0%)

16. MU Stage 2 • Recommendations in development – end of 2011? • Builds on Stage 1 • To include ABCS measures (planned)

17. Regional Extension Centers (RECs) • $677M allocated to support a US system of RECs; currently 62 are funded • To support and serve priority primary care providers : • Solo and small group practices • Community and rural health centers • Rural and critical-access hospitals (n=46) • Other settings that predominately serve uninsured, underinsured, or medically underserved patients http://www.healthit.gov/buzz-blog/local-implementation-support/regional-extension-centers-enabling-meaningful-use-all/

18. REC Responsibilities • Provide training and support services to assist doctors and other providers in adopting EHRs • Offer information and guidance to help with EHR implementation • Give technical assistance as needed • Potential CD partners??

19. Health Information Exchanges • March 2010 – $548M – State Health Information Exchange (State HIE) Cooperative Agreement Program awardees • Funds states’ efforts to rapidly build capacity for exchanging health information across the health care system both within and across states • Jan 2011 – $16M – HIE Challenge Grant Supplement Amount for innovative and scalable solutions http://healthit.hhs.gov/portal/server.pt?open=512&objID=1488&mode=2

20. Beacon Communities • Beacon Community Cooperative Agreement Program: • Funding to 17 selected communities – $250M • Build and strengthen HIT infrastructure and exchange capabilities • Beacon Communities will focus on goals in three areas of health systems improvement: • Quality • Cost-efficiency • Population health • Best Practices http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__onc_beacon_community_program__improving_health_through_health_it/1805

21. Certifications, Standards, Vocabularies, and Formats ONC DICOM ICD-9 &10 HL7 NIST SNOMED CT ELINCS ANSI XML CCHIT RxNorm LOINC SCRIPT NCVHS ASTM

22. Alphabet Soup • HIT – Health Information Technology • General concept that supports storage, retrieval, sharing, and use of health info, data, and knowledge for communication and decision making • EMR – Electronic Medical Records • Within one organization • EHR – Electronic Health Records • Across multiple organizations

23. More Alphabet Soup • HIO – Health Information Organization – oversees and governs HIE through a formal governance structure and participant agreements • RHIO – Regional Health Information Organization – regionally organized HIO • NHIN – National Health Information Network – a network of networks with standards, services, and policies that enable secure HIE via the Internet

24. Even More Alphabet Soup • HL7 – standards for the exchange, integration, sharing, and retrieval of electronic health information • PHR – Personal Health Records – a health record controlled by the individual • CCR – Clinical Care Record • Standardized elements to be sent to physician referrals or transfers • CCD – Clinical Care Document • Standardized elements (the “what) of a CCR transmitted using a standardized exchange architecture (the “how”)

25. EHRs are COMPLICATED http://www.openehr.org/29-OE/version/1/part/ImageData/data/landscape_diag-1.png?branch=main&language=default

26. Practice Management System Simplified EHR Scanned or Faxed Documents CCD HIE/HIO Clinical Data Warehouse Clinical Data Repository - CPOE - CDS PHR Public Health Reporting e-Rx Labs Point-of-Care Data Hospital Images

27. Computerized Physician Order Entry (CPOE) A process of electronic entry of medical practitioner instructions for the treatment of his/her patients • e-prescribing • Labs • Drug-drug and drug-allergy interaction checks • Drug-lab checking • Imaging • Consults • Microbiology, pathology

28. e-Prescription (eRx) • Computer-generated prescriptions created by a healthcare provider and sent directly to a pharmacy • NOT computer-generated faxed or printed prescriptions • Sent electronically through a private, secure, and closed network using nationally recognized transmission standardized • Fast, convenient, LEGIBLE, economical

29. e-Rx (cont’d) • HITECH requirements • Generate a complete active medication list • Select meds, print prescriptions, electronically transmit prescriptions, and conduct alerts for inappropriate dose/route, drug-drug interactions, allergies, etc. • Provide info on lower-cost alternatives (generics) • Provide info on formulary, patient eligibility, and authorization requirements from patient’s insurance • Convey above info using the messaging and interoperability standards of Medicare Part D eRx program

30. Clinical Decision Support (CDS) • Interactive programs that directly assist clinicians with decision-making tasks • Varied functionality – Treatment algorithms, 10-year CVD risk calculator, drug dosing support, alerts/flags/prompts • Alerts • Colors, sounds, icons as indicators • “In-basket” functionality • Pop-up boxes • Over-alerting effect

31. Challenges with EHR Implementation • Cost • Current vendor efforts are targeted at MU criteria only • Restructuring workflow and processes to allow for POC charting • Telling the patient story within constraints of structured data • Medical vs. lay terms

32. Challenges (cont’d) • Physicians like dictation and hate data entry • Gag orders from vendors • May prevent buyers from showing software to others or even discussing potential faults • Heightened privacy and security concerns • Legal issues

33. Potential CD Program Roles • Through existing provider/practice relationships, encourage certain MU objective menu options: • Generate lists of patients by specific conditions (aka registry) • Incorporating clinical lab test results as structured data • Medication reconciliation • Patient reminders • Drug formulary checks

34. Potential CD Program Roles • Partner with state medical associations, primary care associations, or health center organizations to develop recommendations for clinical decision supports to be included in EHR systems • Recommended guidelines (e.g. JNC-7, ATP III) • Recommended functionality (e.g. treatment algorithms, 10-year CVD risk calculator, drug dosing support, basic alerts/prompts)

35. Potential CD Program Roles • Partner with Regional Extension Centers • Provide training and technical assistance • Chronic diseases • Make connections between practices and RECs • Guidelines, guidelines, guidelines • ICD-10 code transition

36. Potential CD Program Roles • Get involved with Health Information Exchange efforts • DOH IT staff are thinking about reportable conditions and immunizations because of MU requirements  Chronic diseases need to be represented

37. EHR Examples • US Department of Veteran’s Affairs – VistA • Free system due to FOIA • http://www.ehealth.va.gov/EHEALTH/CPRS_Demo.asp • Google “EHR demo”

38. Resources

40. Questions? Special thanks to: Hilary K. Wall MPH Health Scientist at CDC DHDSP Slides are adapted from her slides and notes