The Centers for Medicaid and Medicare services (CMS) released the final ruling for the first stage of meaningful use requirements within the electronic health record on July 13, 2010. This first stage outlines requirements through 2012; updated stages are expected in 2013 and 2015. A level of flexibility is built into the first stage as a response to the more than 2,000 public comments received from the winter 2009 interim ruling. The objectives are similar to those initially presented; however there is a split between hospitals having fifteen core requirements while providers have fourteen. There is an additional menu of ten options, allowing them to take different paths towards meaningful use according to their adoption capabilities. The facilities choose five from the menu and can defer the remaining.
Donald Berwick, MD, MPP, FRCP, newly appointed director to CMS, says he particularly likes the word meaningful. “It spans the needs of all involved in the process, and thus a win-win in being meaningful to the care itself, meaningful to the patient, and meaningful to the people who help the patient.” He says that once we get through the awkwardness of the change process we will encounter more continuity and less cost through reducing barriers and complexity to obtaining the care needed.
David Blumenthal, MD, MPP, national coordinator, Office of the National Coordinator for Health Information Technology (ONCHIT), explains that already announced grant-funded activities around the country “will provide elbow-to-elbow assistance in getting through the change process. This includes building a network of regional extension centers, grants to states to become leaders to make information exchangeable within boundaries and across states.” Approximately $548 million had been awarded through March 2010 to 56 states, territories, and qualified state-designated entities with additional goals of creating strategic health IT advanced research projects (SHARP); community college consortia to educate health IT professionals program; assistance for university-based training, and curriculum development centers.
For maximum Medicare payments, providers have until 2012 to qualify through measures paired with the objectives, and hospitals follow in 2013. At the same time the final ruling was released, the Office of the National Coordinator (ONC) published a final rule adopting standards, implementation specifications, and testing/certification criteria for electronic medical record and electronic health record systems. While vocabulary standards, such as Logical Observation Identifiers Names and Codes (LOINC), were included, transport standards were not published at this time. The implementation of such standards will advance semantic interoperability between systems and pave the road for secondary use of data.
The Brookings Institution Conference, Making Enhanced Use of Health Information, was held in May 2010. During the conference, Farzad Mostashari, senior advisor at ONC suggested health IT work should be guided by 10 principles, which include 1) collect once, use many; 2) be humble about what government can do; 3) foster innovation; and 4) standards, shared services, and policies can help.
A variety of activities and events has brought the U.S. to the point of achieving interoperability and building increased value on the data produced during patient care. The challenge being put before the community is to find different ways of using de-identified data for the benefit of the whole population after its initial intent of monitoring one patient.
Secondary use example benefits
In 2007, Premier Healthcare Alliance and CMS in Charlotte, NC, performed a Hospital Quality Incentive Demonstration using 2009 evidence-based-medicine measures retrofitted over 2004 data from 250 hospitals. If the now-known 2009 evidence-based measures had been adopted back in 2004 for treatments involving pneumonia, heart bypass, heart attack, and hip/knee replacements, there may have been 5,700 fewer deaths and a possible savings of $1.35 billion annually in unnecessary treatments.
During 2007 to 2009, the state healthcare administration departments of Florida, Minnesota, Virginia, and Washington worked with the Agency for Healthcare Research and Quality in demonstrating the potential value of incorporating lab data with clinical administrative data. Benefits include adjustments in mortality-risk algorithms for inpatient admissions, and improved hospital quality-performance and patient-safety measures analysis.
Participating hospitals pulled three calendar quarters of inpatient initial diagnosis codes and lab results. Thirty common lab tests were coded to the LOINC vocabulary standard, and the codes were imported into the lab-results file. In Florida’s data alone, 188,000 discharges involved 11.7 million lab records. Merging ICD-9-CM coded administrative data with LOINC-coded clinical data showed that BUN, albumin, and pCO2 had the largest fluctuation in values present upon admission, but pH, bicarbonate, and BUN had the largest impact upon mortality risk. Some 9.58% of patients may have been impacted by different definitions of urgency and treatment options with the adjusted mortality-risk algorithm.
The first stop
In order to accomplish the laboratory objectives and measures in the requirements, computer system foundations first need to be critiqued for how the test catalogs are currently structured. There should be discrete data fields for each of the lab values that are being produced. Multiple patient values should not be embedded within one set of text. Once remedied, the facility will be better suited to move into a phase of vocabulary standard implementation. Several of the meaningful use measures surround the discrete data principle.
On the Web:
• www.fhin.net/FHIN/HITinitiatives/AHRQadding ClinData.shtml
Pamela Banning, MLS(ASCP)CM , PMP(PMI), serves on the LOINC Committee, developing standardized terminology for all facets of medical laboratory reporting. She is a healthcare data analyst for 3M’s Health Information Systems’ Terminology Consulting Services. Contact her at [email protected].