A couple of months ago I was explaining to my wife the definition of EHR “meaningful use” over dinner. She was nodding her head and seemingly listening more intently than normal to my work-related subject.  As soon as I was done talking, she quickly said she really liked the phrase “meaningful use.” Then she advised me to make “meaningful use” of the lawnmower and cut the grass.  Not only do I hear this phrase consistently at work, it now follows me home.

However CMS defines meaningful use as a method to prove that providers are using an EHR to the CMS standards. Until recently the government was very unclear on these standards.  CMS was telling the healthcare industry to get moving now, but they failed to list what the objectives are. I equate it to someone telling you to get in your car and drive without telling you the destination or the direction. Then on July 13, 2010, CMS released its final rule which clarified the vast realm of questions on the incentive program.

In typical government fashion, the final rule document released consisted of 864 pages.  Unless reading encyclopedias is your thing, I would skip to the fact sheets versions on the CMS website.   Below are some links to the fact sheets that I am referring to:

1. CMS FINALIZES DEFINITION OF MEANINGFUL USE OF CERTIFIED ELECTRONIC HEALTH RECORDS (EHR) TECHNOLOGY
2. CMS FINALIZES REQUIREMENTS FOR THE MEDICARE ELECTRONIC HEALTH RECORDS (EHR) INCENTIVE PROGRAM
3. CMS FINALIZES REQUIREMENTS FOR THE MEDICAID ELECTRONIC HEALTH RECORDS (EHR) INCENTIVE PROGRAM
4. MEANINGFUL USE

An important side note is that the measures that you see are just stage 1 measures. There are a total of 3 stages and each stage is increasingly more difficult. You have to meet all three stages if you want a full stimulus payment.

The final rule on EHR meaningful use is broken down into 2 sections. The first category is for core measurements that every eligible provider must demonstrate and report.  These core measurements consist of 15 items. I have categorized these core items into the sections of “no brainers,”  “some work may be required,” and “what was CMS thinking?”

The “no brainers” are core measurements that any decent EHR should do automatically for you, or things I am sure that you are already doing. These include things like drug allergy checking, recording demographics, maintaining medication list, smoking status, maintaining problem lists, and maintaining allergy lists.  With very little work you should be able to cross these off your list.

Other measures might require some new tools or processes to be put into place. These include things like clinical decision support rules, reporting of quality measures (PQI ),  providing clinical summaries to patients in 3 days, IT security risk analysis, and using CPOE for medications.

Lastly “what was CMS thinking?” measures might be more difficult for your practice.  Measures such as recording vitals in the EHR are not hard for any software application, but many specialists don’t take every vital. For example, dermatology practices who see a lot of teenagers would be required to do things like growth charts and BMI charting.  This could affect the efficiency of a specialty practice.  I also think it is interesting that doctors of dental medicine and surgery are eligible providers, but it is almost impossible with these core measures for them to meet the meaningful use standards.  The focus of these measures is clearly on primary care.

Another difficult measure requires patients to be provided with their record electronically when requested. This will require something like a patient web portal, or at a minimum burning CDs for patients. Also one of the core measures is to exchange clinical information electronically. This will be a valuable function, but you will have to rely on what your software vendor and state can do. How difficult these items are will depend heavily on your software vendor, budget, and specialty.

The second CMS category is titled menu measurements which consist of 10 items. A provider must pick 5 of the measurements to report on .The flexibility of picking 5 out of the 10 was a nice surprise from the initial model of all or nothing. The menu measurements on average are more difficult than the core measures so choose wisely. I will save the menu measure for a later discussion.

In the first reporting year (which is 2011) you have 90 days to attest and report these measures. You can pick any 90 day window in 2011 for the reporting. In the following years you will be required to report on the entire year.

Now that practices have the final Stage 1 measures you need to make the decision if you are going after this money or not.  For me I have decided to make “meaning use” of the lawnmower  and cut the grass.

The future state should focus more on the optimal processes and procedure rather than the EHR software.  I firmly believe people and process come before the technology pieces in the EHR puzzle.

I know it sounds like a simple step, but I often see this step rushed or skipped as a shortcut in the new EHR process.

One of my favorite stories about final destinations is one about Albert Einstein.

Albert Einstein was once traveling from Princeton on a train when the conductor came down the aisle, punching each passenger’s ticket. When he came to Einstein, the renowned physicist reached into his vest pocket but could not find his ticket. Then he reached into his other pockets but still could not find the ticket, so he looked into his briefcase. Nothing there. He looked at the seat beside him. Nothing.

The conductor said, “Dr. Einstein, I know who you are. We all know who you are. I’m sure you bought a ticket. Don’t worry about it.” Einstein nodded appreciatively, and the conductor continued down the aisle, punching tickets. The conductor looked back at the end of the car and saw Einstein down on his hands and knees, looking under his seat for the ticket. Rushing back up the aisle, the conductor cried, “Dr. Einstein! Dr.Einstein, don’t worry about your ticket! There’s not a problem. You don’t need a ticket. I’m sure Princeton bought you one and I know who you are!”

Einstein looked up and said, “Young man, I too know who I am. What I don’t know is where I’m going!’”

The point of the story is to articulate that you must clearly know the end destination after implementing a new EHR.

One of the challenges in determining the future state is separating your thinking from how you are doing things now.  Think outside of the box. I have worked with practices looking for a new EHR and they have been in their current vendor’s box for 15 years.  I don’t have to tell you a lot has changed from then to now.  Find out from peers, healthcare technology groups, and the web on the latest healthcare IT trends.  For example did you know that many payers allow for RTCA (Real Time Claim Adjudication) and many EHR vendors are integrating this into their software? Healthcare IT News and Health Informatics are great places for web research on the latest trends.

Another challenge of defining the future state is to stay focused on the business requirements and not how these requirements will be carried out. In other words think about Hawaii and not the 12 hour flight to get there. The “how” part will come later on in the discussion life cycle.

Some guidelines of the future state analysis are:

• Determine best practices implemented in other organizations
• Focus on the end result and not how to get to the end result
• Determine current states problems last so that you don’t get hinder by the current state when thinking of new ideas.
• Document detail “Use Cases”

“Use cases” are a great way to document the future state for the EHR system users and their optimized steps.  “Use cases” describe how users will interact with an EHR in the final state.  Activity diagrams and flowcharts are great communication tools for documenting the different use cases.  Microsoft Visio and their free counterpart Drawanywhere are excellent tools for creating these diagrams.

An example of a high-level clinical swimlane diagram is included here.

Lastly your future state analysis should be included in your RFP to EHR vendors. This is one of the primary measures to determine which software will be the best fit for the organization. Don’t let the software vendors dictate what your final state should be. Vendors will always pick the items that are nearest to their software.

In closing, future state analysis is one of the most important steps in the EHR process.  Keep looking for that train ticket so that final EHR destination is clearly known.

As a kid, when I received some type of toy, the most exciting aspect was figuring out how it worked. I couldn’t just play with it, I needed to tear it apart, analyze it and rebuild it. I guess this has followed me into my career, as I disassembled eRx to its pieces. The term eRx is generally understood as just sending a prescription electronically to the pharmacy. While this is a great feature, there are many other benefits which your practice can capitalize on.

During a typical eRx transaction there are many players involved, which include providers, payers, pharmacists and the main “character behind the  curtain”-  Surescripts. While there are other smaller eRx networks in the country, Surescripts is by far the primary network that handles connections between all stakeholders. Communication between Surescripts and the other involved parties is  achieved with a standard called National Council for Prescription Drug Programs  script (NCPCP script). NCPCP allows everyone to talk the same language.

Participation with Surescripts is free to physicians, but pharmacies are charged on a per-electronic-prescription basis. This is because an eRx provides tremendous time savings to a  pharmacy compared to  paper based prescriptions. Pharmacies were quick to adopt this technology, and now close to 95% of pharmacies are connected to the network.

Surescripts offers services other than routing of prescriptions between the provider to the pharmacy. These lesser known services include refills, Rx history, and Rx eligibility.

e-Refills is a process that typically has the pharmacists requesting an authorization for a renewal of a medication. With e-Refills requests returning digitally to the provider, they are viewed in an application such as an EHR. While receiving a new eRx is a time saver for pharmacists, it is not a huge time saver for a provider. In many studies it can take longer to “write” an e-prescription. However the real time saver on the practice is e-Refills that are received. You will notice that I said practice and not provider. This is because often the clinical support staffs are the ones handling the incoming refill requests.

Reconciling medications with the patient is a common step during the clinical work flow process. The Surescripts network also allows providers to automatically aggregate a patient medication history with the click of a button. Surescripts gathers this information by accessing data from community pharmacies as well as payers. While this is not one hundred percent accurate for gathering all medications every time, it does give clinical staff a substantial head start. This prescription history service results in improved patient safety and quality.Rx Benefit checking is another core service Surescripts offers that can access the patient’s prescription eligibility information in real time during an office visit. During the prescription process physicians can determine if drugs are covered with the patients insurance. Personally, I wish this service was offered more often. When my daughter was a newborn she was prescribed some skin cream. As a new dad I was shocked at the cost when I went to pick up the medication from the pharmacy. When I asked if a generic medication was available,  I had to wait while the pharmacist called the pediatrician for approval. This cumbersome process wasted the time of all involved parties: the patient, the pharmacy, and the provider. An easy way to reduce healthcare costs is simply by using prescription benefit checking.

The one common denominator these additional Surescripts features share is that they rely on the connectivity that your EHR vendor offers. There are some third party websites and applications that offer these services without an EHR, but a vast majority of practices are making use of these with their EHR software. If you are currently examining your choices for EHR these features should take precedence on your needs analysis. Surescripts ranks the EHR interoperability at the following site:  http://www.surescripts.com/certification-status.html

First you may ask, why are these items free? Well there are really two categories that these free applications fall into. The first is that many software companies offer basic or “lite” versions of their full applications to generate more exposure in the crowded software market. Many times the basic versions will handle a majority of your needs. The second category is open source software. Open source typically involves a community of people working together as a whole to create an application that anyone can use and improve upon. Open source is starting to become a rising trend to confront increasing software costs.

Without further ado here is a list some of free applications that may benefit your organization.

• LogMeIn – Free remote access outside the office. Secure and extremely easy to setup
• eDoc Health – Free Healthcare Document Management.  Barcode paper forms to automate scanning.
• Open Office or Google Docs – Free office software very similar to Microsoft Office suite. Also compatible            with Microsoft file formats.
• Mozy – Free Online Backups for critical files such as QuickBooks. Free version is limited at 2 GB of storage.
• OpenVista – Free Enterprise  EMR developed by U.S. government
• VMWare ESXi – Free Virtualized Server Software. This is discussed in more detail in the Virtualization 101     article in this issue.
• Microsoft Steady State – Free Software to lock computer workstations to an optimal state keeping common user caused issue to a minimum.
• K-PACS – Free DICOM Image Viewer that works with your current PACS. Don’t pay a lot to vendors to haveadditional computer view image studies.
• Mirth – Free HL7 interoperability software.  Basically it gets all of your healthcare applications talking toeach other via HL7 or other healthcare standards.