Medical Device Integration Role in EHR “Meaningful Use”
2nd A l M di l D i C ti it2nd Annual Medical Device Connectivity Conference & Exhibition“…Connecting Medical Devices to People, Workflow & Information Systems”
1
Ann Farrell, BSN, RN Principal & Sr. Consultant
San Diego, CaliforniaSeptember 28 ‐ 29, 2010
About Farrell Associates… Virtual, strategic HIT consulting firm – Goal‐oriented, results‐driven,
“practical visionaries”
Business, market, product, competitive strategies, analyses, plans & services
Diverse, North American clients ‐ examples Vendors ‐ examples
‐ GE (IDX) ‐ Cisco ‐ Capsule‐ Eclipsys ‐Meru Networks ‐ Agito‐ InfoLogix ‐ Telus ‐ Sensitron (CareTrends) ‐ Picis (Ingenix) ‐ Spacelabs ‐ Flo Healthcare (Emerson)
Hospitals and Health Systems – examples:‐ Daughters of Charity Health System (CA) : Sisters of Charity Leavenworth Health System (KS)‐ Henry County Hospital (IN)Henry County Hospital (IN)‐ The Ottawa Hospital and Sunnybrook & Women’s Health Sciences Center (Canada)
Investors – DeMatteo Monness, Francisco Partners
2
Ann Farrell, BSN, Principal ‐ Sr. Consultant
RN at pioneering EMR hospital ‐ ED, ICU, CCU, In‐service education (e.g. EKG interpretation), Faculty memberships (Nursing School, EMT)
Vendor Exec – VP R & D (EMR and Data Warehouse Vendors)
Strategist, Business & Market Analyst (EHR ‐ POC Workflow and IT specialist)g y ( p ) HIMSS speaker – Clinical Devices and Medical Device Data Integration
[Nursing Informatics, Management Engineering, Supply Chain Management Committees & Task Forces – HIMSS 2011 Conference Speaker (MDI)
Strong Industry Network – Spyglass, HIMSS, KLAS, AMDIS, HIT/IT vendors, Care Delivery Organizations, investment firms, clinicians, academics, blogs
Speaker at national and local forums, exec retreats and education sessions – US and Canada
Vendome (HCI) and Vendor Sponsored Webinars
Nursing Informatics Textbook (Drs. Saba & McCormick) – EHR Vendor Chapter Author Essential of Nursing Informatics e4/e5 (in press 2010)
3
Essential of Nursing Informatics, e4/e5 (in press 2010)POC = Point of Care
Business Intelligence
Vendors ‐S liProvider l
Are we a learning industry?
SuppliersProviderOrganizations
Clinicians
Consultants
AcademicResearch
Industry Research
Strategies, Plans, & Recommendations based onExperience, Lessons Learned & Industry Best Practices
4
p , y
… and common sense!
Key topics (snapshots)
ARRA and HITECH
Stimulus Payment Qualifications
“Meaningful Use” Criteria & Timelines ‐ Stage 1 Final (7/13/2010)
MDI role in Medication Management and “Meaningful Use”
MDI role in enabling EHR and “Meaningful Use” goals
Remember you’re in the patient care business
5
Remember, you’re in the patient care business…
“America’s healthcare system is neither healthy, caring nor a system…” Walter Cronkite
U.S. dead last in quality, highest in cost
Source: Commonwealth Fund (June, 2010)
6
Sentinel Events – Big Problems
7
Source: HHN Magazine (February, 2010)
Healthcare Reform
Four pillars of healthcare reform: Widespread use of health information technology; Widespread use of health information technology;
Evidence‐backed clinical research;
Payment system reforms; and a Medicare commission that would work to implement
d fi t h tand fine‐tune such components.
8Source: Patient Protection and Affordable Care Act (March 23, 2010)
U S Investment in Healthcare
“ Healthcare spending projected to reach nearly 4.6 trillion by 2019 growing at an average annual ratetrillion by 2019, growing at an average annual rate of 6.3 percent over next decade…”
Economist at the Centers for Medicare and Medicaid Services (2010)
9
What is HITECH?
The American Recovery and Reinvestment Act (ARRA) is a $787B bill, (aka “Stimulus Bill) signed into law by the federal government on February 17, 2009.
The Health Information Technology for Economic and Clinical Health $Act, or HITECH Act, portion of ARRA allocates approximately $40B to be
used to increase use of Electronic Health Records (EHRs) by eligible physicians and hospitals.
In this historic legislation the government conveys its firm belief in the benefits of using electronic health records and readiness to invest federal resources to proliferate its “meaningful use”federal resources to proliferate its meaningful use .
HITECH portion of ARRATitle XIII in Division A pp 112 ‐ 165Title IV in Division B pp 353 ‐ 398
10
Title IV in Division B pp 353 398
Healthcare IT Spending in Stimulus BillApproximately $40 Billion in HIT Spending
Electronic Health Records GovernmentHealth Programs
EHR Adoption Incentives
Community Health Centers$1.5B*
Indian Health Service$85M
Department of HHS$50M
Veterans Benefits Administration$50M
$3B~$32B
ONCHIT$300M
NIST$20M
…plus Broadband and Telemedicine Initiatives
D f A i l
$2B
* Through the Health Resource and Services Administration (HRSA) as grants
HHS DiscretionaryGrants/Loans
Unallocated$1.68B
Department of Agriculture$2.5B
Department of Commerce$3.5B
11
* Through the Health Resource and Services Administration (HRSA) as grants
Stimulus payment qualification
3 General Requirements for EHR “Meaningful Use”1. …using a “Certified EHR” (in a meaningful manner)
2. …achieve “Meaningful Use” criteria – report measures (increasing electronic health information exchange to improve quality of health care and care coordination)
3. …report on clinical quality measures and other measures as selected by the Secretary.
“Implementing an EHR to get Stimulus funds is like having a babyfor the tax write off” Health System CIO
12
for the tax write off ……Health System CIO
IT Use Isn’t Meaningful without a solid strategy!
“In the rush toward ‘meaningful use’ and amid the HIT sales pitches, let's pause for a moment to consider strategy.”
Marco Huesch MBBS PhD Assistant Professor Duke UniversityMarco Huesch, MBBS, PhD Assistant Professor Duke UniversityFuqua School of Business (teaches Provider Strategy)
June 17th, 2010
"By focusing on 'meaningful use ' we recognize that better health care doesBy focusing on meaningful use, we recognize that better health care does not come solely from the adoption of technology itself, but through theexchange and use of health information to best inform clinical decisions at the point of care. Ultimately, 'meaningful use' should embody the goals ofat the point of care. Ultimately, meaningful use should embody the goals of a transformed health system…and, in the long‐term, is when EHRs are used by health care providers to improve patient care, safety, and quality."
Dr. David Blumenthal – National Health IT Coordinator http://healthit.hhs.gov/portal/server.pt
Meaningful Use is NOT the end game (or an implementation strategy !!!)
13
(or an implementation strategy !!!)
Vitals Signs Critical values assessed in context of overall patient assessment and story
– not “stand alone” (a piece of the puzzle)
Subset of nursing assessment data Sensory – see, hear, sound, feel, “know”
Information digital (EHR/medical devices) and paper Information – digital (EHR/medical devices) and paper Interview – patient and family / Significant Others
S b f i d i Subset of nursing documentation
A “data set” – i.e. taken/recorded at same time
Late to very late sign of distress!
14
Vital Signs – “Current State” (not pretty)1. Manual data collection inefficient
MDI saves ~ 1 to 1.5 hrs per shift per RN or CNA 1, 2‐ Periodic monitoring (spot check) ‐ Continuous monitoring
2. Vital Sign data documentation error prone ‐transcription mistakes & “workarounds” lead to errorstranscription mistakes & “workarounds” lead to errors
~23% vital signs inaccurate (paper and EHR manual entry) 3Paper: Jot notes @ POC, transcribe later ‐ or much later‐ on paper chart & form(s)
Electronic: VS collected @ bedside memorized entered in WOW in hallway Electronic: VS collected @ bedside – memorized, entered in WOW in hallway
3. Long “lag time” in VS availability in EHR 6 to 12 hour data “latency” 1, 2
1 CareTrends (Sensitron): El Camino Hospital, CA: Medical Surgical Benefits Study; 20062 iSi C S d W i i l H l h S X ( fi S d ) 2009
‐ Contributes to “failure to rescue syndrome”
‐ Need near real time clinical decision support data (local & remote MDs & Care Managers)
15
2 iSirona Case Study: Weiss Regional Health System, TX (Benefits Study); 20093 Wager, K. A. et al, Comparison of Quality and Timeliness of Vital Signs Data…Intel Motion 2009, CIN Sept. 2010
Stage 1 Hospital Meaningful Use Objectives
Criteria Measures
1. Demographics >50% pts demographic data (structured data)
Stage 1 – CORE OBJECTIVES
2. Vital Signs >50% of pts > 2 yrs – Ht, Wt, BP (structured data)
3. Problem List ‐ Active & Current Diagnosis >80% > 1 entry (structured data)
4. Active Medication List >80% > 1 entry (structured data)
5. Active Medication Allergy List >80% > 1 entry (structured data)
6. Smoking Cessation Status >50% of pts >13 yrs ‐ smoking status (structured data)
7. e‐Copy Discharge Instructions (on request) >50% pts requesting e‐copy DI provided it
8. e‐Copy of Health Information (on request) >50% pts requesting info receive in 3 business days
9. CPOE for medication orders >30% of pts on med(s) – >1 med via CPOE
10. Drug : drug / drug: allergy interaction checks Functionality in place for entire reporting period
11. Exchange key clinical information Perform at least one test of information exchange
12. One clinical decision support rule One CDS rule implemented
? pp p
13. Privacy &security system for patient data Security Risk Analysis: Updates & Deficiency Corrections
14. Report quality measures to CMS or states 2011 – Aggregate data submitted via attestation2012 – Electronically submit measures
Source: Excerpted from NEJM 7/2010
?
16
Source: Excerpted from NEJM 7/2010#15. eScriptions (40%) required for Eligible Providers (not hospitals)
MDI best practice (not required)
Stage 1 Hospital Meaningful Use ObjectivesStage 1 – MENU OPTIONS *
Criteria Measures1. Implement drug formulary checks Checks in place with access to >1 formulary
2. Incorporate clinical lab results (structured data) > 40% lab results +/‐ or numeric in EHR (structured data)
g
3. Pt. lists by condition – quality improvements, reduction in disparities, research or outreach
>1 List of Patients by conditions
4. Via EHR identify patient specific education resources –provide as appropriate
>10% of patients provided patient‐specific education
5. Perform med reconciliation between care settings Med reconciliation >50% transitions of careg
6. Provide summary of care (transfer of care or setting) Care Summary record >50% transitions of care
7. Submit e‐syndromic surveillance data (public health agencies) Perform >1 test of data submission & follow up submission(where registries can receive)
Additional choices for Hospitals and CAHsAdditional choices for Hospitals and CAHs
8. Record Advanced Directives for pts >65 yrs >50% of pts > 65 yrs have Advanced Directive Status recorded
9. Submit reportable lab data results (public health agencies) Perform >1 test of data submission & follow up submission(where registries can receive)
Additional choices for Eligible ProvidersAdditional choices for Eligible Providers
8. Send reminders to patients (prevention and follow up) >20% pts > 65yrs old or <5 are sent appropriate reminders
9. Provide patients timely access to health information (e.g. lab results, problem, med lists etc.)
>10% pts provided e‐access to info (within 4 days after update in EHR)
Eligible Hospitals, Providers & Critical Access
17
Eligible Hospitals, Providers & Critical Access Hospitals Can Select Any 5 of Menu Set
Source: Excerpted from NEJM 7/2010* ONC states Stage 1 Menu Options will be part of Stage 2
Hospital MU – Stages 2 & 3 DRAFT (excerpts)Stage 2 2013 Processes Stage 3 2015 O tcomes [$ P lti ]Stage 2: 2013 – Processes Stage 3: 2015 – Outcomes [$ Penalties]
Continuous quality improvement at Point of Care
Increased data exchange
Improve quality, safety and efficiency,
Focus on decision support for national high priority conditionstiv
es
More robust EHRs
priority conditions
Patient access to self management toolsImprove population health
CPOE 60% (all orders types)‐ Evidence‐based order sets
Object
CPOE 60% (all orders types) Evidence based order sets
eScription (at discharge)
CDS at Point of Care
Closed‐loop Medication Management including eMar
Enhanced CDS (US high‐priority conditions)
Multi‐media
Medical Device eria
“with computer assisted administration”
Clinical Documentation in EHR
Additional Reporting, Chronic Disease Management
Interoperability
Metrics TBD ‐ Quality ‐ Safety ‐ Efficiency
SNOMED
Crit
SNOMED
To include Stage 1 Menu Set (“Halfway to goal”)Interim Final Rule Q1 2011? ‐ 60 day comment periodFinal Q2/3 2011 (?)
IFR – originally 2013 – to be accelerated60 day comment periodFinal? St
atus
18
Q / ( )
Source: Farrell Associates
S
ONC = Office of the National Coordinator
19
Closed Loop Med Management Process Role of Vital Signs as CDS and MURole of Vital Signs as CDS and MU
MDI benefits Nurses & RT Pharmacists & MDs
Assess PatientRN – Interview, Observe S/S, Review EHR/chart
Collect / Validate KEY patient data (CDS data)
Assess PatientRN – Interview, Observe S/S, Review EHR/chart
Collect / Validate KEY patient data (CDS data) RT, Pharmacists & MDs Patients
Allergies Height / Weight (BMI) ‐MDI (MU ‐ 2011) T P R BP (“vital signs”) ‐ MDI (MU ‐ BP 2011) Bedside lab values, e.g. O2 sat ‐MDI I & O ‐ (IV Intake – smart pumps) ‐MDI Other device / monitor data ‐MDI
Allergies Height / Weight (BMI) ‐MDI (MU ‐ 2011) T P R BP (“vital signs”) ‐ MDI (MU ‐ BP 2011) Bedside lab values, e.g. O2 sat ‐MDI I & O ‐ (IV Intake – smart pumps) ‐MDI Other device / monitor data ‐MDI
Document Findings ( POC ‐ MDI)Document Findings ( POC ‐ MDI)
Evaluate PatientMD / Providers ‐ Review CDS dataR lt L b I i
Evaluate PatientMD / Providers ‐ Review CDS dataR lt L b I i
Administer MedsRN/RT – Confirm OrderAssess Patient – Review CDS data(s bset of meds)
Administer MedsRN/RT – Confirm OrderAssess Patient – Review CDS data(s bset of meds) Results – Lab, Imaging
Patient Assessment Data * [eMar if prior meds ordered]
Need accurate, current data* Use MDI data
E O d ( )MU 2011
Results – Lab, Imaging Patient Assessment Data * [eMar if prior meds ordered]
Need accurate, current data* Use MDI data
E O d ( )MU 2011
(subset of meds) Results • Patient Assessment Data• May collect data (e.g. retake VS) ‐MDI• eMar (if prior med(s) ordered)
BCMA = Point of Care
D M d( ) &
(subset of meds) Results • Patient Assessment Data• May collect data (e.g. retake VS) ‐MDI• eMar (if prior med(s) ordered)
BCMA = Point of Care
D M d( ) &Validate OrderPh i t V lid t M d O dValidate OrderPh i t V lid t M d O d
Registered Nurse Physicians Pharmacist Registered NurseEnters Order(s) MU 2011 (meds)(Drug interactions & formulary check ‐MU 2011)Enters Order(s) MU 2011 (meds)(Drug interactions & formulary check ‐MU 2011)
Document Med(s) & Patient ResponseDocument Med(s) & Patient Response
Pharmacist – Validate Med OrdersReview Drug interactions & CDS Data (subset of orders)• Results • Patient Assessment Data * (may collect allergies)[eMar if prior meds ordered]N d t t d tN d t t d t
Pharmacist – Validate Med OrdersReview Drug interactions & CDS Data (subset of orders)• Results • Patient Assessment Data * (may collect allergies)[eMar if prior meds ordered]N d t t d tN d t t d t CDS = Clinical Decision Support
20Copyright ©2010 Farrell Associates
Need accurate, current dataNeed accurate, current data
* Use MDI data
Dispense Med(s)
Need accurate, current dataNeed accurate, current data
* Use MDI data
Dispense Med(s)
CDS = Clinical Decision SupportRT = Respiratory Therapy
MDI = Best (Safe) Practice for Vital Sign Data Collection, CPOE/CDS and eMar
2011 2013 2015
Data capture and sharing
Advanced clinical processes
Improvedand sharing Improved outcomes
STAGE 1 FINAL DRAFT DRAFTRelevant Hospital Criteria
CPOEeMar / BCMA CDS ? Clin doc?
Medical Device Interoperability
STAGE 1 FINAL DRAFT DRAFTVital Signs (Ht/Wt/BP) CPOE (med orders)CDS?
MDI Required?
No BUT
Vital Signs
No Yes ‐ BUT
• CPOE / + eScription
BUT5 more years of non‐productive manual data entry and aged,
21
Vital Signs (productivity, accuracy, timeliness)
CPOE – Med ordersAccurate, up‐to‐date CDS data
• “eMAR w/computer assisted administration”
MDI & BCMA “joined” processes
y g ,inaccurate information used by clinicians in life‐critical decisions
???Best Practice
Questions?
Panel Discussion Day 2 (Noon): “B i i ”“Burning questions”
Thanks!22
Thanks!
Medical Device Integration Role inEHR “Meaningful Use”
THE ENDTHE END
23
Ann Farrell, BSN, RN Principal & Sr. Consultant
MDI Role in EHR Meaningful Use
AppendicesAppendices
2nd Annual Medical Device Connectivity C f & E hibitiConference & Exhibition“…Connecting Medical Devices to People, Workflow & Information Systems”
San Diego, California
24
September 28 ‐ 29, 2010
Show me the money…What Percentage of Organizations Plan To Seek
'Meaningful Use' Incentive Payments?g y
Seventy‐seven percent of HIT professionals surveyed indicated that their organization will attempt to qualify for the "meaningful use“ incentive payment program, while 3% were unsure, according to a new HIMSS
25
iHealth September 17, 2010
The Reality of Meaningful Use
‐ Investment highest ‐ Stages 4 & 6
‐ Hospital IT expenses and budgetsHospital IT expenses and budgets related to clinical sophistication
‐ Stage 6 sites: 80 to 100% of chart electronic
‐ Average ratio of IT capital‐ Average ratio of IT capital budget to operating budget is 30%
‐ Average total capex to reach Stage 6 for academic facilities: $58 million
7
YE A $58 million
‐ Average total capex to reach Stage 6 for general med/surg: $7.4 million
A d ti f ll
A R S
AV
‐Average duration for all facilities to reach Stage 6 from the initial EMR project launch‐7 years
Source: HIMSS Analytics 2008
G
26
CDR—clinical data repositoryCMV—controlled medical vocabulary (such as SNOMED)CDSS—clinical decision support systemsCPOE—computerized prescriber order entryPACS—picture archiving and communications systems
CHIME Concerns
Source: CHIME Survey – August 2010( )
27
College of Healthcare Information Management Executives (CHIME)
Chasing Meaningful Use at Fevered Pitch
Source: CHIME Survey – August 2010
( )
28
College of Healthcare Information Management Executives (CHIME)