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Friday, April 1, 2011

Springtime for Meaningful Use

CMS will begin taking MU attestations for year one incentive fund remittances on April 18th. I would expect that they will make a big PR play on it to help entice the laggard into participation.


I posted this on our HITRC earlier in the week. Have yet to get an answer:
Menu set item for "structured labs" (verbatim from the Final Rule, pg 224)

"More than 40% of all clinical lab tests results ordered by the EP or by an authorized provider of the eligible hospital or CAH for patients admitted to its inpatient or emergency department (POS 21 or 23) during the EHR reporting period whose results are either in a positive/negative or numerical format are incorporated in certified EHR technology as structured data."

Then, denominator & numerator specs on Final Ruie pg 133:
  • "Denominator: Number of lab tests ordered during the EHR reporting period by the EP or authorized providers of the eligible hospital or CAH for patients admitted to an eligible hospital’s or CAH’s inpatient or emergency department (POS 21 & 23) whose results are expressed in a positive or negative affirmation or as a number.
  • Numerator: The number of lab test results whose results are expressed in a positive or negative affirmation or as a number which are incorporated as structured data."

Am I correct to interpret this as every individual analyte parameter returned from a lab order going into the numerator? e.g., my primary doc routine f/u visit labs typically include CBC, UA, lipid panel, metabolic panel, PSA – dozens of individual analyte results each time. Every individual analyte assay is a "test" providing POS/NEG or quantitative data for a clinical decision regarding a patient, not just the parent panel in the order.

It seems to me to be in the provider's advantage to get numerator credit for every structured data "result" within a lab order (beyond the outright clinical decision utility of every analyte metric). But, I'm not sure how this will be construed.

I'm betting that this numerator specification will have to be re-written to say something like this:
  • "Numerator: The number of lab orders whose returned results are expressed in positive or negative affirmations or as numbers which are incorporated as structured data for at least one analyte finding."
The reason I say that owes to having looked at the way the e-MDs certified version reports it: "# of provider lab orders (+/- or numeric results) incorporated as structured data."

"orders," not "tests"

What constitutes the "order"? Everything the doc checks off on the lab sheet or CPOE entry, or every subsidiary parameter assessed by the lab pursuant to the aggregate lab request?

This is but one example of remaining MU interpretation issues.



An interesting read. Click the title above to go to an ONC page containing summary information, a link to the PDF document, and now-accruing public comments at the bottom (there are 36 as I post this, including a number of very good ones). Have your say should you wish. Public review and comment runs through April 22nd.

I will be interested in particular in the "usability" proffer, given what I have posted on this blog thus far on the topic (see pp. 13-14):
Strategy I.A.9: Encourage and facilitate improved usability of EHR technology. The government is collaborating with industry and researchers to improve the usability of EHRs. The usability of EHRs is considered a key barrier to meaningful use and adoption. NIST is developing a set of objective and standardized criteria (standards and test methods) that can be used to evaluate and improve the usability of health IT systems. NIST has released a Common Industry Format (CIF), a standard for developers to report usability test findings and demonstrate evidence of usability in their products in a format that allows for independent evaluation of a single product and comparison across multiple products. NIST is developing guidance and tools for RECs and professional societies on available tools and resources to incorporate concepts of usability in selecting and implementing EHR systems. AHRQ is developing toolkits that medical practices can use to assess the usability of EHR systems and assess the redesign workflow. In addition, AHRQ conducted research and convened industry workgroups that provide perspectives on what constitutes usability and how to systematically improve the usability of EHRs.

ONC has directed one of its four Strategic Health IT Advanced Research Projects (SHARP) (see Strategy V.B.2) to further EHR usability through better cognitive and user-centered design. In addition, ONC is working with private sector groups to encourage the collection of usability information and its dissemination to vendors and consumers through mechanisms they can trust.

A lot to accomplish in a short time.


LOL. Click the image to enlarge. When I go into the mostly small primary care ambulatory clinics I serve and bring up "workflow," I usually get the MEGO blank stares. This is from a booklet I'm assembling for my REC to try to cut to the chase and sell the concept to those lacking any clue or interest (i.e., most of them). Irrespective of the nominal swimlanes and/or nested complexity of any process, this is really the core logic.


More on workflow. Just got permission from the California Health Care Foundation to use in my nascent document a couple of workflow graphics contained in a recent paper they published entitled "Workflow Analysis: EHR Deployment Techniques." (PDF, author, S.A. Kushinka, MBA, Full Circle Projects, Inc.)

Rx refill request, pre- and post EHR deployment
(click either image below to enlarge):

  • Pre EHR, 15 steps between begin and end, shortest path, 13 steps;
  • Post-EHR, 5 steps between begin and end, shortest path, 3 steps.
Beyond the reduction in the number process steps per se (which should yield faster task completion times), it should be noted that, all other things being held equal, every additional task step in a process increases the probability of error (unless everything goes perfectly every time). Additionally, nearly all of the pre-EHR tasks are substantively physical in nature (related to chart and form chasing and pushing), while those following EHR deployment involve much less physical, more efficient EHR interaction.

Thanks, Dawn Weathersby, MSN, RN*, CHCF, and Mr. Kushinka.
*UPDATE: Small world. I probably could simply have used those two Rx workflow graphics above under "Fair Use," but I figured it only polite to ask permission. The author of the CHCF paper, S.A. Kushinka said "yeah, no problem, but I'll copy my contact at CHCF." That person emailed me back to also say "yeah, no problem, just give us a cite." I also sought out Dawn Weathersby, whose name appears in the graphics. Her name had sounded familiar. Turns out she once worked for Lumetra, the then-California QIO, within the federal DOQ-IT program that I had also worked within back during 2005-2007, and these workflows were part of DOQ-IT ("Son of REC") stuff on her part, and are consequently public domain. Dawn is now Director of Healthcare Product Strategy for Oracle. I heard from her today, so I have to give her a shout here.


I was on a HITRC "Privacy & Security CoP" call/webinar today. I snipped these (below) out of their slides.

A Meaningful Use HIPAA-compliant "Privacy and Security Audit" (replete with remediation of any deficiencies uncovered) is one of the Core Set requirements for Stage One Year One attestation (one of the 15 core criteria). I'll be really charitable here and just round up to an expected 6 REC hours per audit assistance.

Our REC is to engage about 1,500 providers. OK, that's 4.5 FTE (9,000 hrs) just to get them through this one measure. Along with all the other Meaningful Use adoption support hand-holding.


More to come...

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