“Although many consumers access their banking information online daily, fewer than 10 per cent use the web to access their personal health information.”
— National Survey, April 2010, California HealthCare Foundation
In order to keep up with government-driven healthcare mandates, such as the Stimulus Bill and ICD-10, stakeholders are seeking innovative solutions and adopting new initiatives and technologies. Healthcare providers need to focus on quantifiable deliverables in order to benefit from mandate incentives and funding. If they don’t make efforts to meet the new guidelines, they run the risk of getting penalised for non-compliance. With this in mind, healthcare providers are taking all possible measures to deliver patient-centered care.
Health information exchange (HIE) and meaningful use (MU) are two federal initiatives that can help deliver better healthcare. HIE connects doctors, nurses and other healthcare providers electronically, and MU provides context and defines the use of health technology to achieve mandate compliance. Establishing MU also determines federal incentive funding.
This white paper discusses the correlation between HIE and MU and provides insight for using this correlation to improve healthcare delivery.
Data-driven healthcare
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| Navin Chandra Nigam |
The Health Information Technology for Economic and Clinical Health (HITECH) Act, embedded within the American Recovery and Reinvestment Act (ARRA), is encouraging healthcare providers to share clinical records with other providers, hospitals and clinics to achieve continuity of care. They can accomplish this by using HIE and obtaining certified electronic health records (EHR) — while avoiding financial penalties. With $36 billion in exclusive funding for the HITECH Act, providers will be able to adopt the MU incentive program in a staged manner. This funding, which originated through the HITECH act in 2006, benefits healthcare providers who adopt certified EHR systems (or MU software). Incentive payments are being distributed from 2011 to 2016, causing providers to adopt EHR systems more quickly than they might usually adopt a new technology.
A US Department of Health and Human Services (HHS) news release cites encouraging results for EHR adoption. It says that HHS has met and exceeded its goal for 50 per cent of eligible professionals by the end of April 2013, which was merely 17 per cent in 2008. Also, eligible hospitals EHR adoption jumped from 8 per cent to80 per cent in the same period.
Another government budget report for FY 2014 cites that HHS has maintained its focus on adoption of healthcare IT and meaningful use of EHR. CMS and the Office of the National Coordinator for Health IT are working together to improve quality, reduce costs, decrease paperwork, and expand access to care through increased adoption and meaningful use of EHRs. HHS aims to increase the number of eligible providers who receive an incentive payment from Medicare and Medicaid EHR Incentive Programs from 230,000 by the end of FY 2013 to 314,000 by the end of FY 2014.
Front-end care providers, such as physicians and hospitals, face inevitable changes as they will need to alter their data capture process and assume additional mandatory reporting. Payers will benefit the most in the adoption of the MU program and implementation of HIE, because the cost of healthcare will decrease. The reduction in cost is due to hospitals and physicians opting to adopt guidelines-driven healthcare delivery and leave behind the older system of paper use in daily tasks. This will reduce medical and medicinal errors, making care more effective and accomplishing one of the goals targeted by ARRA. Product vendors will also find easier ways to cope with changes that are being suggested in stage 2 while reducing the cost of building new features in their products.
Patient-centric medical information
A number of hospitals in the US still use manual processes for charting, administrating medication and scheduling staff and patients. This paper-based method can create interrupted continuity of information and give rise to confusion and/or incorrect data. These issues can result in low-quality care delivery, missing information, test duplication, wrong clinical decisions and could even put patients at risk. Studies indicate that medical errors cost anywhere from $8,000 to $15,000 per bed for a mid-sized hospital. Electronic-based solutions and applications are proven to be substantially helpful in reducing cost of healthcare and improving care delivery.
For example, a patient is travelling and in need of critical medical attention. Electronic medical information such as past medical history, family history, current medication and allergy information can be used to diagnose and potentially save this patient. Not only does the electronic availability of patient records bring down the cost of healthcare by avoiding duplication of records, it also saves time and, more importantly, helps make critical medical decisions supported by sound information and hands-on data.
Implications of meaningful use
It is vital to capture clinical information in a structured and controlled manner during a patient encounter. This structured data provides a base for uniform vocabulary and semantic interoperability and retains consistency in operations. Strict adherence to clinical guidelines is needed for better overall healthcare delivery. Currently, there are vast disparities in data assimilation — from the point of initiation to processes and tools used to capture data.
The MU software has allowed healthcare providers to collect data in a precise standard format at the time of a patient encounter, enabling better communication and accessibility in the greater healthcare community. The data collection procedure is changing work-flow patterns, business operations, processes and diagnostics templates. At the application level, product vendors have initialised changes to put the end user at ease when adopting certified EMR software.
| Meaningful use stages and goals | |||
| 2009 | 2011 | 2013 | 2015 |
HITECH
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Stage 1
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Stage 2
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Stage 3
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Improving patient communication
One of the goals of health information exchange — and an important part of the meaningful use programme — is patient and family engagement. Standards for patient empowerment are consistent with national health priorities and allow patients to have the information they need in order to make informed choices about their healthcare. Disseminating patient information and making it available online for patients to view, download and transmit is one of the objectives of stage 1. This enables patients to access, review or follow up on their health data (or that of their relatives’) in a secure way. Real-time data is captured by certified EMR software and securely sent to the desired destination. When a patient is well informed and aware of steps taken for his/her betterment, they are provided with a sense of security and empowerment.
MU as stepping stone to attain HIE
Healthcare communities come in various forms: large health systems, large and mid-sized hospitals and rural health systems. Fragmentation of health records, legacy systems and an aging population continue to contribute to inconsistent and uneven healthcare delivery across the world.
With HIE, the healthcare community can resolve issues, even across borders. By focusing first on data, they are able to collect, clean, store securely, research, analyse and securely send vast amounts of data.
The ultimate goal of ARRA, HITECH and the reform bill is to thread all of the data fragmented by manual processing together. This is accomplished by filtering and connecting meaningful information from raw data to help reduce record duplication and medical and medicinal errors. MU is a concrete step towards this objective and the* staged manner in which it is being implemented gives sufficient time for the community to respond and adopt EMR applications, bring internal changes and implement the application.
The diagram below represents the high-level strategy proposed by the Health Information Technology (HIT) Policy Committee, an official federal advisory committee to the Office of the National Coordinator (ONC) that makes reports in a content management system (CMS). This strategy is a systematic approach to develop the foundation of technology and processes in order to improve patient outcomes. The HIT Policy Committee has proposed the definition of meaningful use for 2011, 2013 and 2015.
HIE and MU: An intersection of health delivery and patient information
To meet the objectives of HIE, healthcare providers will need to implement and use a certified EHR in order to exchange patient information electronically with other healthcare organisations. At first glance it seems that HIE is not explicitly required in the various meaningful use stages. But several of the requirements — such as availability of electronic patient records or discharge information — need HIE as a facilitator. The HITECH Act also includes funding for states to create an HIE infrastructure that helps providers prepare for and meet meaningful use criteria. The final MU guidelines are expected to be written in a way that allows providers other means of meeting the definition of an established HIE.
The meaningful use programme is unfolding slowly but consistently. Stage 1 has provided guidelines to capture data in a controlled way, while engaging providers to use certified EMRs. Requirements are heavily centered on health information gathering and clinical decision making. Stage 2 is more focused on requirements and information exchange, where an HIE model will be applied to some of the aspects. A safe and secure HIE will give access of stored data to end users and simultaneously allow patients and physicians to become more involved in health data dissemination, ensuring better communication.
| Meaningful use | Stage 1 | Stage 2 | Stage 3* |
| Electronic copy of health Information | Greater introperability | Increased use of patient health record portal | |
| Discharge Instructions | Analysis of data for decision making | Connectivity between EHR and PHR portal | |
| Meaningful requirements summarised | Structured and controlled data capture | Patient controlled data | Data transmission to primary referral centers or HIE’s |
| Discharge Instructions | Support transitions to unaffiliated providers | Data submission to public health agencies | |
| Key clinical information exchange | Structured lab
results |
Self-management health tools and data upload | |
| HIE roles & objectives |
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| *In preliminary suggestion stage | |||
Increasing role of HIE in MU fromstage 1 to stage 2
A major shift of focus occurs when going from stage 1 to stage 2. The requirements of stage 2 need increased interoperability to support the objectives of healthcare reforms. Shifting focus from single patient data collection (in stage 1) to the exchange of medical records within various care delivery organisations allows for faster and more accurate healthcare decision making and results in better quality outcomes. The robust solution to enable interoperability of HIE will give rise to faster accessibility of health data at the national and state level for research, population-based disease management and crisis control. This collection of data will benefit national and individual health greatly; it will also benefit the formulation of healthcare strategies and help monitor resources and infrastructure requirements.
HIE use in meaningful approach
HIE is gaining importance in the meaningful use program. The requirements to meet MU span from testing HIE at stage 1 to connecting to at least three external primary care networks (or establishing bi-directional connection to at least one HIE) in stage 2. There are several requirements in stage 2 that support and encourage the use of HIE in data exchange. These include:
Electronic prescribing: Eligible hospitals (EH) and eligible physicians (EP) place an electronic prescription order with a pharmacy within 10 miles of their hospital or clinic. Using HIE for electronic prescription transmission reduces medicinal errors and record duplication (such as when a paper-based prescription is lost or misplaced) and increases efficiency in terms of authorisation.
Clinical summary of office visits: EPs needs to provide a clinical summary of records for each particular patient visit. While the rule allows for different options for disseminating information, HIE can be very effective here. The online transmission of clinical summaries is more effective than using a CD or USB drive, which can be less secure and more expensive.
Transmission of lab results: One of the most essential aspects of medical information is the secured exchange of lab results. The HIE needs to transmit structured lab results data from EHs to EPs and also facilitate the EH to transmit the data to other hospitals. This reduces the cost incurred when records are duplicated and helps establish online and timely availability of lab results at the point of care.
Patient health information transmission: Patients are able to view online health records — from anywhere, at any time — to ensure they are up to date on their health status and aware of any necessary follow-up steps. The availability of complete longitudinal health records increases patient communication and empowers patients to make more informed health decisions. Communication through personal health records (PHRs) can also enhance geriatric and remote care, by avoiding unnecessary hospital visits.
Medical reconciliation: Tracking medication and the reconciliation of prescribed medications helps reduce medical errors and drug allergies and incompatibilities. As one of the most important aspects of care delivery, medical reconciliation can be handled through the secure and interoperable exchange of medical data. The cost of medicine also decreases when medicinal history is accurately updated and recorded from visit to visit.
Summary care record for each transition of care or referral: Patient records being able to transmit through an HIE to different providers and specialists improves clinical decisions overall. Sending a referral electronically from a primary care physician to a hospital for a patient appointment or admission also speeds up the process.
Medical imaging sharing: Not yet mandatory in the use of certified EHR technology, however, medical imaging sharing is a great opportunity for the betterment of healthcare delivery. Uploaded images with relevant information help care providers make timely decisions and can also reduce the cost of diagnosis duplication.
| HIE involvement in MU stages | ||
| Stage 1 and 2 | Stage 3 | |
| Meaningful use |
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| Quality |
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| Privacy and security |
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Rising role of HIE in Stage 3
Stage 3 of MU is expected to take effect in 2016 for select healthcare providers. On November 16, 2012, the ONC released a request for comment regarding stage 3 meaningful use measures, which represent the preliminary thinking of the HIT Policy Committee. The public is being asked to give their views on the readiness and feasibility of new objectives and measures in the following areas: meaningful use, quality and privacy and security. The comment period ends mid-January 2014, following additional public meetings in 2013. The stage 3 MU requirements will create a mature and robust collaborative healthcare delivery model meeting objectives set at the initiation of healthcare reforms.
At the broader level, preliminary stage 3 requirements fall under the continuation of requirements from the previous stages and those newly introduced in Stage 3.
“While the committee appreciates and recognises today’s challenges in setting up data exchanges, it is the committee’s recommendation that stage 3 is the time to begin to transition from a setting-specific focus to a collaborative, patient- and family-centric approach,” stated a report from the HIT Policy Committee.
HIE is expected to facilitate the connection of multiple care settings and accessibility of medical records. For example, in the absence of HIE, it is necessary to connect with 30 per cent of the primary referral network; and if HIE is available, a connection is mandatory as per stage 3 recommendations.
While Stage 1 set the ground for EHR utilisation to capture data, Stage 2 initiates secure access to patients via PHR and other mediums. Stage 2 requires providers to transmit care summaries to referral centres and other EHR-technology-enabled care providers. It is also required to enable patients to view, download and update their historical and critical information by using web-based technology.
By 2015 or 2016, the meaningful use standards are expected to include and address the following outcome objectives:
- Offer patient-specific educational resources online
- Allow all patients access to their medical records — using PHR population in real time with data from EHR
- Enable the use of self-management tools to outpatients
- Make online web-based patient experience reporting and analysis available
- Offer ability to upload and incorporate patient-generated data (e.g., electronically collected patient survey data, biometric home monitoring data and patient suggestions of corrections to errors in the record) into EHRs and clinician workflow
A more in-depth look at the stage 3 requirements shows a large focus on data connectivity, online medical information availability, clinical data accessibility to patients and transmission of clinical and public health information using different mediums. The requirements also show more and more involvement of patients via different channels such as self-management tools. Stage 2 and stage 3 have shown that the value of HIE is controlled, interoperable and structured data. Patient involvement is also an important criterion that calls for complete medical records data. HIE will remain an important path for every EHR technology adopter.
The real aim of HIE is not only mobilising the data collected by using EHR technology but making health information more accessible in all steps of the medical process. An HIE does much more than just sharing data with providers using EHR technology.
Health information exchange should:
- Create a health-informed community
- Increase patient communication with care providers and education
- Ensure smooth transition of health data to other healthcare facilities without data loss
- Help create nationwide healthcare strategies
- Assist care providers in making better clinical decisions with clinical decision support (CDS) tools
- Analyse data for informed decisions and alerts
- Play a pivotal role in qualitative patient outcomes
Conclusion
EHs, EPs and CAHs need to use patient-centric technology tools — beyond EHR technology — to realise the CMS- and ONC-driven objectives. It’s a daunting task to combine MU requirements with HIE objectives at the national, state and enterprise level, yet the initial efforts have yielded promising results. Establishing HIE will ensure better quality of care when patients need it the most. The need to begin preparing for better quality healthcare is clear.
References:
1. http://www.hhs.gov/news/press/2013pres/05/20130522a.html
2. http://www.hhs.gov/budget/fy2014/fy-2014-budget-in-brief.pdf
3. Reforming hospitals with IT investment Laflamme FM, Pietraszek WE, Rajadhyax NV.McKinsey Quarterly. 2010 Aug.
4. Garg, Amit, et al. Effects of computerised clinical decision support systems on practitioner performance and patient outcomes: a systematic review. The Journal of the American Medical Association. 2005 Mar 9; 293(10):1223-1238.
5. HIMSS Information Exchange 2009
6. http://www.healthit.gov/sites/default/files/draft_stage3_rfc_07_nov_12.pdf
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