The Electronic Health Record:

Using It Effectively & with Meaning

May 7, 2016

Christopher W. Shanahan MD MPH FACPAssistant Professor of Medicine

Boston University School of MedicineBoston Medical Center

1Disclosure: 6/27/2014 CareFusion Corporation Unrestricted Research Grant

Learning Objectives

1. Understand the purpose Meaningful Use (MU)2. Understand progress of MU so far3. Review the basic components of MU4. Understand changes to MU in 20165. Understand usability as key to safe & effective EHR use6. Understand strategies to use EHR more effectively

Office of the National Coordinator for

Health Information Technology (ONC)

• Create Health IT Policy & Standards Committees• Standards, implementation specifications, & certification criteria for electronic exchange & use of

health information• Create Health IT Standards, Certification criteria & Interoperability

• Establish processes for standardized evaluation, adoption & implementation• Establish processes for certification criteria for health IT.

• Create Health IT & Quality Reports• Perform Testing of Health IT Standards• Provide Grants, Loans, & Demonstration Programs for Health IT• Develop Standards for eHealth Privacy & Security• Collaborate with CMS on Medicare & Medicaid EHR Incentive Programs

Authorized by HITECH Act (part of American Recovery & Reinvestment Act of 2009) to:

Purpose of Meaningful Use (MU)Use certified electronic health record technology (CEHRT) to:

• Improve quality, safety, efficiency, & reduce health disparities• Engage patients & family• Improve care coordination• Improve population & public health• Maintain privacy & security of patient health info

Ultimately, MU compliance should lead to:• Better clinical outcomes• Improved population health outcomes• Increased transparency & efficiency• Empowered individuals• More robust research data on health system

Certification Programs• 2010, ONC HIT Certification Program oversees certification &

testing of EHR products.• ONC-Authorized Certification Bodies & Accredited Testing

Laboratories certify & test EHR products. • ONC then adds certified EHR technology (CEHRT) to the

Certified Health IT Product List (CHPL), the authoritative, comprehensive listing of certified EHRs & EHR Module(s).

• EPs & EHs use CHPL to identify their CEHRT & generate a matching CMS EHR Certification ID for MU attestation process.

Source HealthIT.gov Dashboard

Percent of Physicians that have Demonstrated MU of Certified Health IT | 2015

56% of Physicians have demonstrated MU of Certified Health IT

Physician eRx through using an EHR 2008-2014

Source: ONC

% of Physicians

Receipt of Incentives for Adopting EHRs

Source HealthIT.gov Dashboard

Effects of MU Functionalities on Health Care Quality, safety & Efficiency, by Study Outcome Result (% of Studies)

Source HealthIT.gov Dashboard

We’ve come a long way…

Meaningful Use (MU)•MU is the core of the EHR Incentive Payment Programs

•Three Stages of MU:•Stage 1: Data Capture & Information Sharing•Stage 2: Advanced Clinical Processes•Stage 3: Improved Outcomes

Improving Clinical Outcomes & Proving It•Pick a CEHRT

•Register with the EHR Incentive Program• 2016 is last year that an EP can begin participation.• Incentive payments under the Medicaid EHR

Incentive Payments: Up to $63,750 over 6 years.•Attest to Meaningful Use•Get Incentive Pay or be Penalized

Pick Certified EHR Technology (CEHRT)

• CCHIT mapped latest proposed requirements Comprehensive Certification• Providers must use a a2014 Certified EHR

Pick a Complete Certified EHR Technology (CEHRT)

Register with the EHR Incentive Program

Ready, Set, ……Attest

Attestation• Attestation Information• MU Core Measures• Clinical Quality Measures

Changes to MU in 20163/30/2015:

CMS Stage 3 Proposed Rule. (Proposed objectives for Stage 3 MU)

4/9/2015CMS EHR Incentives Programs in 2105 through 2017 Proposed Rule (Outlined proposed modification of Stage 1 & Stage 2 MU Objectives, reporting periods, & timelines to better align with Stage 3)

4/16/2015MACRA (Medicare Access & CHIP Reauthorization Act of 2015) • Sunset MU Payment objectives of EP at the end of CY 2018• Add Merit-based Incentives Payment System (MIPS) incorporates MUMACRA EHR Incentives Programs continue Medicare Payment Adjustment of EPs to end of CY 2019.

Goals & Priorities of Modified Stage 2

• Align with Stage 3 to achieve overall goals of programs 1• Synchronize reporting period objectives & measures

to reduce burden2• Continue to support advanced use of health IT to

improve outcomes for patients3

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2016 Program Requirements

10/15/2015•Final Rule Released

Modified Stage 2 (2015 to 2017)• Stage 3 (2018 & beyond)

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“The Meaningful Use program as it has existed, will now be effectively over &

replaced with something better.” 1/11/16 Andy Slavitt CMS Acting

Commissioner• Focus will move away from the use of technology & towards patient’s outcome

• Providers will be able to customize their goals

• Interoperability• Leveling technology

playing field by requiring open application program interfaces (APIs)

Medicare vs. Medicaid EHR Incentive Payment Program

Medicare EHR Incentive Payment Program

Medicaid EHR Incentive Payment Program

Last year to initiate participation to receive an incentive payment was 2014

Last year to initiate participation is 2016.EPs can receive up to $63,750 in incentive payments

Medicare payment reductions began in 2015 for EPs who choose not to participate

No Medicaid payment reductions for EPs who choose not to participate. Medicare payment adjustments still apply

1st year & All remaining years EPs must meet MU objectives & measures

• Year 1, EPs can receive incentive payment for adopting, implementing or upgrading a CHERT.

• All remaining years, providers must meet same MU objectives required by Medicare EHR incentive program

Last Year of Program is 2016 Last year of program participation is 2021

Changes to MU (Stage 3 & EHR Incentives 2015-2017)• Streamlines program: Deletes redundant, duplicate & “Topped out” measures

• Performance high/unvarying: Improved performance can’t be discerned• Represent care standards that have been widely adopted• Decrease in # of Measures (↓ to 10)

• Simplification of Program Requirements• ↓ provider burden/create a single objectives set promote best practices• Focus on Medicare/Medicaid EHR Incentives or advances use of EHR Technology• Enable providers to focus objectives that support advanced use of Health IT, e.g.

• Health Information Exchange / Consumer engagement / Public health reporting• Increased Flexibility in certain requirements

• Revised Reporting Periods• Align Medicare/Medicaid to a single set of reporting requirements in 2018

• Option to participate starting in 2017 but required by 2018• Focus on Interoperability

CMS Proposed Rules – Changes to Objectives

1. Computerized Provider Order Entry (CPOE)

2. ePrescribing (eRx)3. Clinical Decision Support (CDS)4. Patient electronic access to their

health information (Patient Portal)5. Protect health information

(security Risk Analysis or SRA)6. Patient-specific education

resources

Combines Objectives Stage 1 & Stage 27. Medication Reconciliation8. Summary of Care record for

referrals & transitions of care9. Secure electronic messaging10. Public Health reporting

a. Immunization Registry reportingb. Syndromic surveillance reportingc. Case Reportingd. Public Health Registry Reportinge. Clinical data Registry Reporting

CMS Proposed Rules – Changes to Objectives

• Record Demographics• Record Vital Signs• Record Smoking status• Clinical summaries• Structure Lab results• Patient List

Objectives Eliminated Stage 1 & Stage 2• Patient reminders• Summary of Care

• Measure 1 – any method• Measure 3 - Test

• Electronic Notes• Imaging Results• Family Health History

Comparison of MU Stage 2 vs Modified 2 & 3 Measures

Stage 1/2 Modified Stage 2 & 3

13/17 Core

Higher Thresholds

5 of 9/

3 of 6 Menu

10 Core

2 of 3 Public Health Reporting

• Less Core measures• Public Health Reporting• Higher Thresholds

• “Topped out” Measures: • Performance so high & unvarying that meaningful

distinctions in improved performance can’t be made• Represent care standards have been widely adopted

• All providers must use 2014 certified EHR technology

• Providers may attest using 2015 certified technology EHR technology, or a combination of the two (if the 2015 Edition is available).

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1. Protect electronic protected health information in the CEHRT by implementing technical capabilities.• HIPAA (Security Risk Analysis, updates, other)

2. Use clinical decision support to improve performance on high-priority health conditions.• Implement five clinical decision measures for four or more CQMs at

a relevant point in patient care.• Enable & implement the functionality for drug-drug & drug-allergy

interaction check.

Modified Stage 2 EP Objectives & Measures 2016

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3. Use computerized provider order entry for medication, laboratory, & radiology by licensed healthcare professionals (All three required)

• > 60 % of medication orders • > 30 % of laboratory orders • > 30 % of radiology orders

4. Generate & transmit permissible Rx’s electronically (eRx).• > 50 % of all permissible prescriptions written by the EP are queried for

a drug formulary & transmitted electronically using CEHRT.

Modified Stage 2 EP Objectives & Measures 2016

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5. Health Information Exchange• Transition or referral of patients to another setting of care

or provider of care must: 1. Use CEHRT to create a summary of care record; & 2. Electronically transmit summary (10% or more).

6. Identify patient-specific education resources & provide those resources to the patient.• Provide education resources to patients for more than 10 %

of all unique patients with office visits

Modified Stage 2 EP Objectives & Measures 2016

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7. Medication Reconciliation• Performed for > 50 % of transitions of care (Hospital admit or ED visit)

8. Patient electronic access within 4 business days of the information being available to the EP.• Provide timely access to > 50 % of all unique patients seen during the

reporting period• 2016, at least 1 patient during EHR reporting period (or patient-

authorized rep.) views, downloads or transmits their health info to a 3rd party during EHR reporting period. 2016, at least 5%.

20151 patient

20161 patient

20175%*

* of all unique patients seen within an EHR reporting period

Modified Stage 2 EP Objectives & Measures 2016

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9. Secure electronic messaging communications.• At least 1 patient during the reporting period was sent a

message using the electronic messaging function of CEHRT• Phased approach for its measure’s threshold. • For 2016, “for 1+ patient seen during the reporting period, secure

message sent using electronic messaging function of CEHRT, or in response to a secure message sent by the patient.

10.Public Health Reporting - submit electronically• EPs must meet two of three following measures:

• Immunization Registry Reporting• Syndromic Surveillance Reporting• Specialized Registry Reporting

Modified Stage 2 EP Objectives & Measures 2016

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EHR Modified EP Stage 2 Reporting• 2016: Returning participants

• Full calendar year (Jan 1, 2016 through Dec 31, 2016).• For 1st year participants: Any continuous 90-day period.

• 2017: All EPs required to attest using full calendar year• Exception: Medicaid participants attesting to MU for first

time (90 period only required)

• Providers may continue to use 2014 Edition Certified EHR Technology to attest to meaningful use until 2018.

Source: CMS Webinar 5/7/15

CMS Final Rule: Changes to Timeline

2015• Attest to modified version of stage 2 with

accommodations for Stage 1 providers

2016• Attest to modified version of stage 2

2017• Attest to ether modified version of Stage 2 or Full

version of Stage 3

2018• Attest to Full version of Stage 3

Source: CMS Webinar 5/7/15

Stage of Meaningful Use Criteria by First Year

First Year Demonstrating Meaningful Use

Stage of Meaningful Use

2015 2016 2017 2018 2019 +

2011 Modified 2 Modified 2 Modified 2 or 3 3 3

2012 Modified 2 Modified 2 Modified 2 or 3 3 3

2013 Modified 2 Modified 2 Modified 2 or 3 3 3

2014 Modified 2 Modified 2 Modified 2 or 3 3 3

2015 Modified 2 Modified 2 Modified 2 or 3 3 3

2016 NA Modified 2 Modified 2 or 3 3 3

2017 NA NA Modified 2 or 3 3 3

2018 NA NA NA 3 32019 + NA NA NA NA 3

Objectives for Stage 3: 2017 & BeyondObjective Detail

1. Protect Electronic Patient Health Information (ePHI) a. A security risk analysis must be conducted, including addressing the security (including encryption) of data created or maintained by the CEHRTb. Security updates must be implemented as necessaryc. Identified security deficiencies must be corrected as part of the provider’s risk management process

2. Electronic Prescribing: Generate & Transmit Permissible Prescriptions Electronically (eRx)

a. For Providers: more than 60 percent of prescriptions must be transmitted electronically using CEHRTb. For Hospitals/CAHs: More than 25 percent of hospital discharge medication orders must be transmitted electronically

3. Implement Clinical Decision Support (CDS) Interventions for High-Priority Health Conditions

a. 5 CDS interventions related to 4 or more CQMs must be used at a relevant point in careb. Drug-drug & drug-allergy interaction checks must be enabled & implemented

4. Use Computerized Provider Order Entry (CPOE) for Medication, Laboratory, & Diagnostic Imaging OrdersCPOE must be used for:

a. More than 60 percent of medication ordersb. More than 60 percent of laboratory ordersc. More than 60 percent of diagnostic imaging orders

5. Provide Patient with Timely Electronic Access to Health Information & Patient Specific Education Materials

a. More than 80 percent of all unique patients seen or discharged:i.  Must be provided timely access to view online, download, & transmit his or her health information; &ii. The provider must ensure the patient’s health information is available for the patient to access using any application of their choice that is configured to interact with the provider’s CEHRT

b. use information from CEHRT to identify patient-specific educational resources & provide electronic access to those materials to more than 35 percent of unique patients

6. Patient Engagement & Coordination of Care: Use CEHRT to Engage with Patients or their Authorized Representatives for Improved Coordination of Care

a. More than 10 percent of all unique patients (or their authorized representative) must actively engage with the EHR & either:i. View, download, or transmit to a third party their health information; orii. Access their health information through the use of an application in the provider’s CEHRT; oriii. A combination of (i) & (ii)

b. More than 25 percent of all unique patients must receive an electronic message using the CEHRT Patient generated health data or data from a nonclinical setting must be incorporated into the CEHRT for more than 5 percent of all unique patients

7. Health Information Exchange (HIE): A Summary of Care Record is Provided when Transitioning or Referring a Patient to Another Setting of Care & Incorporates Summary of Care Information from Other Providers into their EHR Using the Functions of CEHRT

a. For > 50 percent of transitions & referrals, the provider that transitions or refers their patient must create a summary of record using CEHRT & electronically transmit the recordb. For > 40 percent of transitions received & new patients, the provider must incorporate into the patient’s EHR an electronic summary of care documentc. For > 80 percent of transitions or referrals received & new patients, the provider must perform a clinical information reconciliation for medication, medication allergies, & a current problem list

8. Public Health & Clinical Data Registry Reporting a. Immunization data; b. Syndromic surveillance data; c. Electronic case reporting; d. Public health registry reports; e. Clinical data registry reports; f. Electronic reportable laboratory result reports 

Stage 3 Final ruleSpecifies MU criteria that EPs must meet to qualify for EHR incentive payments & avoid downward payment adjustments. • Encourages electronic submission of CQMs in 2017• Requires electronic submission of CQMs in 2018• Transitions program to a single stage meaningful use• Changes EHR reporting period to a full calendar year timeline

limited exception: Medicaid EHR Incentive Program for EPs demonstrating first time meaningful use)

Broad effort to increase simplicity & flexibility in the program while driving interoperability & a focus on patient outcomes.

Key Stage 3 Requirements• All physicians must participate in Stage 3 beginning in 2018 or they face a

penalty, regardless of whether have achieved Stage 1 & Stage 2.• Physicians can choose to begin Stage 3 early in 2017

• if so only have to attest to a 90-day reporting period – Not a full year.

• Physicians must meet eight objectives to succeed, five of which rely on interoperability.

• In 2018, providers must upgrade to using 2015 Edition Certified EHR Technology to attest to meaningful use.

• Allow the use of application programming interfaces (APIs) to support patients’ ability to access their health information in more flexible ways than just a patient portal of the EHR, including via mobile devices.

Bait & Switch

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Medicare Access & CHIP Reauthorization Act of 2015 (MACRA)

• Repeals • Sustainable growth rate (SGR) methodology for updates to

Medicare physician fee schedule.• Creates

• Annual positive or flat fee updates for 10 years & institutes a 2-track fee update in 2019.

• Merit-based Incentive Payment System (MIPS) consolidating existing Medicare quality programs.

• Pathway for physicians to participate in an Alternative Payment Model (APM).

MU / Incentives / MACRA & Beyond

MACRA (Merit-Based Incentive Payment System (MIPS) & Alternative Payment Models (APMs) , et.al.)

Pay for Performanc

e

No incentives

MU IncentivesIncentives

(First)

Penalties (Second)

MUEHR Standards Defined Use

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MACRA Timeline (MU)

Payment Adjustments aka Penalties• If MU not met then downward adjustments

• Non-participation (Not Adopting a CEHRT) → reimbursement penalties• Failure to attest: 1% to 2% penalty on 2014 Part B reimbursements, ↑ 1% q year • By 2018 if < 75% of eligible providers are meaningful users penalty continues to increase • July 1, 2016 deadline to file 2015 hardship to avoid 2017 penalty. Hardship Exceptions• Insufficient internet connectivity• Extreme and uncontrollable circumstances• Lack of control over the availability of certified EHR technology• No face-to-face patient interactionAutomatic Hardship exception (No need to submit)• New physicians to the profession in their first year• Hospital-based Physicians: More than 90% of practice inpatient or hospital ED.• Anesthesiology, Pathology, Radiology

2015 2016 2017 2019Penalty 1% 2% 3% 5%

Pick a Plan: Medicare or Medicaid?Medicare EHR Incentive

Program Medicaid EHR Incentive ProgramRun CMS MassHealth Max. incentive amount $44,000 $63,750

Payments over 5 consecutive years 6 years, does not have to be consecutive

Payment adjustmentsBegins 2015 for eligible

providers but decide not to participate

None for providers only eligible for Medicaid program

To receive incentive payments, providers must demonstrate MU

every year• First year: incentive payment for

adopting, implementing, or upgrading EHR technology.

• Subsequent Years: every year.

Payment Calendars

Medicaid incentive qualification must start by 2015 No payments beyond 2021

2011 2012 2013 2014 2015 2016 Total

2011 $18,000 $12,000 $8,000 $4,000 $2,000 $0 $44,000

2012 $18,000 $12,000 $8,000 $4,000 $2,000 $44,000

2013 $15,000 $12,000 $8,000 $4,000 $39,000

2014 $12,000 $8,000 $4,000 $24,000

2015+ $0*

Firs

t Att

esta

tion

Year

Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Total$21,250 $8,500 $8,500 $8,500 $8,500 $8,500 $63,750

Med

icai

dM

edic

are

MU is Complicated

Get Help

Massachusetts eHealth Institute (MeHI)

Usability

Is your system usable?

What would it take to make it usable?

Does the EHR affect your practice?

What about the EHR’s usability?

Usability & Effective Use

“Houston, we have problem…”

Physicians Negative Perceptions of EHR MU

• Physicians preparing for incentive program qualification (N=1,797)

• 23% Agreed MU will help improve care they provide.

• 27% Agreed MU will help improve quality of care. • Outpatient EHR Satisfaction significantly associated

with all belief items.• Findings similar negative perceptions physicians

hold EHR impact found in the literature. PCPs

Medical S

pecialist

s

Surgica

l Specia

lists

35%

26%

21%

% Agree MU will improve quality of care

Is Anybody Addressing This!?!?

AMIA Recommendations

1. Usability & human factors research agenda in health IT• Standardized use cases / Develop measures for adverse events associated with health IT use• Research/promote safe EHR implementation

2. Policy recommendations (for Federal policy initiatives)• Standardization & interoperability across EHR systems (usability)• Adverse event reporting system for health IT with voluntary reporting• Educational campaign on the safe & effective use of EHR

3. Industry recommendations• Common user interface style guide for select EHR functionalities• Formal usability assessments on patient-safety sensitive EHR functionalities

4. Clinical end-user recommendations• Adopt best practices for EHR system implementation & ongoing management• Monitor how IT systems are used & report IT-related adverse events

• Evidence: Some health IT a/w adverse events & medical errors – a/w usability. • Critical: Coordinate/accelerate EHR usability efforts. • Recommend: Focus on usability adversely affecting safety & quality of care.

HIT Usability linked to optimal healthcare practice

• AMIA Task Force on Usability: • Safe & effective use of EHR • EHR usability• EHR usability-associated medical errors

• Recommend: • Analysis & development for EHR implementation Best practices essential to safety & effectiveness. 

• Understanding user behavioral models is important to achieving effective use.

The AMA is backing physicians’ concerns that the current electronic medical records options are not user friendly & get in the way of patient care. AMA president-elect Steven J. Stack, MD, told the Journal that current EMR technology “is not supporting the quality of care we need it to.” Dr. Stack criticized the Federal Meaningful User program, managed by HHS, & its requirements for the issues doctors have with EMR technology.

AMA: Improving Care: Priorities to Improve EHR Usability

EHR should…

• Fit seamlessly into practice / Not distract physicians from patients. • Allow physicians to dynamically allocate & delegate work to care team

members. • Track referral & consultation automatically ensuring ability to follow

patient’s progress/activity throughout care.• Support medical-decision making: Provide concise, context sensitive &

real-time data uncluttered by extraneous info. • Manage information flow adjusted for context, environment & user

preferences.• Expedite user input into product design & feedback in EHR.

The ProblemA model for analysis & understanding of use-related risks of EHR systems.

SZ. Lowry, et.al. Technical Evaluation, Testing, & Validation of the Usability of Electronic Health Records (NISTIR 7804) Feb 2012 U.S. Dept. Commerce, National Instit. of Stds & Technology (NIST)

Four Main ComponentsUse Error Root Causes

Aspects of user interface design that induce use errors when interacting with the system.

Risk Parameters Attributes regarding particular use errors (severity, frequency, ability to be detected, & complexity).

Evaluative Indicators Indications that users are having problems with the system. Identified through direct observations of system in use in situ or user interviews.

Adverse Events Description of outcomes of use error & standard classification of patient harm.

 How did this happen?• Implementation pressure drives Vendors to invest little

time/effort in user-oriented design & enhancement.• First Gen EHRs don’t support efficient & effective clinical

work of clinicians → Slow EHR adoption & effective use.• EHR design/implementation remain not aligned w/

cognitive/workflow of providers across specialties & settings.

Despite poor tools…..

EHR adoption ↑ ↑ d/t Incentive pressures

 EHR Vendors don’t see a problem• User-centered health information technology design & development

• Variable effectiveness & not adopted by all EHR Vendors• Difficult to apply to legacy systems

• AHRQ Health IT usability workshop (July 2010)• Vendors say usability important & a competitive differentiator• But some believe usability:

• was in the eye of the beholder • evaluation is an imperfect science without useful results

• Vendors• Usability for certification: Hesitant until truly valid measures available. • Claim motivated to build/implement EHR to improve patient safety &

quality of care, yet current software practices highly variable. • Some feel difficult or impossible to compare products based on usability

User Interface (UI) Design: Make mine great!• Guides developers / provides basis to evaluate existing designs.

• User should • Easily be able to view system status. • Have control & freedom.• Be able to recognize rather than recall.

• System should • Match the real world.• Maintain consistency & standards.• Prevent errors.• Support flexible & efficient use.• Have aesthetic & minimalist design.• Have help & documentation.• System Help: enables users to recognize, diagnose, & recover from errors.

Make it usable for You

“You're either part of the solution or you're part of the

problem.” - Eldridge Cleaver

Don’t be part of the Problem:

• Really Learn your system• Play, Play, Play: Try things out• Ask lots of questions• Something starting to feel redundant?

• “Is there a faster / more efficient way to do this?” • Can’t figure it out: Ask someone who can.• Copy others:

• Watch / Ask others what they do • Adopt their templates, etc.

• Cultivate positive relationship with IT staff • Report Problems (BIG & small)• Develop a Dialogue with EHR Leadership / Join EHR Committees

Make it usable for you and your team / practice / etc.)