2009 HIMSS Analytics Mapping EMRAM and the Ambulatory EMR Adoption Model to Meaningful Use Criteria September 9, 2009 Mike Davis.

2009 HIMSS Analytics

Mapping EMRAM and the Ambulatory EMR Adoption Model

to Meaningful Use CriteriaSeptember 9, 2009

Mike Davis


Overview

• The majority of “meaningful use” functions identified to this point in time for 2011measures require Stage 4 of the EMR Adoption ModelSM (EMRAM) and Stage 3 of the Ambulatory EMR Model.

• HIMSS Analytics believes that Stage 3 of the EMRAM and ambulatory EMR model should be focused on as a minimum for meeting the majority of 2011 measures for hospitals.

• HIMSS Analytics believes that Stage 6 of the EMRAM and Stage 4 of the ambulatory EMR model should be accomplished by hospitals and clinics to meet the majority of the 2013 measures.

• HIMSS Analytics believes that Stage 6 and higher for the EMRAM and Stage 5 of the ambulatory EMR model will need to be implemented by hospitals and clinics to address the 2015 measures.

• HIMSS Analytics believes that nursing applications (Stage 3 - flow sheets, care plans, and eMAR) should be implemented before CPOE in hospitals.


Health Outcomes Policy Priority• Improve quality, safety, efficiency, and reduce health disparities :

– Provide access to comprehensive patient health data for patient’s healthcare team

– Use evidence-based order sets and CPOE– Apply clinical decision support at the point of care– Generate lists of patients who need care and use them to reach out to patients

(e.g., reminders, care instructions, etc)– Report to patient registries for quality improvement, public reporting, etc

• Engage Patients and Families– Provide patients and families with timely access to data, knowledge, and tools to

make informed decisions and to manage their health • Improve Care Coordination

– Exchange meaningful information among professional healthcare teams• Improve Population and Public Health

– Communicate with public health agencies• Ensure Adequate Privacy and Security Protection for Personal Health Information

– Ensure privacy and security protection for confidential information through operating policies, procedures, technologies, and compliance with applicable law

– Provide transparency of data sharing to patient


Improve Quality, Safety, Efficiency, and Reduce Health Disparities

2011 Objectives Goal is to electronically capture in coded format and to report health information and to use that information to track key clinical conditions:

• Providers– Use CPOE for all order types including medications [OP, IP]

(Ambulatory EMR Stage 2)– Implement drug-drug, drug-allergy, drug-formulary checks [OP, IP]

(Ambulatory EMR Stage 3)– Maintain an up-to-date problem list of current and active diagnoses

based on ICD-9 or SNOMED [OP, IP] (Ambulatory EMR Stage 3)– Generate and transmit permissible prescriptions electronically (eRx)

[OP] (Ambulatory EMR Stage 3)– Maintain active medication/allergy list [OP, IP] (Ambulatory EMR Stage

3)




• Providers– Record demographics; primary language, insurance type, gender, race,

ethnicity [OP, IP] (Ambulatory EMR Stage 3)– Record advance directives (Ambulatory EMRAM Stage 3)– Record vital signs including height, weight, blood pressure [OP, IP]

(Ambulatory EMR Stage 3)– Record smoking status (Ambulatory EMR Stage 3)– Incorporate lab test data into EHR as structured data (Ambulatory EMR

Stage 3)– Generate lists of patients by specific conditions to use for quality

disparities, and outreach (Ambulatory EMR Stage 3)– Report ambulatory quality measures to CMS (Ambulatory EMR Stage 4)




• Providers– Send reminders to patients per patient preference for preventive/ follow

up care (Ambulatory EMR Stage 3)– Implement one clinical decision rule relevant to specialty or high priority

care (Ambulatory EMR Stage 3)– Document a progress note for each encounter (Ambulatory EMR Stage

3)– Check insurance eligibility electronically from public and private payers,

where possible (Ambulatory Practice Management)– Submit claims electronically to public and private payers (Ambulatory

Practice Management)


Engage Patients and Families


• Providers– Provide patients with an electronic copy of their e-health information

(including lab results, problem lists, medication lists, allergies, discharge summary, procedures) upon request (Ambulatory EMR Stage 3)

– Provide patients with timely electronic access to their health information (including lab results, problem lists, medication lists, allergies); (Ambulatory EMRAM Stage 3)

– Provide access to patient specific education resources (Ambulatory EMR Stage3)

– Provide clinical summaries for patients for each encounter (Ambulatory EMR Stage 3)


Improve Care Coordination


• Providers– Capability to exchange key clinical information (e.g. problem list,

medication list, allergies, test results) among providers of care and patient-authorized entities electronically (Ambulatory EMR Stage 4)

– Perform medication reconciliation at relevant encounters and each transition of care (Ambulatory EMR Stage 3)


Improve Population and Public Health


• Providers– Capability to submit electronic data to immunization registries

and actual submission where required and accepted (Ambulatory EMR Stage 3)

– Capability to provide electronic syndromic surveillance data to public health agencies and actual transmission according to applicable law and practice (Ambulatory EMR Stage 4)


Ensure Adequate Privacy and Security Protection for Personal Health Information2011 Objectives Goal is to electronically capture in

coded format and to report health information and to use that information to track key clinical conditions:

• Providers– Compliance with HIPAA privacy and security laws (All

Ambulatory EMR Stages)– Compliance with fair data sharing practices set forth in the

National Privacy and Security Framework (Ambulatory EMR Stage 3)




• Hospitals– 10 percent of all orders (any type) entered by authorizing provider (e.g.

MD, DO, RN, PA, NP) through CPOE (EMRAM Stage 3 for RN, PA, NP; Stage 4 for MD, DO)

– Implement drug-drug, drug-allergy, drug-formulary checks [OP, IP] (EMRAM Stage 1, 3, and 4)

– Maintain an up-to-date problem list of current and active diagnosis based on ICD-9 or SNOMED [OP, IP] (EMRAM Stage 3 and 6)

– Maintain active medication list [OP, IP] (EMRAM Stage 1 and 3) – Maintain an active allergy list (EMRAM Stage 1 and 3)– Record demographics; primary language, insurance type, gender, race,

ethnicity [OP, IP] (EMRAM Stage 2)




• Hospitals– Record advance directives (EMRAM Stage 3)– Record vital signs including height, weight, blood pressure; calculate

and display BMI [OP, IP] (EMRAM Stage 3)– Record smoking status (EMRAM Stage 3)– Incorporate lab test data into EHR as structured data (EMRAM Stage 2)– Generate lists of patients by specific conditions (EMRAM Stage 3)– Report hospital quality measures to CMS (EMRAM Stage 3)– Implement one clinical decision rule relevant to specialty or high priority

care (EMRAM Stage 3)




• Hospitals– Check insurance eligibility electronically from public and private

payers, where possible (Patient Access function)– Submit claims electronically to public and private payers

(Revenue Cycle Management function)




• Hospitals– Provide patients with an electronic copy of their e-health information

(including lab results, problem lists, medication lists, allergies, discharge summary, procedures) upon request (EMRAM Stage 3)

– Provide patients with an electronic copy of their discharge instructions and procedures at time of discharge, upon request (EMRAM Stage 3)

– Provide access to patient specific education resources (EMRAM Stage 3)




• Hospitals– Capability to electronically exchange key clinical information

(e.g. problem list, medication list, allergies, test results) among providers of care and patient authorized entities (EMRAM Stage 3)

– Perform medication reconciliation at relevant encounters and each transition of care (EMRAM Stage 3)




• Hospitals– Capability to submit electronic data to immunization registries and actual

submission where required and accepted (EMRAM Stage 3)– Capability to provide electronic submission of reportable lab results to

public health agencies and actual submission where it can be received (EMRAM Stage 1)

– Capability to provide electronic syndromic surveillance data to public health agencies and actual transmission according to applicable law and practice (EMRAM Stage 3)


Ensure Adequate Privacy and Security Protection for Personal Health Information


• Hospitals– Compliance with HIPAA privacy and security laws (All EMRAM

Stages)– Compliance with fair data sharing practices set forth in the

National Privacy and Security Framework (EMRAM Stage 2)



2011 Measures: – Report quality measures, including:

• Percent diabetics with A1c under control [EP] • Percent hypertensive patients with BP under control [EP] • Percent of patients with LDL under control [EP] • Percent of smokers offered smoking cessation counseling [EP, IP]

(EMRAM Stages 3 and 6; Ambulatory EMR Stage 4 for all of the above)

– Percent of patients with recorded BMI [EP] (EMRAM Stage 3; Ambulatory EMR Stage 3)

– Percent eligible surgical patients who received VTE prophylaxis [IP] (EMRAM Stage 3)

– Percent of orders (for medications, lab tests, procedures, radiology, and referrals) entered directly by physicians using CPOE (EMRAM Stage 4; Ambulatory EMRAM Stage 3)

– Use of high-risk medications (Beer’s criteria) in the elderly (EMRAM Stage 1, 3, and 4; Ambulatory EMRAM Stage 3)

– Percent of patients over 50 with annual colorectal cancer screenings [EP] (EMRAM Stage 3; Ambulatory EMR Stage 3)



2011 Measures:– Percent of females over 50 receiving annual mammogram [EP] (EMRAM Stage

3; Ambulatory EMR Stage 3)– Percent of patients at high-risk for cardiac events on aspirin prophylaxis [EP]

(EMRAM Stage 1 and 3; Ambulatory EMR Stage 4)– Percent of patients who received flu vaccine [EP] (EMRAM Stage 1 and Stage 3;

Ambulatory EMR Stage 3)– Percent of lab results incorporated into the EHR in coded format [EP, IP]

(EMRAM Stage 2; Ambulatory EMR Stage 3)– Stratify reports by gender, insurance type, primary language, race ethnicity [EP,

IP] (EMRAM Stage 3, Ambulatory EMR Stage 3)– Percent of all medications entered into EHR as generic, when generic options

exist in the relevant drug class [EP, IP] (EMRAM stage 1, 3 and 4; Ambulatory EMR Stage 3)

– Percent of orders for high-cost imaging services with specific structured indications recorded [EP, IP] (EMRAM Stage 1, 3, and 4; Ambulatory EMRAM Stage 3)

– Percent claims submitted electronically to all payers [EP, IP] (RCM functions)– Percent patient encounters with insurance eligibility confirmed [EP, IP] (RCM

and PM functions)



2011 Measures:– Percent of all patients with access to personal health

information electronically [EP, IP] (EMRAM Stage 2; Ambulatory EMR Stage 4)

– Percent of all patients with access to patient specific educational resources [EP, IP] (EMRAM Stage 3; Ambulatory EMR Stage 3)

– Percent of encounters for which clinical summaries were provided [EP] (Ambulatory EMR Stage 3)



2011 Measures:– Report 30 day readmission rate [IP] (Patient Access

Management)– Percent of encounters where med reconciliation was performed

[EP, IP] (EMRAM Stage 3; Ambulatory EMR Stage 3)– Implemented ability to exchange health information with external

clinical entity (specifically lab, care summary and medication lists [EP, IP] (EMRAM Stage 3; Ambulatory EMR Stage 3)

– Percent of transitions of care for which summary care record is shared (e.g. electronic paper, e-FAX) [EP, IP] (EMRAM Stage 3; Ambulatory EMR Stage 3)



2011 Measures:– Report up-to-date status for childhood immunizations

[EP] (Ambulatory EMR Stage 3)– Percent of reportable lab results submitted

electronically [IP] (EMRAM Stage 2)



2011 Measures:– Full compliance with HIPAA privacy and security laws

(All Stages)– Conduct or update a security risk assessment and

implement security updates as necessary (All Stages)



2013 Objectives Goal is to electronically capture in coded format and to report health information and to use that information to track key clinical conditionsProviders– Use CPOE for all orders (Ambulatory EMR Stage 3)– Use evidence-based order sets [OP, IP] (Ambulatory EMR Stage 4)– Manage chronic conditions using patient lists and decision support [OP,

IP] (Ambulatory EMR Stage 3)– Provide clinical decision support at the point of care (e.g., reminders,

alerts) [OP, IP] (Ambulatory EMR Stage 3)– Specialists report to relevant external disease (e.g., cardiology, thoracic

surgery, cancer) or device registries approved by CMS (Ambulatory EMR Stage 4)



2013 Objectives Goal is to electronically capture in coded format and to report health information and to use that information to track key clinical conditionsProviders– Access for all patients to PHR populated real time with health data

(Ambulatory EMR Stage 4)– Offer secure patient-provider message capability (Ambulatory EMR

Stage 4)– Provide access to patient-specific educational resources in common

primary languages (Ambulatory EMR Stage 3)– Record patient preferences (e.g. preferred communication media,

advance directive, healthcare proxies, treatment options) (Ambulatory EMR Stage 3)

– Document family medical history in compliance with GINA (Ambulatory EMR Stage 4)

– Upload data from home monitoring device (Ambulatory EMR Stage 4)



2013 Objectives Goal is to electronically capture in coded format and to report health information and to use that information to track key clinical conditionsProviders– Retrieve and act on electronic prescription fill data (Ambulatory

EMR Stage 3)– Produce and share an electronic summary care record for every

transition of care (place of service, consults, discharge) (Ambulatory EMR Stage 4)

– Perform medication reconciliation at each transition of care from healthcare setting to another (Ambulatory EMR Stage 3)



2013 Objectives Goal is to electronically capture in coded format and to report health information and to use that information to track key clinical conditionsProviders– Receive immunization histories and recommendations from

immunization registries (Ambulatory EMR Stage 4)– Receive health alerts from public health agencies (Ambulatory EMR

Stage 4)– Provide sufficiently anonymized electronic syndrome surveillance data

to public health agencies with capacity to link to personal identifiers (Ambulatory EMR Stage 4)



2013 Objectives Goal is to electronically capture in coded format and to report health information and to use that information to track key clinical conditionsProviders– Use summarized or de-identified data when reporting data for

population health purposes (e.g. public health, quality reporting, and research), where appropriate, so that important information is available with minimal privacy risk (Ambulatory EMR Stage 4)



2013 Objectives Goal is to electronically capture in coded format and to report health information and to use that information to track key clinical conditionsHospitals– Use CPOE for all orders (EMRAM Stage 4)– Use evidence-based order sets (EMRAM Stage 4)– Record clinical documentation in EHR (EMRAM Stages 3 and 6)– Generate and transmit permissible prescriptions electronically (EMRAM

Stage 4)– Manage chronic conditions using patient lists and decision support

(EMRAM Stage 3 and Stage 6)– Provide clinical decision support at the point of care (e.g., reminders,

alerts) (EMRAM Stage 3, 5, and 6)– Specialists report to relevant external disease (e.g. cardiology, thoracic

surgery, cancer) or device registries (EMRAM Stage 6)– Conduct closed loop medication administration management, including

eMAR and computer-assisted administration (EMRAM Stage 5)



2013 Objectives Goal is to electronically capture in coded format and to report health information and to use that information to track key clinical conditionsHospitals– Access for all patients to PHR populated real time with health data

(EMRAM Stage 2 and higher)– Provide access to patient-specific educational resources in common

primary languages (EMRAM Stage 3)– Record patient preferences (e.g. preferred communication media,

advance directive, healthcare proxies, treatment options) (EMRAM Stage 3)

– Document family medical history in compliance with GINA (EMRAM Stage 6)



2013 Objectives Goal is to electronically capture in coded format and to report health information and to use that information to track key clinical conditionsHospitals– Retrieve and act on electronic prescription fill data (EMRAM

Stage 4)– Produce and share an electronic summary care record for every

transition in care (place of service, consults, discharge) (EMRAM Stage 3 and 6)

– Perform medication reconciliation at each transition of care from one healthcare setting to another (EMRAM Stage 3)



2013 Objectives Goal is to electronically capture in coded format and to report health information and to use that information to track key clinical conditionsHospitals– Receive immunization histories and recommendations from

immunization registries (EMRAM Stage 3)– Receive health alerts from public health agencies (EMRAM Stage 2 and

higher)– Provide sufficiently anonymized electronic syndrome surveillance data

to public health agencies with capacity to link to personal identifiers (EMRAM Stage 3 and higher)



2013 Objectives Goal is to electronically capture in coded format and to report health information and to use that information to track key clinical conditionsHospitals– Nothing noted



2013 Measures: – Additional quality reports using HIT-enabled NQF-endorsed quality

measures [EP, IP] (EMRAM Stage 3 and higher; Ambulatory EMR Stage 4)

– Percent of all orders entered by physicians through CPOE [EP, IP] (EMRAM Stage 4; Ambulatory EMR Stage 3)

– Potentially preventable Emergency Department Visits and Hospitalizations [IP] (Ideally accomplished with business intelligence and/or a clinical data warehouse that can be effectively implemented at Stage 3 or higher)

– Inappropriate use of imaging (e.g. MRI for acute low back pain) [EP, IP] (Ideally accomplished with business intelligence and/or a clinical data warehouse that can be effectively implemented at Stage 3 or higher)

– Other efficiency measure (TBD) [EP, IP]



2013 Measures:– Percent of patients with full access to PHR populated in real time with

EHR data [OP, IP] (EMRAM Stage 2 and higher; Ambulatory EMR Stage 3 and higher)

– Additional patient access and experience reports using NQF-endorsed HIT-enabled quality measures [EP, IP] (EMRAM Stage 3 and higher; Ambulatory EMR Stage 4)

– Percent of patients with access to secure patient messaging [EP] (Ambulatory EMR Stage 4)

– Percent of educational content in common primary languages [EP, IP] (EMRAM Stage 3; Ambulatory EMR Stage 3)

– Percent of all patients with preferences recorded [IP] (EMRAM Stage 3)– Percent of transitions where summary record is shared [EP, IP]

(EMRAM Stage 3 and higher; Ambulatory EMR Stage 4)– Implemented ability to incorporate data uploaded from home monitoring

devices [EP] (Ambulatory EMR Stage 4)



2013 Measures:– Access to comprehensive patient data from all

available sources (EMRAM Stage 7; Ambulatory EMR Stage 4)

– 10 percent reduction in 30 day re-admission rates for 2013 compared to 2012 (EMRAM Stage 6 and higher)

– Improvement in NQF-endorsed measures of care coordination (EMRAM Stage 3 and higher; Ambulatory EMR Stage 4)



2013 Measures:– Percent of patients for whom an assessment of immunization

need and status has been completed during the visit [EP] (Ideally accomplished with CDSS and business intelligence and a clinical data warehouse that can be implemented at Stage 3 or higher)

– Percent of patients for whom a public health alert should have triggered, and audit evidence that a trigger appeared during the encounter (Ideally accomplished with CDSS and business intelligence and a clinical data warehouse that can be implemented at Stage 3 or higher)


Ensure Adequate Privacy and Security Protections for Personal Health Information

2013 Measures:– Provide summarized or de-identified data when

reporting data for health purposes (e.g. public health, quality reporting, and research), where appropriate, so that important information is available with minimal privacy risk (Ideally accomplished with business intelligence and a clinical data warehouse that can be implemented at Stage 2 or higher)



2015 Objectives Goal is to achieve and improve performance and support care processes and on key health system outcomes:– Achieve minimal levels of performance on quality, safety, and efficiency

measures (EMRAM Stages 5 and above; Ambulatory EMR Stage 4 and above)

– Implement clinical decision support for national high priority conditions (EMRAM Stages 3 and above; Ambulatory EMR Stage 4)

– Medical device interoperability (EMRAM Stage 3 as the initial stage for integration with medical devices)

– Multimedia support (e.g. x-rays) [OP, IP] (EMRAM Stage 3 and above; Ambulatory EMR Stage 4)



2015 Objectives Goal is to achieve and improve performance and support care processes and on key health system outcomes:– Patients have access to self management tools (Web

services to provide access to sites such as WebMD or MayoClinic.com)

– Electronic reporting on experience of care (provided by a service such as Press Ganey of SF-36 providers)



2015 Objectives Goal is to achieve and improve performance and support care processes and on key health system outcomes:– Access comprehensive patient data from all available

sources (EMRAM Stage 7; Ambulatory EMR Stage 5)



2015 Objectives Goal is to achieve and improve performance and support care processes and on key health system outcomes:– Use of epidemiologic data (EMRAM Stage 7; Ambulatory EMR

Stage 5)– Automated real-time surveillance (adverse events, near misses,

disease outbreaks, bioterrorism) (EMRAM Stage 3; Ambulatory EMR Stage 4)

– Clinical dashboards (EMRAM Stage 2; Ambulatory EMR Stage 3)

– Dynamic and ad hoc quality reports (EMRAM Stage 7; Ambulatory EMR Stage 5)


Ensure Adequate Privacy and Security Protections for Personal Health Information

2015 Objectives Goal is to achieve and improve performance and support care processes and on key health system outcomes:– Provide patients, upon request, with an accounting of treatment,

payment, and healthcare operations disclosures (EMRAM Stage 3; Ambulatory EMR Stage 3)

– Protect sensitive health information to minimize reluctance of patient to seek care because of privacy concerns (All Stages of Both Models)



2015 Measures:– Clinical outcome measures (TBD) [OP, IP] (Projected

EMRAM Stage 6 and 7; Projected Ambulatory EMR Stage 5)

– Efficiency measures (TBD) [OP, IP] (Projected EMRAM Stage 6 or 7; Projected Ambulatory EMR (Stage 5)

– Safety measures (TBD) [OP, IP] (Projected EMRAM Stage 5 or higher; Projected Ambulatory EMR Stage 5)



2015 Measures:– NPP quality measures related to patient and family

engagement [OP, IP] (EMRAM Stage 7; Ambulatory EMR Stage 5)



2015 Measures: – Aggregate clinical summaries from multiple sources

available to authorized users [OP, IP] (EMRAM Stage 7; Ambulatory EMR Stage 5)

– NQF-endorsed care coordination measures (TBD) (EMRAM Stage 7; Ambulatory EMR Stage 5)



2015 Measures:

– HIT-enabled population measures [OP, IP] (EMRAM Stage 7; Ambulatory EMR Stage 5)

– HIT-enabled surveillance measures [OP, IP] (EMRAM Stage 7; Ambulatory EMR Stage 5)



2015 Measures:– Provide patients, on request, with a timely accounting

of disclosures for treatment, payment, and healthcare operations, in compliance with applicable law(s) (EMRAM Stage 3; Ambulatory EMR Stage 3)

– Incorporate and utilize technology to segment sensitive data (EMRAM Stage 7; Ambulatory EMR Stage 5)


Hospital & Provider Advice

• Ensure that your EMR vendor can deliver the functions identified within the levels of the EMRAM and ambulatory EMR model.

• If you are not at a Stage 3 or Stage 4 for EMR functions on the EMRAM or ambulatory EMR model, submit a request for information to your EMR vendor(s) to generate written documentation as to their capabilities in meeting the 2011 and 2013 measures with their EMR applications and implementations.

• Determine whether your existing vendor can meet the 2011 and 2013 measurements within the timeframes you have for implementation and adoption of EMR applications in your facility. If your requirements can’t be met, institute replacement proceedings immediately (vendor/product evaluation and selection processes).

• Negotiate an implementation timeline and process that meets your needs and define penalties for missing deadlines (this is a two way street, and vendors may also assign penalties for missing deadlines for hospital and clinic functions of the implementation).

• Create a strategy for meeting 2015 measures to be identified that can be implemented soon after 2013 using business intelligence and clinical data warehouse functions.

2009 HIMSS Analytics Mapping EMRAM and the Ambulatory EMR Adoption Model to Meaningful Use Criteria September 9, 2009 Mike Davis.

Documents

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cms ambulatory emr stage

encounter ambulatory

request ambulatory emr

ambulatory emr model

erx op ambulatory emr

ambulatory emr adoption

health disparities