The Direct Project - Gluing EHR's Together

Most of us believe that the push towards Electronic Health Records (EHR’s) is a good thing and a necessary step along the road toward making each person’s EHR available for any healthcare provider who might need to treat that patient, whether the patient is in Los Angeles or Prairieville, LA. This goal of universal EHR availability is called the Nationwide Health Information Network (NHIN). Providers are certainly making progress towards the NHIN, prodded along by the governments “carrot and stick” approach under the HITECH Act (Meaningful Use) Stage 1 and the availability of better technology and more tech-savvy healthcare providers.  

 

Another step toward NHIN is enabling EHR’s to talk to one another. Until recently, communication between EHR’s from different vendors was a bit like people located in different countries and speaking different languages, not fluent in each other’s language, trying to converse by telephone. There is a standard called HL7 but it was designed to exchange transactional data, not an entire health record. HITECH Stage 1 provided for the use of either the CCD or CCR a standard, which is, effectively, a universal language. One other piece seems to have been neglected until this year, however – and was omitted from HITECH Stage 1 – a secure standard for exchanging CCD/CCR clinical data. Think of this piece as the phone line in the international conversation.

 

Although that was a major oversight, it is being quickly (relative to how quickly things happen in healthcare IT) addressed through something called the “Direct Project” (http://wiki.directproject.org/). According to a February 2, 2011 News Release from HHS.gov, the goal of the Direct Project is an:

 

“easy-to-use, internet-based tool that can replace mail and fax transmissions of patient data with secure and efficient electronic health information exchange”

 

Towards this end, there have been committees, meetings, etc. and some standards have emerged.

 

The Direct Project has widespread support. According to Dr. Doug Fridsma, on his March 21 “HealthIT Buzz” posting, “support for the Direct Project represents approximately 90% of market share covered by the participating health IT vendors”.

 

In the next post, we’ll address the technological underpinnings of the Direct Project.

 

Definitions: 

• CCD/CCR –The ASTM Continuity of Care Record (CCR) and the Continuity of Care Document (CCD) HL7 standard. The HL7 CCD standard actually resulted from a collaborative effort between HL7 and ASTM to harmonize the data format between ASTM’s Continuity of Care Record (CCR) standard and HL7’s Clinical Document Architecture (CDA) standard.
• HITECH – In February of 2009, the American Reinvestment and Recovery Act (ARRA) allocated $19 billion in funding for hospitals and clinics that make “meaningful use” of certified Electronic Medical Record (EMR) systems. The Health Information Technology for Economic and Clinical Health (HITECH) Act lists criteria for eligible hospitals and vendor software

What is ONC?

ONC is the Office of the National Coordinator for Health Information Technology. The Office of the National Coordinator operates within the Office of the Secretary for the U.S. Department of Health and Human Services (HHS). ONC’s primary focus is the coordination and implementation of health information technology and electronic exchange of health information.  

 

According to ONC’s website, their mission includes the following:

 

• Promoting development of a nationwide Health IT infrastructure that allows for electronic use and exchange of information that:
• Ensures secure and protected patient health information
• Improves health care quality
• Reduces health care costs
• Informs medical decisions at the time/place of care
• Includes meaningful public input in infrastructure development
• Improves coordination of care and information among hospitals, labs, physicians, etc.
• Improves public health activities and facilitates early identification/rapid response to public health emergencies
• Facilitates health and clinical research
• Promotes early detection, prevention, and management of chronic diseases
• Promotes a more effective marketplace
• Improves efforts to reduce health disparities
• Providing leadership in the development, recognition, and implementation of standards and the certification of Health IT products;
• Health IT policy coordination;
• Strategic planning for Health IT adoption and health information exchange; and
• Establishing governance for the Nationwide Health Information Network.

The position of the National Coordinator was established in 2004 by George Bush’s administration and legislatively mandated by the HITECH Act. Farzad Mostashari, a physician and public health expert, currently holds the position of National Coordinator. Mostashari took the position in July 2009.

 

ONC has played a large role in the Medicare and Medicaid Electronic Health Record Incentive Programs established under the HITECH Act. ONC wrote the Final Rule documentation, a staged approach to adopting capabilities, standards and specifications required for achieving meaningful use. To date, only documentation on meeting the measures for Stage 1 of meaningful use have been released to the public. Furthermore, ONC was tasked with establishing a program for the testing and certification of health information technology as being in compliance with certification criteria to meet defined meaningful use requirements. ONC wrote testing requirements, test cases and test tools with NIST and established ONC-Authorized Testing and Certification Bodies (ATCB’s) to perform the testing and certification of EHR systems. ONC has selected six organizations to serve as ATCB’s. ONC also maintains the ONC Certified HIT Product List (CHPL), a list of certified Inpatient and Ambulatory EHR systems. The CHPL can be viewed here.

What is a CAH?

A CAH is a critical access hospital.  

A CAH is a hospital that is certified to receive cost-based reimbursement from Medicare. The reimbursement that CAHs receive is intended to improve their financial performance in order to reduce hospital closures. Each hospital must review its own unique situation to determine if becoming a CAH would be beneficial. CAHs are certified under a different set of Medicare Conditions of Participation which are more flexible than the acute care hospital Conditions of Participation.

The following is a list of criteria that a hospital must meet in order to be considered a CAH: 

• Located in a state that has a State Flex Program
• Designated by the State as a CAH
• Located in a rural area
• Provide 24-hour emergency care services
• Provide no more than 25 inpatient beds; a CAH can also operate a rehabilitation or psychiatric unit with up to 10 beds
• Have an average annual length of stay of 96 hours or less
• Located more than 35 miles from the nearest hospital or CAH (or more than 15 miles in areas with mountainous terrain or only secondary roads)
• Participate in Medicare

In addition to receiving cost-based reimbursement from Medicare, some other advantages of becoming a CAH are having access to Flex Program grant funds, flexible staffing and services, and having the CAH network with acute care hospitals for support.

What is an EP?

An EP is an Eligible Professional. Different types of EPs are eligible for the Medicare and Medicaid programs. Unlike eligible hospitals, EPs are not eligible to participate in both the Medicare and Medicaid programs. Below is a listing of the eligible professionals in each program:

 

Eligible Medicare EPs include:

• Doctors of Medicine or Osteopathy
• Doctors of Dental Surgery or Dental Medicine
• Doctors of Podiatric Medicine
• Doctors of Optometry
• Chiropractors

 

Eligible Medicaid EPs include:

• Physicians
• Nurse Practitioners
• Certified Nurse - Midwife
• Dentists
• Physicians Assistants who practice in a Federally Qualified Health Center (FQHC) or Rural Health Center (RHC) that is led by a Physician Assistant

 

Medicaid EPs also must have a minimum of 30% Medicaid patient volume (20% minimum for pediatricians) or practice predominantly in a FQHC or RHC and have at least 30% patient volume to needy individuals.

 

Hospital based providers, defined as a provider who provides 90% or more of their services in either the inpatient or emergency department of a hospital, are not eligible for the Medicaid or Medicare programs.

What is an EHR?

An EHR is an Electronic Health Record. It is an electronic record of patient health information collected over one or more encounters in any healthcare setting. Generally, the following information is included in the patient health information:

• Demographic Information
• Problem Lists
• Medication and Allergy Lists
• Vital Signs
• Medical History
• Immunization Information
• Lab and Radiology Reports
• Billing Information

EHRs have the ability to generate a complete record of a clinical patient encounter, as well as aiding other healthcare-related activities through the system’s interface including evidence-based decision support, quality management, and outcomes reporting.

 

The implementation of EHRs has several advantages including reducing costs, improving quality of care, promoting evidence-based medicine, and improving record keeping and mobility. Some disadvantages include the cost of implementing EHR systems and the time required to learn new systems.

How does NIST fit into HITECH Certification and Meaningful Use (MU)?

NIST is the National Institute of Standards and Technology and was formerly known as the National Bureau of Standards (NBS) between 1901 and 1988. NIST is a measurement standards laboratory which is a laboratory of metrology, the science of measurement, which establishes standards for a country or organization. NIST is a non-regulatory federal agency within the U.S. Department of Commerce. NIST's mission is to promote U.S. innovation and industrial competitiveness by advancing measurement science, standards, and technology in ways that enhance economic security and improve quality of life. Their core competencies include measurement science, rigorous traceability and development and use of standards.

The American Recovery and Reinvestment Act of 2009 encourages eligible professionals, eligible hospitals and critical access hospitals to move toward the use of electronic health records. The ARRA legislation calls for the Office of the National Coordinator (ONC) for Health IT, in consultation with NIST, to establish a program for the testing and certification of health information technology as being in compliance with certification criteria to meet defined meaningful use requirements.

In collaboration with ONC, NIST developed testing requirements, test cases, and test tools in support of the health IT certification program. NIST’s approved test procedures can be viewed here. Questions about the test procedures can be sent to NIST at hit-tst-fdbk@nist.gov.

What is ARRA?

ARRA is the American Recovery and Reinvestment Act of 2009. This Act, commonly referred to as ‘the Stimulus’ or ‘The Recovery Act,’ was passed by Congress on February 17, 2009. ARRA was the government’s response to the economic crisis. The Act includes a number of projects and programs but its immediate goals were the following:  

• Stimulate economic activity and invest in the nation’s long-term growth
• Provide assistance to those most impacted by the economic recession
• Produce new jobs and protect existing jobs
• Increase levels of accountability and transparency in government spending

ARRA contains general incentives related to health care information technology in, such as the creation of a national health care infrastructure, and specific incentives designed to encourage the adoption of certified electronic health record (EHR) systems among hospitals and providers. In addition to the programs related to the healthcare industry, ARRA also addresses tax incentives for individuals and companies, and programs related to education, infrastructure, transportation, energy infrastructure, housing, scientific research, government buildings and facilities, etc.

To read more about ARRA and track the spending related to this Act, visit http://www.recovery.gov/.

What is the HITECH Act?

The Health Information Technology for Economic and Clinical Health (HITECH) Act is part of the American Recovery and Reinvestment Act of 2009 (ARRA) which was passed February 17, 2009. According to the Final Rule documentation, two titles of the ARRA , Title IV of Division B and Title XIII of Division A, constitute the Health Information Technology for Economic and Clinical Health Act or HITECH Act. Title IV amends the Social Security Act to establish incentive payment programs for eligible professionals, eligible hospitals, critical access hospitals and Medicare Advantage Organizations to encourage these entities to adopt meaningful use of healthcare information and certified electronic health records.

The bill has four main goals to improve health information technology:

• Give the government a leadership role in the development of standards in the general use of and the exchange of electronic health information. These standards are intended to improve quality and coordination of care.
• Invest billions of dollars in healthcare infrastructure and incentive programs to reward eligible professionals (EP) and hospitals that use certified systems to electronically exchange patient information.
• Save billions of dollars by improving quality and coordination of care and reducing medical errors and duplicative care.
• Strengthen requirements on security and privacy related to healthcare information.

While the U.S. Government has been encouraging the healthcare industry to move toward electronic health records since 2004, they received limited response. President Bush set aside millions of dollars to fund demonstration projects to ‘test the effectiveness of health information technology and establish best practices for more widespread adoption in the healthcare industry’ and established the Office of the National Coordinator for Health Information Technology to lead the way. The HITECH Act, put in place by the Obama Administration, has established a less voluntary approach since there are financial incentives for those who participate and financial penalties for those who choose not participate or do not adopt in a timely manner.

Common Acronyms for HITECH Certification and Meaningful Use (MU)

While reading through all of the HITECH Certification and Meaningful Use (MU) articles, procedures, laws, etc., one difficulty I've found in fully understanding the documentation is due to the number of acronyms used by the writers. So, I thought it might be helpful to get a list of the most common acronyms and not only define what they stand for, but write a short piece on each to give people an idea about how each fits into certification and meaningful use (MU).

 

Here's my list:

• HITECH - Health Information Technology for Economic and Clinical Health Act
• ARRA - American Recovery and Reinvestment Act of 2009
• NIST - National Institute of Standards and Technology
• ONC - Office of the National Coordinator for Health Information Technology
• CMS - Centers for Medicare & Medicaid Services
• EHR - Electronic Health Record
• EP - Eligible Professional
• CAH - Critical Access Hospital
• PQRI - Physician Quality Reporting Initiative
• A/I/U - Adopt, Implement, or Upgrade
• CCN - CMS Certification Number
• CQM - Clinical Quality Measure
• HIT - Health Information Technology

Over the next week or so I will post the definitions of these acronyms - tune back in to read more about these important certification and MU concepts.

 

If there is an acronym that I left off that you think should be included in the list, post a comment and I will research it for you!

Complete EHR vs. Modular EHR

In order for providers and hospitals to attest to ‘Meaningful Use’ and receive incentive payments, they will first need a Certified Electronic Health Record (EHR).  EHR's can be certified in one of two ways: Complete EHR Certification or Modular EHR Certification. 

Complete EHR
A complete EHR has been tested and certified by an Authorized Testing and Certification Body (ACTB) and meets all of the government’s requirements as a whole.  This means that if an eligible professional (EP) or hospital implements a complete EHR, they can register for the Medicare EHR Incentive Program and begin attesting to Meaningful Use criteria once they have met meaningful use for a consecutive 90-day reporting period.  EP’s and hospitals will need to register on the CMS website to attest Meaningful Use (MU).

Unfortunately, with a complete EHR, you cannot buy individual pieces of the system and assume that the pieces are certified as modules.   

Modular EHR
A modular EHR allows an EP or hospital to combine certified modules from different systems in order to meet the government requirements for a certified EHR.  For modular certification, the ONC Certification Numbers for each of the certified products must be collected and submitted to ONC as a ‘package’ solution.  ONC reviews the package solution and if it meets all requirements for a certified system, they issue a new certification number which is used to attest Meaningful Use (MU).

A modular approach may be seen as a more complex solution due to the work required ensuring all modules integrate together, but the modular approach also has a number of advantages:

·    Complete EHR's can be very expensive compared to the modular approach.

·    If an EP or hospital already has a module(s) in place that staff is familiar with, it may be inefficient and costly to train the staff on a new system.  

·    Transferring data to a new system may be time consuming and costly.

·    The modular approach allows the EP or hospital to use their vendor of choice for each application. 

A modular approach also allows an EP or hospital to buy certain certified modules in addition to self-certifying their homegrown system to meet the requirements on the remaining modules. 

Using a Complete EHR and Certified Modules
The ONC Regulations FAQ 9-10-014-1 clarifies the rules further to include the possibility of using a certified module in addition to possessing a complete EHR if the modular function is preferred or superior to the function in the complete EHR. 

Meeting the definition of Certified EHR Technology can be achieved in numerous ways; including using EHR technologies that perform duplicative or overlapping capabilities (if that is what an eligible health care provider chooses to do) so long as all of the applicable certification criteria adopted by the Secretary have been met and those EHR technologies are certified. Consequently, an eligible health care provider could use both certified capabilities (e.g., CPOE) at the same time in two different sections/departments of its organization. The eligible health care provider would however be responsible for reconciling the data between those two certified capabilities for purposes of reporting to CMS or the States.

Dynamic Health IT
Dynamic Health IT is ready to assist you or can take the lead role in your certification process.  We offer practical and effective solutions, including software addressing HITECH Certification criteria which can easily be integrated with your current systems.  We have expertise with the criteria and certification methodology used by the most popular ATCB’s – CCHIT and Drummond Group.