The Electronic Health Record:Using It Effectively & with Meaning

The Electronic Health Record:
Using It Effectively & with Meaning
May 7, 2016
Christopher W. Shanahan MD MPH FACP
Assistant Professor of Medicine
Boston University School of Medicine
Boston Medical Center
1
Disclosure: 6/27/2014 CareFusion Corporation Unrestricted Research Grant

Learning Objectives
1. Understand the purpose Meaningful Use (MU)
2. Understand progress of MU so far
3. Review the basic components of MU
4. Understand changes to MU in 2016
5. Understand usability as key to safe & effective EHR use
6. 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

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

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

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

Changes to MU in 2016
3/30/2015:
CMS Stage 3 Proposed Rule. (Proposed objectives for Stage 3 MU)
4/9/2015
CMS 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)
4/16/2015
MACRA (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 MU
MACRA 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 programs1
• Synchronize reporting period objectives & measures
to reduce burden2
• Continue to support advanced use of health IT to
improve outcomes for patients3

2016 Program Requirements
10/15/2015
•Final Rule Released
Modified Stage 2 (2015
to 2017)
•Stage 3
(2018 & beyond)
24

“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)
25

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 2
7. Medication Reconciliation
8. Summary of Care record for
referrals & transitions of care
9. Secure electronic messaging
10. Public Health reporting
a. Immunization Registry reporting
b. Syndromic surveillance reporting
c. Case Reporting
d. Public Health Registry Reporting
e. 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
• 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).

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.
31
Modified Stage 2 EP Objectives & Measures 2016

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.
32

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
33

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%.
34
2015
1 patient
2016
1 patient
2017
5%*
* of all unique patients seen within an EHR reporting period

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 35

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.
36Source: 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
2016 NA Modified 2 Modified 2 or 3 3 3
2017 NA NA Modified 2 or 3 3 3
2018 NA NA NA 3 3
2019 + NA NA NA NA 3

Objectives for Stage 3: 2017 & Beyond
Objective 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 CEHRT
b. Security updates must be implemented as necessary
c. 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 CEHRT
b. 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 care
b. Drug-drug & drug-allergy interaction checks must be enabled & implemented
4. Use Computerized Provider Order Entry (CPOE) for
Medication, Laboratory, & Diagnostic Imaging Orders
CPOE must be used for:
a. More than 60 percent of medication orders
b. More than 60 percent of laboratory orders
c. 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; or
ii. Access their health information through the use of an application in the provider’s CEHRT; or
iii. 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 record
b. For > 40 percent of transitions received & new patients, the provider must incorporate into the patient’s EHR an electronic
summary of care document
c. 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 rule
Specifies 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.

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).
43

MU / Incentives / MACRA & Beyond
MACRA
(Merit-Based Incentive Payment System (MIPS) & Alternative Payment Models (APMs) , et.al.)
Pay for
Performance
No
incentives
MU Incentives
Incentives
(First)
Penalties
(Second)
MU
EHR Standards Defined Use

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 interaction
Automatic 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 2019
Penalty 1% 2% 3% 5%

Pick a Plan: Medicare or Medicaid?
Medicare EHR Incentive
Program
Medicaid EHR Incentive Program
Run CMS MassHealth
Max. incentive amount $44,000 $63,750
Payments over 5 consecutive years
6 years, does not have to be
consecutive
Payment adjustments
Begins 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*
FirstAttestationYear
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
MedicaidMedicare

Massachusetts eHealth Institute (MeHI)

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.
35%
26%
21%
PCPS MEDICAL
SPECIALISTS
SURGICAL
SPECIALISTS
% 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 Problem
A 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 Components
Use 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.)

The Electronic Health Record:Using It Effectively & with Meaning

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