Module 17. Electronic Health Records and Meaningful Use

The need for skills in health information technology (IT) has never been greater. With the increasing implementation of electronic health records (EHRs) and the use of disease registries to monitor and track patient populations, practice facilitators will need to have a working knowledge of EHRs and registries and how to use them most effectively.

It is important to understand that in an outpatient setting, as opposed to inpatient, a medical record covers the lifetime of a patient, not one episode of care (an inpatient stay). Thus, you need a longitudinal record from which you can generate reports over time.

If you work with a practice that is still paper based, the longitudinal record is an important concept for the practice to keep in mind when choosing an ambulatory care EHR. In addition, not all ambulatory practices are the same. Depending on specialties provided, (e.g., oncology, HIV services), there may be specific documentation or scheduling needs that a particular vendor has not considered before.

EHR Implementation

Regardless of which EHR a practice uses, the practice facilitator should immediately determine how hardware and software are supported and by whom. If all or a portion of the EHR is resident (supported by the organization that purchased the EHR), the internal IT support person is often the key to leveraging the EHR for project needs. He or she should be the first contact for IT-related questions. This is an important relationship to establish, as this person will also know if the practice needs additional external support.

Module 2 in this handbook discusses some of the challenges that safety net practices face in implementing and optimizing health IT. For example, EHRs only help practices manage population health if they have the features and capabilities that let them analyze data across groups of patients. Practices face a dizzying array of choices of EHR products. Once they have made a selection, learning how to use their EHR effectively is also a laborious process. As a practice facilitator, you will need to be familiar with various EHR products and how to extract data from them.

Fortunately, resources are available for both you and your practices. One is the Health Resources and Services Administration’s Health IT Adoption Toolbox, available at http://www.hrsa.gov/healthit/toolbox/HealthITAdoptiontoolbox/index.html. It is a compilation of planning, implementation, and evaluation resources to help community health centers, other safety net providers, and ambulatory care providers implement health IT applications in their facilities.

Another set of resources is the 62 Regional Extension Centers (RECs) funded to help primary care providers adopt and use EHRs. RECs represent a range of organizations that serve local communities throughout the country. REC services include outreach and education, EHR support (such as working with vendors or helping providers choose a certified EHR system), and technical assistance in implementing health IT and using it in a meaningful way to improve care. You can locate an REC near your practices by going to http://www.healthit.gov/providers-professionals/regional-extension-centers-recs.

Impact of EHRs on Workflow

As a facilitator, you will need to help your practices integrate their EHRs into their workflows. Module 5 on mapping workflows will guide you in mapping the workflow regarding entry of documentation into the EHR and use of EHR data to identify patients whose conditions are not under control or who have not received appropriate preventive services.

EHRs can also improve care when, for example, standing orders are entered to authorize nurses and other staff to carry out medical orders per practice-approved protocol. For instance, one study showed that EHR reminder tools combined with standing orders for screening, immunizations, and diabetes measures helped staff adopt new roles (Nemeth, et al., 2012).

You can also help your practices use their EHRs to identify patient education materials suitable for each patient. For example, EHRs can be linked to libraries of easy-to-understand print and audiovisual materials. Data stored in the EHR, such as the patient’s preferred language, can be used to select appropriate materials. You can also help your practices learn to use the EHR to produce visual displays (e.g., lab results over time) that can be used for patient education, shared decisionmaking, and action planning.

If your practices have selected EHRs that do not have the full functionality needed to support the Care Model or PCMH, you will need to help the practice supplement their care management capacity. For example, if their EHRs cannot identify a population of patients due for a chronic care service, the practice will need to maintain registries, much as they would have to do if they did not have EHRs.

A registry is a database of patients with specific diagnoses, conditions, or procedures. While an EHR contains patient-specific information about all patient encounters at a health care center, a registry is a subset of the patients in the EHR. A registry is generally easier to use for tracking patient progress and outcomes than an EHR. Although a registry can be a standalone application, it is often populated by an EHR to avoid entering key data items twice.

The types of reports an EHR generates is key to helping a practice actively manage patients, track operational indicators, and meet meaningful use, regulatory, and accreditation requirements. Depending on the type of report, it can be at the practice or provider level, but starting with the practice level is a good way to identify red flags that require drilling down to the provider level. For example, if compliance with the stage 1 meaningful use mandate of maintaining an up-to-date problem list for 80 percent of patients is at 60 percent for the center, the next step should be provider-specific compliance.

Conducting a comprehensive workflow analysis is a critical step to health IT implementation.

–Health Resources and Services Administration

EHR Reports

The types of reports an EHR generates is key to helping a practice actively manage patients, track operational indicators, and meet meaningful use, regulatory, and accreditation requirements. Depending on the type of report, it can be at the practice or provider level, but starting with the practice level is a good way to identify red flags that require drilling down to the provider level. For example, if compliance with the stage 1 meaningful use mandate of maintaining an up-to-date problem list for 80 percent of patients is at 60 percent for the center, the next step should be provider-specific compliance.

These data can be powerful motivators for provider change, as providers see how they’re performing against the practice as a whole and other providers, as well as positive reinforcement for those exceeding expectations. Other reports can be used the same way:

  1. Number of open/closed encounters (day/week/month)
  2. Productivity (number of patients seen per hour)
  3. Referral patterns, both internal, for supportive services (e.g., social work, nutrition) and specialists, and external, for specialists and community-based organizations
  4. Patient flow, as measured through wait time and cycle time
  5. Health/functional status, by patient and population
  6. Educational materials provided
  7. Adherence to recommended treatment guidelines, decision support use, and literature searches.

When you review data, your first question should always be, “Does this pass the sniff test?” Often, you can spot data glitches by thinking logically about what you are looking at. For example, suppose a report shows that a lab value for a glomerular filtration rate, used for measuring kidney failure, is not being documented in the EHR, but the physicians are adamant that they are documenting the lab results. That’s a red flag. So you ask a physician to show you where it is in the record, and you discover it is in a text field that the report is not searching.

For data to be useful, they must be accurate and therefore credible. The old adage garbage in = garbage out has never been more applicable than with an EHR, so instilling a sense of ownership of what is put into the EHR by documenters is very important. Practice facilitators must always stress the importance of timely and accurate documentation. They should share ways quality documentation can benefit providers (e.g., helping them meet meaningful use requirements, creating a solid legal defense [if it isn’t documented, it didn’t happen], communicating with the rest of the care team, and most importantly, giving the patient an up-to-date medical record). If the data are suspect and subject to second guessing, the important task of using data to measure and improve performance and health outcomes cannot happen.

Relationship of Meaningful Use to EHRs

In February 2009 President Obama signed into law the American Recovery and Reinvestment Act (ARRA) as an economic stimulus package providing investment in the Nation’s infrastructure, employment, transportation, education, and other fields. Within ARRA, the Health Information Technology for Economic and Clinical Health (HITECH) Act specifically targeted health care by providing the means to structure a paperless national health information network. To do so, the HITECH Act provides more than $40 billion, including:

  • $20+ billion for incentive payments to hospitals and providers.
  • $650 million for RECs to help providers adopt health IT.
  • $560 million for State governments to lead the development of health information exchanges (HIEs).
  • $4.7 billion for the adoption and use of broadband and telemedicine advancement.
  • $500 million for the Social Security Administration and $85 million for the Indian Health Service.
  • $50 million for IT within the Veterans Benefit Administration.

The ARRA HIT Policy Committee further proposed “meaningful use” as the key criteria providers (hospitals and eligible providers, known as EPs) must meet to unlock tens of millions of dollars of Federal health care IT subsidies under ARRA. For primary care providers, this funding is directly tied to documenting important factors in primary patient care such as smoking status and current medications Practice facilitators must be familiar with this key driver of reimbursement for primary care at the local site level, since EHR funding is tied to meeting meaningful use criteria. Leveraging meaningful use is a powerful way to achieve quality documentation in the EHR (for specific improvement projects as well as better patient care) and is always something to keep in mind.

Stages of Meaningful Use

In primary care, meaningful use consists of three stages:

  1. Stage 1: transferring data to EHRs and being able to share information
  2. Stage 2: includes new standards such as online access for patients to their health information and electronic health information exchange between providers
  3. Stage 3: implementation.

Stage 1

Stage 1 began in 2011 and remains the starting point for all providers. It consists of transferring data to EHRs and being able to share information, including the capability of producing electronic copies of medical records upon a patient’s request and printing a copy of the visit summary for patients at the end of their visit. The focus is on data gathering and sharing. Stage 1 has the following measures:

  1. A core set of 15 measures that must be met through structured data entry, including patient demographics, computerized physician order entry (CPOE) for medication orders, updated problem/medication/allergy lists, recording of vital signs and smoking status, and a printed Clinical Summary given to the patient after each visit.
  2. An additional menu set of 24 measures of which 19 must be met through structured data entry, including patient-specific education resources, medication reconciliation, and patient electronic access.
  3. Clinical quality measures to be submitted to the Centers for Medicare & Medicaid Services (CMS), including hypertension management, preventive care and screening measures, and childhood immunization status.

Table 17.1 shows examples of the minimum thresholds for meeting meaningful use established in stage 1.

Table 17.1. Examples of stage 1 measures

Meaningful Use ObjectiveMeasure
Use CPOE for medication orders.CPOE is used for at least 30% of all medication orders.
Maintain an up-to-date problem list of current and active diagnoses based on ICD-9-CM or SNOMED CT®.At least 80% of all unique patients seen by the EP have at least one entry or an indication of none recorded as structured data.
Generate and transmit permissible prescriptions electronically (eRX).At least 75% of all permissible prescriptions written by the EP are transmitted electronically using certified EHR technology.
Maintain active medication list.At least 80% of all patients seen by the EP have at least one entry (or an indication of none if the patient is not currently prescribed any medication) recorded as structured data.
Record smoking status for patients age 15 years or older.More than 50% of all unique patients age 15 years or older have smoking status recorded as structured data.

Key: ICD-9-CM = International Classification of Diseases, 9th Revision, Clinical Modification; SNOMED CT = Systematized Nomenclature of Medicine—Clinical Terms.

Stage 2

Stage 2 (to be implemented in 2014) includes new standards such as online access for patients to their health information and electronic health information exchange between providers. Stage 2 builds on stage 1 measures, with an emphasis on using clinical decision support (reminders to ensure adherence to evidence-based guidelines) to improve performance on high-priority health conditions. Table 17.2 includes examples of stage 2 measures.

Table 17.2. Examples of stage 2 measures

Meaningful Use ObjectiveMeasure
Use CPOE for medication, radiology, and laboratory orders.More than 60% of medication, 30% of laboratory, and 30% of radiology orders during the EHR reporting period are recorded using CPOE.
Use clinically relevant information to identify patients who should receive reminders for preventive/followup care and send these patients the reminder, per patient preference.More than 10% of all unique patients who have had two or more office visits within the 24 months before the beginning of the EHR reporting period were sent a reminder, per patient preference when available.
Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach.Generate at least one report listing patients with a specific condition.
Automatically track medications from order to administration using assistive technologies in conjunction with an electronic medication administration record (eMAR).More than 10% of medication orders during the EHR reporting period are tracked using eMAR.
Record smoking status for patients age 13 years or older.More than 80% of all unique patients age 13 years or older have smoking status recorded as structured data.

Stage 3

Stage 3 implementation is expected in 2016 and includes demonstrating that the quality of health care has been improved for the population served. Examples of addressing conditions that affect a large proportion of the underserved population include improving outcomes for low birth weight babies and reducing hospital admissions for ambulatory care-sensitive conditions such as diabetes and childhood asthma.

The HITECH Act has also funded States and communities to support and accelerate meaningful use through health IT infrastructure and exchange capabilities such as HIEs and RECs. As a practice facilitator, you are in the unique role of being able to help primary care practices optimize health IT. Enhancing EHR capabilities at the local level and exploring linkages between a local EHR and its larger community through an HIE, a mandate that States must comply with starting in 2014, helps foster population-focused improvement efforts and furthers the core mission of the community health center.

Examples of two States that have made significant progress in connecting providers electronically can serve as exemplars for the State you work in:

  1. The NY eHealth (eHealth) Collaborative serves as a model for coordinating all exchange efforts throughout the State of New York. As an increasing number of private practices, nursing homes, clinics, and hospitals implement EHRs, these providers have the option to connect to information hubs in their region of the State for sharing patient data. eHealth then links all the regional nodes to a statewide network that primary care physicians can securely access for complete and accurate information about their patients. Consider a pregnant patient who receives her primary care in her hometown of Buffalo and travels to the Bronx to visit relatives. While there she goes into labor prematurely. Thanks to the eHealth network, her prenatal records from her patient care team at the community health center she visits in Buffalo are available online to the Bronx hospital where she is being treated
  2. The Massachusetts eHealth Institute (MeHI) at the MassTech Collaborative is improving health care for the Massachusetts population through the use of IT. The institute runs the Massachusetts health information highway (HIway), the statewide HIE for clinical information among a variety of providers, including doctors’ offices, hospitals, laboratories, pharmacies, skilled nursing facilities, and health plans. It also serves as the REC for helping providers achieve meaningful use goals. In addition, the institute works with MassHealth, the State insurance program for low- and moderate-income Massachusetts residents, on the Medicaid EHR Incentive Payment Program. This program supports the goal for all providers to have access to a federally certified EHR that communicates with other certified EHRs by 2015.

Meaningful Use Funding

Funding for meaningful use is the key to succeeding. EHR incentive programs are available for Medicare and Medicaid providers. Facilitators can help their practices qualify for and draw down incentive payments by being knowledgeable about how to apply for funding and the processes needed for accountability.

CMS has defined the minimum requirements that providers must meet to qualify for payments for stages 1 and 2 of meaningful use. Providers apply online by going to the CMS Registration Guide for Eligible Providers, which walks the provider through all the steps to enroll. Providers must have a National Provider Identifier and a National Plan and Provider Enumeration System (NPPES) number and be enrolled in the Provider Enrollment, Chain, and Ownership System (PECOS). There are instructions on how to enroll for providers who do not have accounts. The registration process outlines how the incentive payments will be made and to whom, based on the provider’s NPPES/PECOS accounts.

Eligible providers who demonstrate meaningful use of certified EHR technology can receive up to $44,000 from Medicare over 5 consecutive years. Medicare incentive payments are made approximately 4 to 8 weeks after the provider attests that they have successfully demonstrated meaningful use of certified EHR technology for the stage that they have applied for. Medicaid incentives, which are greater, are paid by the States, and timeframes vary by State. The steps for applying and reporting through the three stages are clearly outlined at http://www.echoman.com/meaningful-use-step-by-step.

Deciding whether to apply for Medicare or Medicaid funding is the first step (see Table 17.3). Once a provider is enrolled in stage 1, the timeline is set for proceeding through stage 2 and stage 3 reporting. As of 2013, all providers are reporting on stage 1 measures, as stage 2 does not become effective until 2014. However, providers in stage 1 are already planning for stage 2 and looking ahead to stage 3 in 2016.

Table 17.3. Comparison of EHR incentive programs

Medicare EHR Incentive ProgramMedicaid EHR Incentive Program
Run by CMS.Run by your State Medicaid agency.
Maximum incentive amount is $44,000.Maximum incentive amount is $63,750.
Payments over 5 consecutive years.Payments over 6 years; does not have to be consecutive.
Payment adjustments will begin in 2015 for providers who are eligible but decide not to participate.No Medicaid payment adjustments.
Providers must demonstrate meaningful use every year to receive incentive payments.In the first year providers can receive an incentive payment for adopting, implementing, or upgrading EHR technology. Providers must demonstrate meaningful use in the remaining years to receive incentive payments.

Demonstrating meaningful use every year happens through an attestation process. Attestation is a legal statement that the EP has met the thresholds and all requirements of the EHR Incentive Program and is done electronically through the CMS link: https://ehrincentives.cms.gov. For stage 1, attestation pertains to:

  • 15 core objectives.
  • 5 out of 10 menu objectives.
  • 3 core (or 3 alternate core) clinical quality measures.
  • 3 out of 38 additional clinical quality measures.

More information on EHR incentives and certification and how to attain meaningful use is available at http://www.healthit.gov/providers-professionals/how-attain-meaningful-use.

Meaningful Use and Quality Improvement

Meaningful use reinforces the concept of meeting patient needs as outlined in the landmark Institute of Medicine study Crossing the Quality Chasm: A New System for the 21st Century (IOM, 2001): care that is safe, efficient, effective, timely, person centered, and equitable. The same technology that can qualify providers for meaningful use incentive payments can also serve to implement the Care Model or achieve PCMH status. Table 17.4 displays how various meaningful use criteria and health IT capabilities relate to Care Model and PCMH features.

Table 17.4. Crosswalk between meaningful use and health IT capabilities and Care Model and PCMH features

Meaningful Use and Health IT Capability*Care Model DomainsPCMH Standards
Maintain up-to-date problem listsClinical Information SystemsPlan and Manage Care
Generate lists of patients with a specific conditionDelivery System DesignIdentify and Manage Patient Populations
Incorporate lab resultsDecision SupportIdentify and Manage Patient Populations
Participate in HIECommunity ResourcesProvide Community Resources
Send remindersSelf-Management SupportPlan and Manage Care
Use clinical decision supportDecision SupportMeasure and Improve Performance
Use CPOE for medication, radiology, and laboratory ordersClinical Information SystemsPlan and Manage Care
Record demographics

Provide patient education materials in non-English languages

Self-Management SupportIdentify and Manage Patient Populations
Make health information accessible to patientsInformed, Empowered Patient and FamilyProvide Self-Care Support

* Includes proposed stage 3.

As a facilitator, you can help your practices attain meaningful use. One way you can assist them is in helping them to map and then redesign key workflows. Some of the workflows that may need to be redesigned are shown in the box below.

Workflows That May Require Redesign

  • Recording patient demographics.
  • Recording vital signs electronically.
  • Maintaining up-to-date problem list.
  • Maintaining active medication list.
  • Maintaining active allergy list.
  • Recording smoking status.
  • Providing patients with clinical summaries for each office visit.
  • E-prescribing.
  • Checking for drug-drug and drug-allergy interactions.
  • Exchanging electronic information with other sites of care.
  • Implementing a decision support rule and tracking compliance with the rule.
  • Maintaining systems to protect privacy and security of patient data.
  • Reporting clinical quality measures to CMS or States.
  • Generating lists of patients for QI or outreach.
  • Providing electronic health education resources.
  • Performing medication reconciliation between care settings.
  • Generating summary of care record for referrals and transitions.
  • Providing immunization data to regional registries.
  • Providing surveillance data to public health agencies.
  • Using patient reminders for prevention/chronic care.
  • Providing patient access to lab results, problem and medication lists, and allergy information.
  • Performing drug formulary check.
  • Entering lab results into EHR.
Adapted from Bodenheimer T. Personal communication, January 2011.

References

Institute of Medicine. Crossing the quality chasm: a new system for the 21st century. Washington, DC: National Academy Press; 2001:

Nemeth LS, Ornstein SM, Jenkins RG, et al. Implementing and evaluating electronic standing orders in primary care practice: a PPRNet study. J Am Board Fam Med 2012 Sept-Oct; 25(5):594-604.

Page last reviewed May 2013
Internet Citation: Module 17. Electronic Health Records and Meaningful Use. May 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/prevention-chronic-care/improve/system/pfhandbook/mod17.html