ED managers' responsibilities will increase with…

ED managers' responsibilities will increase with meaningful use rule

Getting emergency physicians onboard is crucial

The world of the ED manager changed significantly in July, when the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator (ONC) for Health Information Technology released the final rule for the definition of the term "meaningful use."

Those standards are part of the Health Information Technology for Economic and Clinical Health (HITECH). Act, itself part of the American Recovery and Reinvestment Act of 2009 (ARRA). The rule outlines how electronic health records, or EHRs, must be used to qualify for Medicare and Medicaid financial incentives under the HITECH Act.

"Prior to this final rule, ED orders were excluded under the guise they were part of outpatient services, but such huge numbers of comments really wanted to include the ED," says Patricia Daiker, RN, vice president of marketing for Medhost, a Wakefield, MA-based provider of healthcare throughput software.

In the interim rule, Daiker says, Department of Health and Human Services officials said that hospitals were required to show that 10% of all orders were placed in an EHR, including lab reports and radiology reports. "Now they've just narrowed the scope to medication orders, and increased the percentage to 30%," she explains.

Because such a large percentage of admitted patients go through the ED, note observers, overall hospital compliance should be much easier. It certainly will raise the profile of the ED. Todd Rothenhaus, MD, FACEP, senior vice president and CIO of Caritas Christi Healthcare in Boston, says, "If their CIO never paid attention to them before, they are now. It is a bit of a game-changer."

Know your terms

ED managers must understand some critical terms to help their facilities comply with the standards, says James McClay, MD, FACEP, associate professor of emergency medicine at the University of Nebraska Medical Center in Omaha.

"First of all, in the phrase 'meaningful use of certified information,' there are two loaded definitions: 'meaningful use' and 'certified,'" McClay says.

The term "certified" refers to the vendors of the systems used by the ED, he says. "If the ED is not using a certified vendor and is still doing documentation on paper, they are not contributing to compliance," says McClay. "If they are working with the hospital EHR vendor and they're using the built-in module, it's up to the vendor to certify the module."

However, most EDs operate on a departmental system in some form or other, so if they are going to contribute to the hospital's meaningful use compliance, their departmental system would have to be certified, he says. The government has established certifying bodies that will make that determination, McClay adds.

The ED manager has to sort out all of this by first asking the vendor representatives if the system they have installed is going to be certified, he says. "Also, they may only be certified for a particular version of the software. You may be on version 6, and the vendor is certified on version 7," he says. "In that case, you'd have to upgrade."

The ONC web site contains specific information on the meaningful use requirements. (Go to http://healthit.hhs.gov/portal, and click on "meaningful use.")

Rothenhaus says, "The hospital and the CIO need the ED to really participate now in helping achieve meaningful use. For example, they will be asking physicians to use CPOE [computerized physician order entry] and electronic prescribing. If you have a system rolled out and you're not using it, you have to, and if you do not have one, you will have to put in a plan. Some hospitals will have to scramble." (Rothenhaus says compliance should be earned in three stages. See the story, below. He also recommends a team approach, which is described in the Management Tip, below.)

E-prescribing a challenge

Electronic prescribing is complicated, says McClay.

"If you're doing this, you're transmitting information from your system directly to the pharmacy," notes McClay, adding that not all pharmacies are participating, "You need to know all those things," he says.

In addition, to do e-prescribing, you have to go through an intermediary, McClay says. Your software vendor for your system is not also the broker for transmission of transcription. "Ideally, your vendor would provide you tooling" to communicate with this third party, McClay says. "The first-tier vendor generally either builds this into the reports you can generate or sends someone who can provide that service for you."

Earn compliance in three stages

In seeking compliance with meaningful use standards, there are three stages the ED manager must go through, says Todd Rothenhaus, MD, FACEP, senior vice president and CIO of Caritas Christi Healthcare in Boston.

"The first is developing a strategy for choosing a system, whether it's a 'best of breed' or an enterprise module," Rothenhaus says. "The second is getting it configured for meaningful use, and the third is getting people to use it."

Set up is a 'pretty key piece,' he adds, due to the complexity of triage notes and nursing documentation for metrics. "There are some 'un-ED-like' requirements such as smoking cessation questionnaires, which may be counter-productive for throughput," Rothenhaus notes. "Accordingly, you have to choose what meaningful use objectives you want to be measured on and build that data capture into your system." The meaningful use objectives are broken into a "core set" of 15 that all hospitals must meet and a "menu set" of 10 procedures from which you can choose five to defer. (See list, below.)

"Each hospital gets to choose how they want to be scored, so there have to be some meetings between inpatient and ambulatory folks as to which ones from the menu set they want to report on," says Rothenhaus.

Meaningful Use Standards

The Core Set

Record patient demographics.
Record vital signs/chart changes.
Maintain current and active diagnoses.
Maintain active medication list.
Maintain active allergy list.
Record adult smoking status.
Provide patient clinical summaries.
Provide electronic health information copy on demand.
Generate and transmit prescriptions electronically.
Use computerized physician order entry for drug orders.
Implement drug-drug/drug-allergy interaction checks.
Be capable of electronic clinical information exchange.
Implement one clinical decision support rule.
Protect patient data privacy and security.
Report clinical quality measures to CMS or states.

The Menu Set

Implement drug formulary checks.
Incorporate clinical lab test results.
Generate patient lists by condition.
Identify patient-specific education resources.
Perform medication reconciliation between care settings.
Provide summary of care for transferred patients.
Submit electronic immunization data to registries.
Submit electronic epidemiology data to public health agencies.
Send care reminders to patients.
Provide timely patient electronic access to health information.

Source: The Centers for Medicare and Medicaid Services.

Management Tip

Create a team for compliace

When it comes to meeting meaningful use standards, "the first thing ED leadership needs to do is create a team that will strategize on helping the hospital meet them," says Todd Rothenhaus, MD, FACEP, senior vice president and CIO of Caritas Christi Healthcare in Boston. "It should not be a very big group, but it should be collaborative, including nursing, physician leadership, and administration."

In addition, you should have someone from IT supporting the plan, Rothenhaus says. "In most organizations, meaningful use criteria will be driven a little more by IT than by some other types of measures like pay for performance, which are driven and collected by quality and safety and administration folks," he explains.