Certified Electronic Health Record Technology Research Articles

The impact of county-level factors on meaningful use of electronic health records (EHRs) among primary care providers.

This study examines the impact of county-level factors on "meaningful use" (MU) of electronic health records (EHRs) for 8415 primary care providers (PCPs) that enrolled in the Florida Medicaid EHR Incentive Program through adopting, improving, or upgrading (AIU) a certified EHR technology. PCPs received incentive payments at enrollment and if they used their EHRs in meaningful ways; ways that benefit patients and providers alike they received additional payments. We conducted a retrospective cohort study of these providers over the 2011-2018 period while linking their records to other state data. We used the core constructs of the resource dependence theory (RDT), a well-established organization theory in business management, to operationalize the county-level variables. These variables were rurality, poverty, educational attainment, managed care penetration, changes in population, and number of PCPs per capita. The unit of analysis was provider-years. For practical and computational purposes, all the county variables were dichotomized. We used analysis of variance (ANOVA) to test for differences in MU attestation rates across each county variable. Odds ratios and corresponding 95% confidence intervals were derived from pooled logistic regressions using generalized estimated equations (GEE) with the binomial family and logit link functions. Clustered standard errors were used. Approximately 42% of these providers attested to MU after receiving first-year incentives. Rurality and poverty were significantly associated with MU. To some degree, managed care penetration, change in population size, and number of PCPs per capita were also associated with MU. Policy makers and healthcare managers should not ignore the contribution of county-level factors in the diffusion of EHRs among physician practices. These county-level findings provide important insights about EHR diffusion in places where traditionally underserved populations live. This county-perspective is particularly important because of the potential for health IT to enable public health monitoring and population health management that might benefit individuals beyond the patients treated by the Medicaid providers.

Using a certified electronic health record technology platform to screen, test and refer patients with prediabetes.

The objective of this study was to determine if certified electronic health record technology (CEHRT) can be used to identify and refer patients with prediabetes to lifestyle change programs (LCPs) recognized by the National Diabetes Prevention Program (DPP). This pilot utilized a prediabetes registry, patient portal, and clinical decision support to increase referrals. Data from 36 primary care providers showed 4930 patients were eligible for DPP LCP, 293 referrals were generated, compared to 20 referrals in the baseline period, and 116 patients enrolled. Referral to enrollment conversion rates were 41% in the study period and 69% in the post-study 1-year period. CEHRT functionalities can support systematic identification and management of prediabetes. The referral rate increased 7-fold compared to the baseline period, with high referral to enrollment conversion rates. CEHRT coupled with active provider engagement can serve as a tool to identify prediabetes patients and facilitate LCP referrals and enrollment.

A method for measuring the effect of certified electronic health record technology on childhood immunization status scores among Medicaid managed care network providers.

To provide a methodology for estimating the effect of U.S.-based Certified Electronic Health Records Technology (CEHRT) implemented by primary care physicians (PCPs) on a Healthcare Effectiveness Data and Information Set (HEDIS) measure for childhood immunization delivery. This study integrates multiple health care administrative data sources from 2010 through 2014, analyzed through an interrupted time series design and a hierarchical Bayesian model. We compared managed care physicians using CEHRT to propensity-score matched comparisons from network physicians who did not adopt CEHRT. Inclusion criteria for physicians using CEHRT included attesting to the Childhood Immunization Status clinical quality measure in addition to meeting "Meaningful Use" (MU) during calendar year 2013. We used a first-presence patient attribution approach to develop provider-specific immunization scores. We evaluated 147 providers using CEHRT, with 147 propensity-score matched providers selected from a pool of 1253 PCPs practicing in Maryland. The estimate for change in odds of increasing immunization rates due to CEHRT was 1.2 (95% credible set, 0.88-1.73). We created a method for estimating immunization quality scores using Bayesian modeling. Our approach required linking separate administrative data sets, constructing a propensity-score matched cohort, and using first-presence, claims-based childhood visit information for patient attribution. In the absence of integrated data sets and precise and accurate patient attribution, this is a reusable method for researchers and health system administrators to estimate the impact of health information technology on individual, provider-level, process-based, though outcomes-focused, quality measures. This research has provided evidence for using Bayesian analysis of propensity-score matched provider populations to estimate the impact of CEHRT on outcomes-based quality measures such as childhood immunization delivery.

Identification of Master Patient Index Record Challenges from Healthcare Professionals’ Perspectives

Abstract Background A Master Patient Index (MPI) system is essentially a database that is built into an Electronic Health Record (EHR) system to maintain a unique identifier for each patient seen at the organizational or enterprise level. The current study is to identify the gaps between the revenue cycle and patient information functionalities used in Electronic Health Records (EHRs) in collecting and reporting patient information. Additional focus was on perceptions of healthcare professionals who are familiar with MPI systems on the impact of these gaps of ensuring maximum reimbursements and adequacy of services provided. The study also sought to glean their perceptions vis-a-vis key challenges in the EHRs that affect organizational workflow. Methods A semi-structured questionnaire was used to collect information from healthcare professionals responsible for the MPI. The population studied is healthcare organizations using EPIC as the Electronic Health Records (EHRs). Results This study confirmed systems gaps between EPIC and other downstream systems used by the healthcare organizations to process patient information, as well as the extent of patient matching challenges that healthcare professionals have encountered in the MPI. These challenges include varying methods of matching patient data; lack of data standardization; absence of policies and procedures; frequently changing demographic data; multiple required data points needed for record matching; and default and null values in key-identifying fields. Conclusions The study offered evidence found in the literature that implies that duplicate records continue to plague healthcare organizations. Widespread technological interoperability insufficiency among healthcare facilities points to future challenges for federal policy makers as they seek to promote interoperability programs to demonstrate meaningful use of certified electronic health record technology (CEHRT). Key messages The study confirmed that despite a low level of duplication in the MPI, the organizations have lost revenue during the last 6 months. Duplicate records in the EHR systems has led to downstream problems in the revenue cycle, including denials and insurance takebacks that impact hospital revenue cycle efficiency.

Adoption of computerized information management systems (CIMS) functions: Urban versus rural primary healthcare providers

ABSTRACT This study examined whether there are differences in the adoption of specific Computerized Information Management Systems (CIMS) functionalities between urban and rural primary healthcare providers. A self-administered questionnaire was mailed to 1721 primary healthcare providers in both rural and urban areas in the state of Texas, with a 70 percent response rate (n = 1204). Chi-square goodness of fit was used to determine the frequency of adoption of specific CIMS functions and factor analyses for patterns of adoption. Findings revealed higher rates of adoption of key CIMS functions among urban primary healthcare providers compared with rural providers in the areas of clinical documentation and decision support. As such, many of the functions highlighted in the new Centers for Medicare & Medicaid Services (CMS) Promoting Interoperability (PI) seemingly are already being used by urban primary healthcare providers. Results also showed that higher rates of inadequate interoperability standards are related to clinical documentation, results viewing, and computerized order-entry functionalities by rural and urban primary healthcare providers. Accordingly, widespread technological interoperability inadequacy among rural and urban primary healthcare providers points to future challenges for federal policy makers as they seek to promote interoperability to demonstrate meaningful use of certified electronic health record technology (CEHRT).

Hospital Characteristics Associated with Certified EHR Adoption among US Psychiatric Hospitals.

ObjectiveThe aim of this study was to explore the relationship between hospital characteristics and certified electronic health record (EHR) adoption in psychiatric hospitals in the US.MethodsData were drawn from the American Hospital Association Annual Survey Database and the Centers for Medicare and Medicaid Services Hospital Compare data sets in 2016. Binary logistic regression analysis and χ2 tests were performed to examine the relationship between certified EHR adoption and hospital characteristics.ResultsOf 1,059 psychiatric hospitals in the US, 502 (47.4%) have adopted certified EHR technology. Large hospitals (OR 2.29, 95% CI 1.52–3.44; p<0.001), not-for-profit hospitals (OR 1.74, 95% CI 1.22–2.49; p=0.008), and hospitals participating in a network (OR 1.78, 95% CI 1.34–2.37; p<0.001) were more likely to adopt certified EHRs. Hospitals in the northeast were less likely to implement certified EHRs compared to other regions. However, there was no significant association found between EHR utilization and system affiliation, urban location, teaching status, or participation of health-maintenance organizations and preferred provider organizations.ConclusionThe study results suggested variations in EHR adoption according to hospital location, size, ownership, and network participation. This study fills a gap in previous work on certified EHR adoption that focused exclusively on general hospitals, but overlooked psychiatric hospitals. Future policies designed to influence the implementation of certified EHRs should take into consideration how hospital size, ownership, and network-affiliation status affect certified EHR adoption among psychiatric hospitals.

CMS Issues Final Rule for Medicare Quality Reporting in 2018

CMS Issues Final Rule for Medicare Quality Reporting in 2018

Expanding Role of Certified Electronic Health Records Technology in Radiology: The MACRA Mandate

Radiology has historically been at the forefront of innovation and the advancement of technology for the benefit of patient care. However, challenges to early implementation prevented most radiologists from adopting and integrating certified electronic health record technology (CEHRT) into their daily workflow despite the early and potential advantages it offered. This circumstance places radiology at a disadvantage in the two payment pathways of the Medicare Access and CHIP Reauthorization Act of 2015: the Merit-Based Incentive Payment System (MIPS) and advanced alternative payment models (APMs). Specifically, not integrating CEHRT hampers radiology’s ability to receive bonus points in the quality performance category of the MIPS and in parallel threatens certain threshold requirements for advanced APMs under the new Quality Payment Program. Radiology must expand the availability and use of CEHRT to satisfy existing performance measures while creating new performance measures that create value for the health care system. In addition, radiology IT vendors will need to ensure their products (eg, radiology information systems, PACS, and radiology reporting systems) are CEHRT compliant and approved. Such collective efforts will increase radiologists’ quality of patient care, contribution to value driven activities, and overall health care relevance.

MACRA Final Rule Offers Options for Value-Based Reporting

MACRA Final Rule Offers Options for Value-Based Reporting

Implementation of Certified EHR, Patient Portal, and "Direct" Messaging Technology in a Radiology Environment Enhances Communication of Radiology Results to Both Referring Physicians and Patients.

Since 2009, the Federal government distributed over $29 billion to providers who were adopting compliant electronic health record (EHR) technology. With a focus on radiology, we explore how EHR technology impacts interoperability with referring clinicians' EHRs and patient engagement. We also discuss the high-level details of contributing supporting frameworks, specifically Direct messaging and health information service provider (HISP) technology. We characterized Direct messaging, a secure e-mail-like protocol built to allow exchange of encrypted health information online, and the new supporting HISP infrastructure. Statistics related to both the testing and active use of this framework were obtained from DirectTrust.org, an organization whose framework supports Direct messaging use by healthcare organizations. To evaluate patient engagement, we obtained usage data from a radiology-centric patient portal between 2014 and 2015, which in some cases included access to radiology reports. Statistics from 2013 to 2015 showed a rise in issued secure Direct addresses from 8724 to 752,496; a rise in the number of participating healthcare organizations from 667 to 39,751; and a rise in the secure messages sent from 122,842 to 27,316,438. Regarding patient engagement, an average of 234,679 patients per month were provided portal access, with 86,400 patients per month given access to radiology reports. Availability of radiology reports online was strongly associated with increased system usage, with a likelihood ratio of 2.63. The use of certified EHR technology and Direct messaging in the practice of radiology allows for the communication of patient information and radiology results with referring clinicians and increases patient use of patient portal technology, supporting bidirectional radiologist-patient communication.

Associations between healthcare quality and use of electronic health record functions in ambulatory care.

Contemporary electronic health records (EHRs) offer a wide variety of features, creating opportunities to influence healthcare quality in different ways. This study was designed to assess the relationship between physician use of individual EHR functions and healthcare quality. Sixty-five providers eligible for "meaningful use" were included. Data were abstracted from office visit records during the study timeframe (183 095 visits with 61 977 patients). Three EHR functions were considered potential predictors: acceptance of best practice alerts, use of order sets, and viewing panel-level reports. Eighteen clinical quality measures from the "meaningful use" program were abstracted. Use of condition-specific best-practice alerts and order sets was associated with better scores on clinical quality measures capturing processes in diabetes, cancer screening, tobacco cessation, and pneumonia vaccination. For example, providers above the median in use of tobacco-related alerts had higher performance on tobacco cessation intervention metrics (median 80.6% vs. 66.7%; P < .001), and providers above the median in use of diabetes order sets had higher quality on diabetes low density lipoprotein (LDL) testing (68.2% vs. 59.5%; P == .001). Post hoc examination of the results showed that the positive associations were with measures of healthcare processes (such as rates of LDL testing), whereas there were no positive associations with measures of healthcare outcomes (such as LDL levels). Among primary care providers in the ambulatory setting using a single EHR, intensive use of certain EHR functions was associated with increased adherence to recommended care as measured by performance on electronically reported "meaningful use" quality measures. This study is relevant to current policy as it uses quality metrics constructed by contemporary certified EHR technology, and quantitative EHR use metrics rather than self-reported use. In the early stages of the "meaningful use" program, use of specific EHR functions was associated with higher performance on healthcare process metrics.

CMS Revises ‘Meaningful Use’ Criteria for Electronic Records

CMS Revises ‘Meaningful Use’ Criteria for Electronic Records

Sexual Orientation and Gender Identity Data Collection Update: U.S. Government Takes Steps to Promote Sexual Orientation and Gender Identity Data Collection Through Meaningful Use Guidelines.

Collecting data on sexual orientation and gender identity (SO/GI) in healthcare settings and in electronic health records (EHRs) is essential to understanding, addressing, and reducing LGBT health disparities. The federal government took two key steps in early 2014 in support of asking SO/GI questions in clinical settings as part of the meaningful use of EHRs. First, the Office of the National Coordinator for Health Information Technology issued proposed 2015 Edition Certified EHR Technology (CEHRT) Criteria, which suggest Systematized Nomenclature of Medicine (SNOMED) code sets for SO/GI data collection in 2017. To facilitate the effective and accurate collection of SO/GI data, 153 LGBT and HIV groups recommended that the national coordinator request that the National Library of Medicine develop new codes to reflect SO/GI data. Second, the Health Information Technology Policy Committee submitted recommendations to the national coordinator, including the recommendation that "CEHRT [certified EHR technology] provides the functionality to capture … sexual orientation, gender identity." If the national coordinator accepts this recommendation, it will be put up for public comment in fall 2014 along with other Stage 3 proposed rules. Also, the 2017 Edition CEHRT Notice of Proposed Rule Making Criteria will be up for comment in fall 2014. Final Stage 3 Meaningful Use Guidelines will be published in summer 2015, and other key steps will take place into 2017. A critical parallel step is the training of clinical staff on LGBT health disparities and how to use SO/GI data and manage them in ways that meet the clinical needs of LGBT patients and protect confidentiality and privacy. We must also educate LGBT community members about why offering this information is important for their health and how collecting SO/GI data in EHRs is an important step to understanding LGBT health, reducing disparities, and improving outcomes.

Creating value: unifying silos into public health business intelligence.

Introduction:Through September 2014, federal investments in health information technology have been unprecedented, with more than 25 billion dollars in incentive funds distributed to eligible hospitals and providers. Over 85 percent of eligible United States hospitals and 60 percent of eligible providers have used certified electronic health record (EHR) technology and received Meaningful Use incentive funds (HITECH Act1).Technology:Certified EHR technology could create new public health (PH) value through novel and rapidly evolving data-use opportunities, never before experienced by PH. The long-standing “silo” approach to funding has fragmented PH programs and departments,2 but the components for integrated business intelligence (i.e., tools and applications to help users make informed decisions) and maximally reuse data are available now.Systems:Challenges faced by PH agencies on the road to integration are plentiful, but an emphasis on PH systems and services research (PHSSR) may identify gaps and solutions for the PH community to address.Conclusion:Technology and system approaches to leverage this information explosion to support a transformed health care system and population health are proposed. By optimizing this information opportunity, PH can play a greater role in the learning health system.

Changes to Stage 1 Meaningful Use in 2014: Impact on Radiologists

The goal of this work is to provide radiologists an update regarding changes to stage 1 of meaningful use in 2014. These changes were promulgated in the final rulemaking released by the Centers for Medicare and Medicaid Services and the Office of the National Coordinator for Health Information Technology in September 2012. Under the new rules, radiologists are exempt from meaningful use penalties provided that they are listed as radiologists under the Provider Enrollment, Chain and Ownership System (PECOS). A major caveat is that this exemption can be removed at any time. Additional concerns are discussed in the main text. Additional changes discussed include software editions independent of meaningful use stage (i.e., 2011 edition versus 2014 edition), changes to the definition of certified electronic health record technology (CEHRT), and changes to specific measures and exemptions to those measures. The new changes regarding stage 1 add complexity to an already complex program, but overall make achieving meaningful use a win-win situation for radiologists. There are no penalties for failure and incentive payments for success. The cost of upgrading to CEHRT may be much less than the incentive payments, adding a potential new source of revenue. Additional benefits may be realized if the radiology department can build upon a modern electronic health record to improve their practice and billing patterns. Meaningful use and electronic health records represent an important evolutionary step in US healthcare, and it is imperative that radiologists are active participants in the process.

Leveraging Cloud Computing to Address Public Health Disparities: An Analysis of the SPHPS.

As the use of certified electronic health record technology (CEHRT) has continued to gain prominence in hospitals and physician practices, public health agencies and health professionals have the ability to access health data through health information exchanges (HIE). With such knowledge health providers are well positioned to positively affect population health, and enhance health status or quality-of-life outcomes in at-risk populations. Through big data analytics, predictive analytics and cloud computing, public health agencies have the opportunity to observe emerging public health threats in real-time and provide more effective interventions addressing health disparities in our communities. The Smarter Public Health Prevention System (SPHPS) provides real-time reporting of potential public health threats to public health leaders through the use of a simple and efficient dashboard and links people with needed personal health services through mobile platforms for smartphones and tablets to promote and encourage healthy behaviors in our communities. The purpose of this working paper is to evaluate how a secure virtual private cloud (VPC) solution could facilitate the implementation of the SPHPS in order to address public health disparities.

Pharmacists can help with meaningful use

The potential for pharmacists to contribute to the federally defined "meaningful use" of the electronic health record (EHR) continues to grow, but the money is another story: pharmacy groups do not know of any pharmacist arranging to share in the related incentive payments for which physicians and hospitals are eligible.

“Meaningful Use” of EHR in Dental School Clinics: How to Benefit from the U.S. HITECH Act's Financial and Quality Improvement Incentives

Through the 2009 HITECH (Health Information Technology for Economic and Clinical Health) Act, the U.S. government committed $27 billion to incentivize the adoption and "meaningful use" of certified electronic health records (EHRs) by providers, including dentists. Given their patient profiles, dental school clinics are in a position to benefit from this time-delimited commitment to support the adoption and use of certified EHR technology under the Medicaid-based incentive. The benefits are not merely financial: rather, the meaningful use objectives and clinical quality measures can drive quality improvement initiatives within dental practices and help develop a community of medical and dental professionals focused on quality. This article describes how dentists can qualify as eligible providers and the set of activities that must be undertaken and attested to in order to obtain this incentive. Two case studies describe the approaches that can be used to meet the Medicaid threshold necessary to be eligible for the incentive. Dentists can and have successfully applied for meaningful use incentive payments. Given the diverse set of patients who are treated at dental schools, these dental practices are among those most likely to benefit from the incentive programs.

Achieving Meaningful Use and Operational Efficiency.

The Centers for Medicare and Medicaid Services (CMS), through the Electronic Health Record (EHR) Incentive Program, are providing incentive payments to eligible professionals as they demonstrate meaningful use of certified EHR technology. Eligible professionals can receive up to $44,000 over a 5-year period for Medicare participation if they successfully demonstrate the ability to automatically generate, transmit, and meet thresholds for specific reporting elements from the EHR. Meeting the meaningful use requirement involves a reorganization of workflow within the clinical setting so that the data elements necessary to produce the relevant measurements are documented in the electronic medical record (EMR) as they are delivered. A by-product of this is operational efficiency improvement in three areas: coordination of data input throughout the care team to reduce or remove bottlenecks, assignment of responsibility for specific activity, and real-time objective monitoring of the work process. Using the reporting system functionality of a certified EMR deployed in a two-physician medical oncology practice at the New London Cancer Center, the objective measurement of the ability of each of the eligible providers in the clinic to improve their individual MU scores was tracked. Analysis of the progress of each provider revealed gaps. Process issues were identified by work group: secretaries, laboratory preparation and phlebotomy staff, nurses, and clinicians. The designated physician leader met with each group to discuss the sections relevant to that particular group. By discovering and addressing work processes that were not utilizing the ability of the EHR to capture and document (ie, meaningful use of the EHR), rapid progress that affected all of the eligible providers and all patients cared for was made. Changes resulted in increased clarity of clinical and administrative responsibilities during patient processing and clinical care provision. Meaningful use attestation was completed in 14 weeks. Completion of the documentation necessary to meet the requirements of the EHR Incentive Program led to the discovery of systemic inefficiencies in administrative and clinical workflows. Addressing these bottlenecks, along with using the reporting capability of the EHR to measure the impact of workflow changes, enabled the administrative and care teams to make changes quickly and effectively. The certified EHR provided guidance and status-reporting capabilities that allowed the practice to achieve the meaningful use requirement.

Improvement in Stroke Performance Measures

> Trust but verify. > > —Ronald Reagan Collecting and monitoring performance measure data are resource-intensive, requiring time and effort by a team that includes health care providers treating the patients and documenting their care, quality personnel monitoring and working to optimize performance rates, and quality abstractors, who extract information from the medical record. Recently, an additional group of people have become involved, informatics personnel, who strive to extract information electronically and improve performance measure adherence rates through improved electronic health record (EHR) functionality such as documentation templates and electronic reminders. Article see p 503 With the increased focus on measuring processes and outcomes of care, performance measurement will become increasingly widespread.1–3 The National Quality Forum (NQF), the nonprofit organization created to help improve the quality of health care,4 continues to endorse new measure sets. The Centers for Medicare and Medicaid Services (CMS) Voluntary Pay for Reporting Initiative, which began in 2005 with the voluntary hospital-based collection of 10 NQF-endorsed measures, continues to expand, with 76 measures planned by 2014.1 In addition to the increased burden of data collection, the stakes for performance are rising—the CMS “Pay for Reporting” program has become “Pay-for-Performance,” with reimbursement linked to adherence rates.5 Stroke, one of costliest conditions for Medicare and a leading cause of disability and mortality,6 has been a focus for performance measurement activities. Eight NQF-endorsed stroke performance measures are currently used as part of the voluntary Joint Commission Primary Stroke Center certification and will be part of the CMS Hospital Inpatient Prospective Payment System program beginning with 2013 stroke hospital discharges.1 In addition, collection of 7 stroke performance measures using certified EHR technology is required if hospitals wish to qualify for incentive payments through the CMS Electronic Health Record Meaningful Use Incentive program.7 Given the increased concentration …