Through my consulting experience with numerous hospitals, I've learned that hospitals often see the use of a single, certified electronic health record (EHR) as the required or preferred path to successful attestation. However, not only is it not required to use one system for meaningful use, but using a single enterprise system is also often not the best option nor the easiest way to meet attestation requirements.
This article is part of a series to help you make an educated choice when selecting an ED information system (EDIS).
1. First of all, it’s important to note that the meaningful use supports the use of more than one system.
The meaningful use rules have two categories of EHR certification: complete and modular. Complete certification means that a product meets all certification measures. Under modular certification, systems can be certified to a subset of certification measures for the types of workflows that they were designed for; these kinds of systems are what we fondly refer to as “best-of-breed.”
Hospitals are able to put together a combination of modular and/or complete systems to attest to meaningful use. Having duplicate certified measures in the hospital is OK (e.g., if two systems are certified for CPOE, it’s fine). This allows hospitals to position themselves for success by choosing technology solutions that are best suited for their end-users’ needs.
In the first two years of the program, over 50 percent of hospitals used more than one certified solution to successfully attest. Of this group, 32 percent used four or more systems.
2. End-user adoption is critical to meaningful use success.
Achieving meaningful use threshold percentages primarily relate to end-user actions, such as documenting clinical information.
Clinical systems designed to support the needs of end users in their particular environment have much higher adoption rates than enterprise systems; this is clearly evidenced in reports from KLAS.
Hospitals that use best-of-breed solutions in particular care settings have an easier time acquiring required data and meeting meaningful use measure thresholds. Why?
- End users are using a tool that makes it easy for them to capture information.
- Because of this, they’re more likely to use the tool and enter information.
- Unlike with an enterprise system, it’s easier to get the information into the system without affecting workflow, throughput and efficiency due to the best-of-breed’s inherent design.
3. Reconciliation is only required when thresholds are not met in one system and data from another system needs to be included.
This is an obvious statement, but it’s one that tends to go under the radar. Data reconciliation only affects measures with thresholds and only affects numerators. The denominator is chosen by the hospital and not affected by the number or types of certified systems being used (e.g. the “observation” or “all ED patients methods”).
If a measure threshold is exceeded with data from one system, reconciling with others is not necessary; reconciliation can only increase the numerator, and underreporting meaningful use measures is not a concern.
Many hospitals view data reconciliation as an impediment to using more than one system for meaningful use, but in fact, most reconciliation is straight forward. For sites using more than one certified EHR for any particular measure, such as CPOE, some reconciliation of results between the systems may be necessary.
Still, the vast majority of clinical measures with thresholds use the “unique patient” concept — meaning that an action only needs to be taken once in any certified system during an entire reporting year to meet meaningful use for a particular patient. This significantly simplifies data reconciliation.
Identifying a unique patient is a straightforward and simple task and is generally based on medical record number. Reconciliation then merely consists of comparing “failures” in one system to “successes” in others.
4. Closely related to the above point, the 2014 rules around quality measures have made it simpler for hospitals with multiple EHR systems to report.
Beginning in 2014, hospitals can choose which quality measures to report on and have the flexibility to minimize the need to combine data or look across multiple systems. Hospitals can also choose quality measures based on what they’re more likely to be successful with.
In general, there are a few categories of information that are likely to be contained in multiple systems and relevant for the calculation of quality measures. However, although this information may exist in multiple places, it’s also likely that it will all “naturally” exist in one, thus reducing the need for reconciliation. These categories include ED throughput time stamps, CPOE orders and medication administration..
Systems certified for quality measures in 2014 are able to accept information from external systems — this has transferred much of the reconciliation impact from the hospitals to the vendors.
Carefully Consider Your EDIS Options
While many hospitals achieved Stage 1 with only their inpatient system using the “observation services method,” Stage 2 brings increased threshold requirements and new measures that will require certified solutions for both the inpatient and ED environments.
An EDIS will have far reaching implications and can positively affect productivity, satisfaction and revenue. Conversely, an EDIS system not designed to support the unique ED environment can have a profound and opposite effect.
The certified solutions you choose do not dictate which patient population you use (e.g., all ED patients or observation services). This is a choice the hospitals make independent of the certified solutions they have. Just because you have a certified EDIS doesn't mean you have to use the all ED patients method.
In summary, meaningful use supports a multisystem approach to attestation; due to the impact on workflow, usability and record of adoption, achieving required thresholds can be easier with a best-of-breed system that was made for the environment it supports; and finally reconciliation and reporting can be easily accomplished with multiple EHRs.
Meaningful use requirements and expectations will only continue to increase, and I highly encourage hospitals to consider the benefits of a best-of-breed system for the ED.
