Installation and Maintenance of Health IT Systems

1. Installation and Maintenance of Health IT Systems System Selection – Software and Certification This material (Comp 8 Unit 2) was developed by Duke University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000024. This material was updated in 2016 by The University of Texas Health Science Center at Houston under Award Number 90WT0006. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.

2. System Selection – Software and Certification Learning Objectives • Compare and contrast COTS (Commercial Off-The-Shelf) and In-House /homegrown systems and describe their relative advantages and disadvantages • Verify system compliance with ONC-ACB certification • Identify purpose and categories of ARRA “Meaningful Use” criteria

3. Off-the-Shelf Software • Commercial Off-the-Shelf (COTS) • Modifiable Off-the-Shelf (MOTS) • 200+ companies claim to make an EHR (Electronic Health Record) • May include “freeware” with commercial support

4. Advantages of COTS • Lower development costs • Wider “test market” to find bugs and limitations • Vendor training and product support, bug fixes • Easier learning curve • Eliminate development time

5. Disadvantages of COTS • Unalterable source code • Compatibility issues • Uncertain upgrade schedules • Business practices may have to be modified, and workflow often has to be adapted to the particular product design. (Rice, 2009)

6. In-House / Homegrown • Locally-installed and managed EHR implementation • Only available to institutions with existing IT infrastructure and investment • Developed by • extending existing In-House systems, or • adapting open-source or other publically available software for institution needs

7. Advantages of In-House • Developed wholly by the operating institution • Design is specifically tailored to meet institutional objectives • Can mesh comfortably with existing workflow processes

8. Disadvantages of In-House • Higher development costs, initial and throughout product lifecycle • Dependent on expertise of in-house development staff • Lack of vendor support – bug fixes, upgrades • Training must be developed in-house. • Longer development time

9. EHR Certification • Office of the National Coordinator for Health Information Technology (ONC) provides for a certification program for EHR Technology • Temporary Certification Program in effect June 2010 • Permanent Certification Program in January 2011, replacing temporary program in 2012 • American National Standards Institute (ANSI) is the ONC-Approved Accreditor (AA) for the Permanent Certification Program – ANSI will certify the ATCBs • Only 6 ATCBs as of Dec. 2011 (http://healthIT.hhs.gov/ATCBs) • ATCBs are the Authorized Testing and Certification Bodies that grant certification to the products and vendors of Complete EHRs and EHR Modules. • Current list is available at http://onc-chpl.force.com/ehrcert • Certification is a prerequisite for participation in the Medicare and Medicaid incentive programs, which provide payment to doctors, clinics, and hospitals that “demonstrate meaningful use of certified EHR technology” (ONC, 2011; CMS 2011)

10. Standards and Certifications Criteria Final Rule • Final Rule on an initial set of standards, implementation specifications, and certification criteria adopted July 13, 2010 • Interoperability, to work with systems sharing information • Functionality, to perform a set of well-defined functions • Security, to store and transmit confidentially and reliably • Utility, to support meaningful use of HIT data (SCCFR)

11. Why Certification? • Reduce risks to physicians in EHR investment • Facilitate interoperability of EHR systems • Enhance availability of EHR adoption through stimulus incentives • Ensure that EHR systems and networks are secure and protect privacy (Pizzi, 2007)

12. Why Certification? (cont’d) • Allow evaluation time to be used more efficiently • Narrow the initial field of vendors • Assure basic functionality and interoperability, allowing you to focus evaluation more on special or unusual needs of your institution

13. What are ARRA and “Meaningful Use”? • ARRA (American Recovery and Reinvestment Act, a.k.a. “stimulus bill”) • Passed by Congress February 2009 • Over $22 billion allocated to modernize health IT system. • HITECH (Health Information Technology for Economic and Clinical Health) Act: initially rewards institutions for “meaningful use” of EHRs, then in 2015 imposes penalties. (U.S. Department of Transportation, 2009) (CMS.gov, 2011)

14. Meaningful Use Criteria: Stage 3 • According to Centers for Medicare & Medicaid Services (CMS), the objectives for hospitals & providers are to: • Protect patient health information • Clinical decision support • Computerized provider order entry (CPOE) • Electronic Prescribing (CMS, 2015)

15. Meaningful Use Criteria: Stage 3 (cont’d) • Health information exchange • Patient-specific education • Medication reconciliation • Patient electronic access • Secure Messaging • Public Health (CMS, 2015)

16. Meaningful Use Criteria: Stage 3 (cont’d) 1. Protect patient health information Conduct or review a security risk analysis…addressing the security to include encryption 2. Clinical decision support M1 – Implement 5 clinical decision support interventions for 4 or more CQMs or high-priority conditions M2 – enabled and implemented drug-drug and drug-allergy interaction checks for entire reporting period (CMS, 2015)

17. Meaningful Use Criteria: Stage 3 (cont’d) 3. Computerized Provider Order Entry (CPOE) M1 - >60% of medical orders use CPOE M2 - >30% of lab orders use CPOE M3 - >30% of radiology orders use CPOE 4. Electronic Prescribing - >50% of permissible prescriptions are queried for drug formulary and transmitted using CEHRT (CMS, 2015)

18. Meaningful Use Criteria: Stage 3 (cont’d) 5. Health Information Exchange – transitions or referrals to another setting or provider: (1) uses CEHRT to create a summary of care; and (2) electronically transmits the summary for more than 10% of the transitions 6. Patient-specific Education – resources identified by CEHRT are provided to 10% of unique patients with office visits (CMS, 2015)

19. Meaningful Use Criteria: Stage 3 (cont’d) • Medication Reconciliation – medication reconciliation is performed for more than 50% of transitions of care in which the patient is transitioned into care • Patient Electronic Access M1 - > 50% of all unique patients are provided timely access to view, download, and transmit M2 – At least 1 patient views, downloads or transmits to a third party (CMS, 2015)

20. Meaningful Use Criteria: Stage 3 (cont’d) 9. Secure Messaging 2015 – capacity for patients to send/receive was fully enabled 2016 – secure message sent to the patient using EM function or in response to a secure message for at least 1 patient 2017 – 2016 secure messaging functionality for more than 5% of unique patients (CMS, 2011)

21. Meaningful Use Criteria: Stage 3 (cont’d) 10. Public Health M1 – Immunization Registry Reporting – EP is in active engagement with a public health agency to submit immunization data M2 – Syndromic Surveillance Reporting – EP in active engagement with a public health agency to submit syndromic surveillance data M3 – Specialized Registry Reporting – active engagement to submit data to specialized registry (CMS, 2015)

22. Meaningful Use Criteria: Next Stages • Merit-based Incentive Payment System (MIPS)

23. Typical EHR Costs to Consider • Start up costs • Initial hardware and network upgrades • Initial software and licensing • Initial interfaces • Maintenance costs • Annual software licensing, upgrades, support • Annual interface upgrades and support

24. Typical EHR Costs to Consider (cont'd) • Training costs • Administrators • Users • Productivity costs • Lost during transition • Consultant fees

25. System Selection – Software and CertificationSummary • COTS advantages and disadvantages weighed against in-house advantages and disadvantages • Costs involved in startup and maintenance of the system should be addressed • Certified systems and modules are preferred • Meaningful use priorities should be addressed

26. System Selection – Software and CertificationReferences References About ARRA. Retrieved from HITECH Answers website: http://www.hitechanswers.net/about/about-arra/ ARRA Meaningful Use Snapshot. (n.d.). Retrieved from Medical Information Technology, Inc. website: http://www.meditech.com/interoperability/pages/ARRA_snapshot_final_0311.pdf Certified Health IT Product List. Retrieved from Office of the National Coordinator for Health Information Technology, US Department of Health & Human Services website: http://onc-chpl.force.com/ehrcert Electronic Medical Record [cited 2010 June 20]. Retrieved from: http://en.wikipedia.org/wiki/Meaningful_Use#Meaningful_Use EHR Incentive Programs Overview. (n.d.). Retrieved from Centers for Medicare & Medicaid Services website: https://www.cms.gov/EHRIncentivePrograms/ Medicare and Medicaid Programs; Electronic Health Record Incentive Program (2010, July). Federal Register. [Internet]. Retrieved from http://www.federalregister.gov/articles/2010/07/28/2010-17207/medicare-and-medicaid-programs-electronic-health-record-incentive-program . Fornes, D. (2008, February 6). Should CCHIT Influence Your EHR Selection? [Web log post]. Retrieved from Software Advice - The Medical Blog: http://blog.softwareadvice.com/articles/medical/should-cchit-influence-your-ehr-selection

27. System Selection – Software and CertificationReferences References Gates, M. (2009, Winter). All Systems Go? How to Select an EHR That Meets Your Needs. Correct Care, (pp 12-15). Retrieved from http://www.ncchc.org/filebin/images/Website_PDFs/23-1.pdf Goals for EHR System. Retrieved June 20, 2010, from Health Technology Review website: http://www.healthtechnologyreview.com/viewarticle.php?aid=113 HITECH Act Enforcement Interim Final Rule. (n.d.). Retrieved from U.S. Department of Health & Human Services website: http://www.hhs.gov/ocr/privacy/hipaa/administrative/enforcementrule/hitechenforcementifr.html McKinney, D. (2001, August). Impact of Commercial Off-The-Shelf (COTS) Software and Technology on Systems Engineering. Retrieved from Presentation to INCOSE Chapters website: http://www.incose.org/northstar/2001Slides/McKinney Charts.pdf Medicare and Medicaid Programs; Electronic Health Record Incentive Program; Final Rule, 75 Fed. Reg. 44314 (2010) 42 CFR Parts 412, 413, 422, and 495 http://edocket.access.gpo.gov/2010/pdf/2010-17207.pdf ONC-Authorized Testing and Certification Bodies. Retrieved from Office of the National Coordinator for Health Information Technology, US Department of Health & Human Services website: https://www.healthit.gov/policy-researchers-implementers/about-onc-health-it-certification-program

28. System Selection – Software and CertificationReferences References Pizzi, R. (2007, October 30). EHR adoption an "ugly process," but CCHIT can improve appeal. Retrieved from Healthcare IT News website: : http://www.healthcareitnews.com/news/ehr-adoption-ugly-process-cchit-can-improve-appeal Rice, R. (2009). Testing COTS-Based Applications. Retrieved June 21, 2010, from http://www.riceconsulting.com/articles/testing-COTS-based-applications.htm Standards & Certification. Retrieved from Office of the National Coordinator for Health Information Technology, US Department of Health & Human Services website: https://www.healthit.gov/policy-researchers-implementers/standards-and-certification-regulations Standards & Certification Criteria Final Rule. Retrieved from Office of the National Coordinator for Health Information Technology, US Department of Health & Human Services website: https://www.healthit.gov/policy-researchers-implementers/standards-certifications-criteria-final-rule Images Slide 13: ARRA Recovery.gov logo. (2009). Retrieved from: https://www.transportation.gov/recovery Slide 13: Center for Medicare and Medicaid Services EHR Incentive Programs logo. (2011). Retrieved from: http://www.cms.gov/EHRIncentivePrograms/Downloads/EHRIncentiveLogoweb.JPG

29. Installation and Maintenance of Health IT Systems Elements of a Typical Electronic Health Record System This material was developed by Duke University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000024. This material was updated in 2016 by The University of Texas Health Science Center at Houston under Award Number 90WT0006.