The Pharmacist's Guide to Meaningful Use

The Pharmacist’s Guide to Meaningful Use

What is Meaningful Use?

At the legislative level, Meaningful Use(MU) is a proposed rule created by CMS to implement the provisions of the American Recovery and Reinvestment Act of 2009 (ARRA). It establishes criteria to promote the adoption of meaningful use of technology in healthcare. The primary goals are to improve the quality and value of healthcare in the United States through the use of technology such as electronic health records (EHR), computerized provider order entry (CPOE), medication reconciliation tools, and clinical decision support (CDS). It should be noted that as of 3/8/2010, the rule is not final. In addition, there may be incentives from CMS if your organization chooses to implement these criteria. More information on Health Information Technology is available at the CMS website (http://www.cms.hhs.gov/Recovery/11_HealthIT.asp).

Improving quality, safety, efficiency, and reduce health disparities

Objective: Use of CPOE for orders (any type) directly entered by authorizing provider (for example, MD, DO, RN, PA, NP) 
Measure: CPOE is used for at least 10 percent of all orders
The RPh: Implementation of CPOE, building and maintenance of medication orders and order sets to support its use by physicians. This can require a significant number of pharmacy resources that are trained to configure the EHR for use.

Objective: Implement drug-drug, drug-allergy, drug- formulary checks
Measure: The eligible hospital has enabled this functionality.
The RPh: Pharmacy plays a critical role in management and analysis of medication alerts in the EHR. This objective only requires that it be turned on. However, most institutions choose to make the information truly meaningful to physicians and pharmacists by analyzing and fine tuning the alerts. Various studies have shown over 50% of the severe interactions shown to providers are not clinically significant. The numbers are higher for moderate and mild alerts. Consequently you may want to design a process to review overridden alerts on a monthly/quarterly basis to eliminate the unwanted alerts from firing. This requires resources to review the data.

Hospital Objective: Maintain active medication list.
Measure: At least 80 percent of all unique patients admitted by the eligible hospital have at least one entry (or an indication of “none” if the patient is not currently prescribed any medication) recorded as structured data.
The Rph: Medication Reconciliation processes vary widely per institution. Some use nurses, physicians, patient care technicians, pharmacy technicians, or pharmacists to perform reconciliation. This objective requires medication reconciliation on admission, and does not address transfers or discharges. The Joint Commission requires medication reconciliation in all areas. As stewards of medication use, the pharmacy is often involved the design and workflow processes for medication reconciliation.

Objective: Maintain active medication allergy list. 
Measure: At least 80 percent of all unique patients admitted to the eligible hospital have at least one entry (or an indication of “none” if the patient has no medication allergies) recorded as structured data.
The RPh: Maintenance of medication allergies varies with institution. Some have separate pharmacy, eMAR, or EHR systems resulting in separate databases. This can create synchronization issues if different data types are used in each (“high” in one system might be “severe” in another). Identifying these challenges can help design and reconfigure existing systems to ensure compliance. In addition, pharmacists may want to consider mandatory allergy review, but this is not a requirement for MU.

Objective: Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, and outreach
Measure: Generate at least one report listing patients of the eligible hospital with a specific condition.
The RPh: This may or may not involve pharmacy, depending on what conditions and quality measures are chosen. If they are medication use related, the pharmacy may need to provide resources to help design and develop the reports.

Objective: Implement five clinical decision support rules relevant to specialty or high clinical priority, including for diagnostic test ordering, along with the ability to track compliance with those rules
Measure: Implement five clinical decision support rules relevant to the clinical quality metrics the Eligible Hospital is responsible for as described further in section II.A.3.
The RPh: Clinical decision support is considered by many Informatics professionals to be one of the biggest benefits of implementing an EHR. These rules do not have to be medication based, but many great examples include medication-lab or medication-disease rules. An example might be to design an alert that warns a physician if they order warfarin with no accompanying INR on file in the last 24 hours. If medication use rules are chosen, the pharmacist will play a pivotal role in their design and implementation.

Engage patients and families in their healthcare

Objective: Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, allergies, discharge summary, and procedures), upon request.
Measure: At least 80 percent of all patients who request an electronic copy of their health information are provided it within 48 hours.
The RPh: This objective implies the use of the internet or similar electronic tools to provide the patient online access to their medical information. Many EHR vendors provide these patient portals as part of their system. The Pharmacist might be involved in the design and policy review process anytime medication information is shown to patients.

Improve coordination of care

Eligible Hospital Objective: Capability to exchange key clinical information (for example, discharge summary, procedures, problem list, medication list, allergies, diagnostic test results), among providers of care and patient authorized entities electronically.
Measure: Performed at least one test of certified EHR technology's capacity to electronically exchange key clinical information.
The RPh: This objective implies your institution can electronically transmit a medication list to another hospital or provider if requested. Some EHR vendors provide this functionality in their systems already. Consequently, pharmacist involvement may be required to design and develop medication related communication to other systems.

Objective: Perform medication reconciliation at relevant encounters and each transition of care. 
Measure: Perform medication reconciliation for at least 80 percent of relevant encounters and transitions of care.
The RPh: Similar to medication reconciliation on admission, this objective requires reconciliation if the patient is transferred to a different level of care (e.g. medicine ward to ICU). As stewards of medication use, the pharmacy is often involved the design and workflow processes for medication reconciliation. Transfer reconciliation differs from admission, because it only involves hospital ordered medications. The pharmacist may need to consider this when designing the transfer workflow.
Improve population and public health

Objective: Capability to submit electronic data to immunization registries and actual submission where required and accepted.
Measure: Performed at least one test of certified EHR technology's capacity to submit electronic data to immunization registries.
The RPh: Depending on governance at your institution, immunizations may fall under partial responsibility of the pharmacy for because they are often maintained as medication orders. However, this objective addresses the “immunization administration log” in the system. The pharmacy may need to be involved in its design if they maintain the drug records in the EHR.

Ensure adequate privacy and security for personal health information
Objective: Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities.
The RPh: This is often controlled by the HIPAA security officer at your facility, representing an important reminder to pharmacists for protection of patient information. Please remain diligent, following applicable standards and policies set forth by your institution. In addition the pharmacist may want to consider privacy when designing any of the objectives of Meaningful Use.

Reporting of provider clinical quality measures electronically to CMS from your EHR

These clinical quality measures encompass a wide range of medical specialties, including Endocrinology, Primary Care, Cardiology, Pulmonology, Oncology, Obstetrics and Gynecology, Psychiatry, Radiology, Ophthalmology, Procedures/Surgery, Neurology, Pediatrics, Nephrology, Gastroenterology, Podiatry, and core measures (Blood pressure for example).
These proposed clinical quality measures include criteria such as “Percentage of patients aged 18-75 years with DM who had most recent HbA1c >9.0%”. An complete list can be viewed at http://www.cms.hhs.gov/PQRI/20_AlternativeReportingMechanisms.asp#TopOfPage.
Your EHR would need to capture this information and submit it to CMS at the interval required. In order to qualify, the Electronic Provider would need to submit information on just two of the core measure groups (inquiry for tobacco use, blood pressure, etc) and just one of the specialty measure groups (cardiology, endocrinology, etc). You can review these in detail on page 142 of the proposed rule.
Depending on which measures your organization chooses, the Pharmacy may or may not be involved in the process.
The RPh: The pharmacist may be involved in development of medication related reports or electronic communications to CMS. Identification of specific medication records in the EHR for report generation is an area where pharmacist may be required to provide resources. The pharmacy may also be involved in committees that implement and monitor clinical quality measures (e.g. Pharmacy and Therapeutics, Medication Use Safety).
Reporting of hospital clinical quality measures electronically to CMS from your EHR

Unlike provider measures, ALL of the measures for hospitals must be submitted electronically for payment year 2012. They must be attested to (provide data if they ask) by the end of the 2011 payment year. These are proposed on page 153 of the proposed rule, with “Emergency Department Throughput; median time from ED arrival to time of departure from the emergency room for patients admitted to the facility via the ED”. The method of electronic submission has not been finalized.
Many of these hospital measures were adopted from The Joint Commission, such as “Ischemic Stroke - Thrombolytic therapy for patients arriving within 2 hours of symptom onset” or “Platelet monitoring on unfractionated heparin.”
Specific classes of medications included in the measurements are: antithrombotics, anticoagulants, thrombolytics, antihyperlipidemics, antiplatelets, ACEI/ARBs, Beta-blockers, and antibiotics.
The RPh: Like provider measures, the pharmacist may be involved in hospital quality reporting to CMS. Because all of these measures are required, it is more likely the pharmacist will be involved in the process.

Remember MU as proposed pertains to Medicare and Medicaid. It is not currently required for private insurers. However, interoperability of electronic personal health information in the US may push legislation into all healthcare sectors.