Meaningful Use is a Team Effort
The federal EHR Incentive program (Meaningful Use) earmarks incentive money for clinicians to “meaningfully use certified EHR technology.” The first stage of this process is focused mainly on getting clinicians used to having a computer screen in front of them, rather than a paper chart, as they go about day-to-day work.
The Medicare pathway to Meaningful Use requires that each physician who enrolls in the program attest to completion of a set of criteria – 15 core measures, plus 5 of 10 menu items. The Medicaid pathway only requires Adoption, Implementation or Upgrade (AIU) of an EHR in the first year, with attestation to the 20-of-25 measures taking place in the second year.
The Meaningful Use criteria involve some workflow changes that may impact (hopefully improve) day-to-day practice for physicians. Everyone in the practice, from front-office staff to nursing and medical assistant staff to the clinical professionals, is impacted by the implementation of an EHR system – and everyone’s effort is needed in order to achieve the criteria needed for Attestation.
More than simply a charting-assistant tool, modern EHRs track patients as they move through the office, serve as a platform for in-office messaging, capture lab tests and scanned documents, and offer electronic prescribing (both for new prescriptions as well as for refills). It also involves opening up the chart information to patients, through electronic access – mainly a PHR window into the doctor’s chart.
Since different pieces of information can be captured by different roles within the practice, we wanted to offer suggestions for workflow enhancements that may be useful for a practice to adopt, and ease the collection of data needed for Attestation.
Front desk (check-in)
The front desk staff mainly is using the calendar features of the EHR to schedule patients, and check them in when they arrive for appointments. They are therefore in a good position to capture the demographic information on patients, either on the phone when making an appointment, or on check-in when the patient arrives.
One of the Meaningful Use requirements is to collect all 5 elements of demographic information on at least 50% of the patients seen – date of birth and gender are likely already there, but preferred language, race and ethnicity are likely not. Therefore, front office staff can make these entries into the EHR as patients arrive. This may be a new workflow for them, and likely will require education/attention to this item.
Nursing/medical assistants
Once a patient arrives (using the Practice Fusion system, the calendar appointment status is changed from “pending” to “in lobby”), they are ready to be roomed. Nursing-level personnel then collects the vital signs, verifies the chief complaint (which is automatically copied from the appointment), designates which room the patient is in, and advances the status from “in lobby” to “in room” (which is how the physician can see who is waiting to be seen).
One of the Meaningful Use requirements is to collect vital signs on at least 50% of patients seen during the measurement period (90 days, on the first year of the program) – height, weight and blood pressure need to be recorded at least once for each patient seen during the measurement period. Nursing personnel will be ones to best enter this, as it is part of their traditional workflow.
Another Meaningful Use requirement is to collect Smoking Status for each patient (at least 50% of patients 13 years or older seen during the measurement period). Asking patients if they smoke is something that nursing personnel can do as part of collecting the vital signs. If not done by them, then the clinician will need to enter this during the clinical exam – but if nursing incorporates this into their routine workflow, it will help.
Front desk (check-out)
Once a patient is done with the examination, then stopping by a checkout window is often part of an in-office workflow. Follow-up appointments, referrals, scheduling of tests (e.g. x-rays), requests for outside records, and the like, typically all take place then. This is an opportunity to enroll the patient in the PHR, if not already done – enrolling the patient can be done at intake, by nursing, or by the clinicians, but check-out is another place where this can be accomplished.
Enrolling the patient in the PHR addresses several Meaningful Use items. Providing a patient an electronic copy of their health information (criterion #12) needs to be done for at least 50% of patients who ask for it – of course, if no one asks, then the denominator is zero. But the PHR accomplishes this.
A more difficult Meaningful Use criterion, however, is to give patients a clinical summary that is updated after each visit, and to do so for 50% of office visits during the 90 day period (criterion #13). Typically, the chart note is not completed by the end of the visit when the patient checks out, so printing out the “P” section of the progress note, as well as the Summary section (problem list, medications list, allergy list) is not practical – though that is one way of achieving this goal. Creating a CCR export for each patient is also a possible way of achieving this, but this is also not likely to be practical (or helpful for patient care, since few patients will have the ability to display a CCR).
However, the PHR accomplishes all these pieces for the purpose of Meaningful Use. What this means, then, is that at least 50% of patients seen during the 90-day measurement period should be enrolled in the PHR. This can be a challenge, and will likely be facilitated by giving front-office and other personnel the ability to enroll patients (or their healthcare surrogates – often, family members in the case of elderly or computer non-user patients) in the PHR.
Conclusions
Achieving Meaningful Use is a group effort. It’s not just about the doctors – everyone in the practice is impacted by EHR use in one way or another, and everyone has a role to play. There are several items of data collection that fit with different staff roles in a typical practice, as we detailed above. Team/staff meetings to review these potentially new responsibilities is a worthwhile thing for everyone to do.
Our goal is to help every eligible practice achieve Meaningful Use. The money is earmarked already, and awaiting distribution upon successful Attestation.
