Installation and Maintenance of Health IT Systems

1. Installation and Maintenance of Health IT Systems System Selection – Software and Certification This material Comp8_Unit2 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.

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-ATCB certification • Identify purpose and categories of ARRA “Meaningful Use” criteria Installation and Maintenance of Health IT Systems System Selection – Software and Certification

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 Installation and Maintenance of Health IT Systems System Selection – Software and Certification

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 Installation and Maintenance of Health IT Systems System Selection – Software and Certification

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) Installation and Maintenance of Health IT Systems System Selection – Software and Certification

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 Installation and Maintenance of Health IT Systems System Selection – Software and Certification

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 Installation and Maintenance of Health IT Systems System Selection – Software and Certification

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 Installation and Maintenance of Health IT Systems System Selection – Software and Certification

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) Installation and Maintenance of Health IT Systems System Selection – Software and Certification

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) Installation and Maintenance of Health IT Systems System Selection – Software and Certification

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) Installation and Maintenance of Health IT Systems System Selection – Software and Certification

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 Installation and Maintenance of Health IT Systems System Selection – Software and Certification

13. What are ARRA and “Meaningful Use”? (Recovery.org, 2009) • 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. (Hitechanswers) (cms.gov, 2011) Installation and Maintenance of Health IT Systems System Selection – Software and Certification

14. Meaningful Use Criteria: Stage 1 • According to Centers for Medicare & Medicaid Services (CMS), the priorities for hospitals & providers are to: • Improve quality, safety, and efficiency, and reduce health disparities • Engage patients and families in their health care • Improve care coordination • Improve population and public health • Ensure adequate privacy and security protections for personal health information (CMS, 2011) Installation and Maintenance of Health IT Systems System Selection – Software and Certification

15. Meaningful Use Criteria: Stage 1 (cont’d) 1. Improve quality, safety, and efficiency, and reduce health disparities • Computerized Provider Order Entry (CPOE, directly entered by authorizing provider) for 10+% of all orders • Drug-drug, drug-allergy, drug-formulary checks • Up-to-date problem list of current and active diagnoses, based on ICD-9 or SNOMED vocabularies • Active medication list • Active medication allergy list (CMS, 2011) Installation and Maintenance of Health IT Systems System Selection – Software and Certification

16. Meaningful Use Criteria: Stage 1 (cont’d) 1. Improve quality, safety, and efficiency, and reduce health disparities (cont'd) • Demographics • Preferred language, insurance type, gender, race, ethnicity, date of birth, date and cause of death • Vital signs • Changes in height, weight, blood pressure; calculate and display Body Mass Index (BMI); plot and display growth charts, including BMI, for children 2-20 years (CMS, 2011) Installation and Maintenance of Health IT Systems System Selection – Software and Certification

17. Meaningful Use Criteria: Stage 1 (cont’d) 1. Improve quality, safety, and efficiency, and reduce health disparities (cont'd) • Smoking status (13+ years old) • Laboratory test results as structured data • Lists of patients by specific conditions • Report quality measures to CMS or states • Five clinical decision support rules, including for diagnostic test ordering, along with ability to track compliance • Submit claims electronically, public and private (CMS, 2011) Installation and Maintenance of Health IT Systems System Selection – Software and Certification

18. Meaningful Use Criteria: Stage 1 (cont’d) 2. Engage patients and families in their health care • Provide patients with electronic copy of health information upon request • Diagnostic test results, problem list, medication lists, allergies, discharge summary, procedures • Discharge instructions at the time of discharge (CMS, 2011) Installation and Maintenance of Health IT Systems System Selection – Software and Certification

19. Meaningful Use Criteria: Stage 1 (cont’d) 3. Improve care coordination • Electronically exchange key clinical information • Medication reconciliation at relevant encounters and each transition of care • Summary of care record for each transition of care and referral (CMS, 2011) Installation and Maintenance of Health IT Systems System Selection – Software and Certification

20. Meaningful Use Criteria: Stage 1 (cont’d) 4. Improve population and public health • Capability to: • Submit data to immunization registries • Submit data on reportable lab results (as required by state or local law) to public health agencies • Provide electronic syndromic surveillance data to public health agencies • Actual data submissions under certain circumstances (CMS, 2011) Installation and Maintenance of Health IT Systems System Selection – Software and Certification

21. Meaningful Use Criteria: Stage 1 (cont’d) 5. Ensure adequate privacy and security protections for personal health information • Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities. (CMS, 2011) Installation and Maintenance of Health IT Systems System Selection – Software and Certification

22. Meaningful Use Criteria: Next Stages • Projected timeline of implementation • Stage 2: 2013 • Stage 3: 2015 • Requirements • Not yet officially defined • Expected to require taking stage 1 functions even further; e.g., increasing e-prescribing from 40% to 50% (stage 2) and then to 80% (stage 3) (Federal Register, 2011) Installation and Maintenance of Health IT Systems System Selection – Software and Certification

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 Installation and Maintenance of Health IT Systems System Selection – Software and Certification

24. Typical EHR Costs to Consider (cont'd) • Training costs • Administrators • Users • Productivity costs • Lost during transition • Consultant fees Installation and Maintenance of Health IT Systems System Selection – Software and Certification

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 Installation and Maintenance of Health IT Systems System Selection – Software and Certification

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 Gates, M. (2009, Winter). All Systems Go? How to Select an EHR That Meets Your Needs. Correct Care, Retrieved from http://www.ncchc.org/pubs/CC/selecting_ehr.html Installation and Maintenance of Health IT Systems System Selection – Software and Certification

27. System Selection – Software and CertificationReferences References 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%20Charts.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: http://healthIT.hhs.gov/ATCBs 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 Installation and Maintenance of Health IT Systems System Selection – Software and Certification

28. System Selection – Software and CertificationReferences References Standards & Certification. Retrieved from Office of the National Coordinator for Health Information Technology, US Department of Health & Human Services website: http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__standards_and_certification/1153 Standards & Certification Criteria Final Rule. Retrieved from Office of the National Coordinator for Health Information Technology, US Department of Health & Human Services website: http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__standards_ifr/1195 Images Slide 13: ARRA recovery.gov logo http://www.recovery.gov/News/mediakit/Picture%20Library/circle_recovery_logo.jpg Slide 13: Center for Medicare and Medicaid Services EHR Incentive Programs logo http://www.cms.gov/EHRIncentivePrograms/Downloads/EHRIncentiveLogoweb.JPG Installation and Maintenance of Health IT Systems System Selection – Software and Certification